Specificity of Anhedonic Depression and Anxious Arousal with Sexual Problems, and the Validation of Sexual Functioning Measures Among Healthy Males and Females

Home , Sexual arousal disorder

SPECIFICITY OF ANHEDONIC DEPRESSION AND ANXIOUS AROUSAL WITH SEXUAL PROBLEMS, AND THE VALIDATION OF SEXUAL FUNCTIONING MEASURES AMONG HEALTHY MALES AND FEMALES.

A thesis submitted to Kent State University in partial fulfillment of the requirements for the degree of Master of Arts.

David A. Kalmbach

August, 2011

Thesis written by David A. Kalmbach B.A., Kent State University, 2008 M.A., Kent State University, 2011

Approved by

Jeffrey A. Ciesla, Ph.D. Advisor

Maria S. Zaragoza, Ph.D. Chair, Department of Psychology

Timothy Moerland, Ph.D. Dean, College of Arts and Sciences

TABLE OF CONTENTS

LIST OF TABLES iv

LIST OF FIGURES vi

INTRODUCTION…………………………………………………………….. 1

METHOD………………………………………………………………...... 11

Participants…………………………………………...... 11

Procedures…………………………………………...... 11

Measures…………………………………………...... 12

Data Analysis Plan………..…………………...... 13

RESULTS……………………………………………………………………... 15

DISCUSSION………………………………………………………………… 35

REFERENCES………………………………………………………………... 40

iii

LIST OF TABLES

TABLE 1………..……………………………………………………………….. 17 MSFI MTMM CFA FACTOR LOADINGS, STANDARDIZED REGRESSION WEIGHTS

TABLE 2………………………………………………………………...... 19 MALES PFSF MTMM CFA FACTOR LOADINGS, STANDARDIZED REGRESSION WEIGHTS

TABLE 3………………………………………………………………………... 20 FSFI MTMM CFA FACTOR LOADINGS, STANDARDIZED REGRESSION WEIGHTS

TABLE 4………………………………………………………………………… 21 FEMALES PFSF MTMM CFA, FACTOR LOADINGS, STANDARDIZED REGRESSION WEIGHTS

TABLE 5………………………………………………………………………… 23 MALE MSFI AND PFSF INTERNAL CONSISTENCIES AND FACTOR CORRELATIONS

TABLE 6………………………………………………………………………… 24 FEMALE FSFI AND PFSF INTERNAL CONSISTENCIES AND FACTOR CORRELATIONS

TABLE 7………………………………………………………………………… 27 MSFI AND MASQ CORRELATIONS AMONG MALE

TABLE 8………………………………………………………………………… 27 PFSF AND MASQ CORRELATIONS AMONG MALES

TABLE 9………………………………………………………………………… 28 FSFI AND MASQ CORRELATIONS AMONG ALL FEMALES

TABLE 10………………………………………………………………………… 28 PFSF AND MASQ CORRELATIONS AMONG ALL FEMALES

TABLE 11………………………………………………………………………… 31 MSFI AND MASQ, UNIQUE EFFECTS OF PREDICTORS OF SEXUAL PROBLEMS IN MALES

TABLE 12………………………………………………………………………… 31 PFSF AND MASQ, UNIQUE EFFECTS OF PREDICTORS OF SEXUAL PROBLEMS IN MALES

TABLE 13………………………………………………………………………… 32 FSFI AND MASQ, UNIQUE EFFECTS OF PREDICTORS OF SEXUAL PROBLEMS IN FEMALES

TABLE 14………………………………………………………………………… 33 PFSF AND MASQ, UNIQUE EFFECTS OF PREDICTORS OF SEXUAL PROBLEMS IN FEMALES

LIST OF FIGURES

FIGURE 1………………………………………………………………...... 39 PARTIAL MODEL OF MSFI MTMM CFA

INTRODUCTION

Affective and sexual problems are frequently comorbid. The associations among these problems appear complex and bidirectional; however, the influence of affective problems on sexual functioning has received the most attention in the literature. In fact, the relations between affective and sexual problems have become so well accepted that many of the most widely used measures of depression and anxiety include items assessing sexual problems. Furthermore, in their influential text on the treatment of sexual problems, Masters and Johnson (1970) highlighted the influence of anxiety on sexual difficulties. Similarly, Kaplan held that both depression and anxiety were often the causes of sexual problems (1987). Given the relation between psychological wellbeing and sexual functioning, researchers have examined how affect relates to sexual functioning.

Although a general association between affective and sexual problems is widely accepted, the relation appears complex. Affective problems are multidimensional, and various affective experiences may have differing effects on sexual functioning.

Likewise, human sexuality is complex and different aspects of interpersonal relationships and the sexual response cycle may be more vulnerable to disruption in the face of affective disturbance. Thus, rather than studying a single association between two

unifactorial variables, there are many potential associations between the multidimensional aspects of both affect and sexual functioning. The goal of the present study is to examine any potential specificity between anxiety and depression for various sexual problems.

Researchers have offered various accounts of what comprises the sexual response cycle, with much agreement between models. Sexual desire is commonly thought of as the first phase of human sexual response and is conceptualized as the psychological and physiological sensations that motivate a person to seek out or become receptive to sexual experiences (Kaplan, 1979). The next phase of sexual response is arousal, which comprises both psychological and physiological features. Psychologically, when a person feels sexually aroused, they experience subjective mental excitement and erotic feelings in anticipation of sexual activity (Kaplan, 1974). Physiologically, both men and women experience increased heart and respiration rates, as well as heightened blood pressure and vasocongestion of the skin (Masters & Johnson, 1970). In men, sexual arousal may result in erection of the penis, whereas females may experience vaginal lubrication. Following the arousal phase is the orgasm phase. During orgasm, the lower pelvic muscles contract and sexual tension is released, often resulting in sensations of euphoria. In men, orgasm results in ejaculation. Following the orgasm phase is the resolution phase (Masters & Johnson, 1970), during which the body returns to its pre- arousal state, thus concluding the sexual response cycle.

Researchers have also examined other aspects of human sexuality outside the sexual response cycle. One general aspect of human sexuality is sexual self-image,

which refers to how people feel about their sexuality. For instance, people with high sexual self-images feel desirable and sensual. However, people with low sexual self- images do not hold themselves or their abilities in high regard and are likely to harbor many sexual concerns, which may deal with frustration or distress toward one’s sexuality or sex-life. Related to sexual self-image and sexual concerns is sexual satisfaction, which refers to a person’s satisfaction toward their sex-life. Depending on how sexual satisfaction is operationally defined, the term can reflect a person’s satisfaction with the quantity and quality of sexual activity experienced or can take a more relational emphasis, such as reflecting satisfaction with intimacy experienced. Another more general aspect relevant to sexuality is sexual pleasure, which refers to the degree to which one derives pleasure from sexual activity. Like sexual self-image and satisfaction, many factors may influence sexual pleasure, such as level of arousal, orgasm achievement, and intimacy. However, aspects of sexuality exist that are less general, but rather more specific to certain behaviors or feelings. One such behavior regarding sexuality is sexual avoidance, which describes behavior through which a person avoids sexual activity.

Influencing factors of sexual avoidance are many and range from holding conservative sexual attitudes to sexual performance anxiety. Another aspect of sexual functioning is sexual pain, described as pain during sexual activity, particularly intercourse. Sexual pain can be caused by a number of physiological (e.g., dyspareunia) or psychological

(e.g., vaginismus) conditions.

Problems with many of these aspects of human sexuality, from desire to pain, have been associated with affective problems (Laurent & Simons, 2009). The relation of

depression and sexual desire has received considerable attention, with studies revealing positive associations between depression and low levels of sexual desire (Angst, 1998;

Bancroft, Janssen, Strong, & Vukadinovic et al., 2003; Bancroft, Janssen, Strong, Carnes et al., 2003; Casper et al., 1985; Frohlic & Meston, 2002; Howell et al., 1987; Kennedy,

Dickens, Eisfeld, & Bagby, 1999; Lykins, Janssen, & Graham, 2006; Schreiner-Engel &

Schiavi, 1986). However, associations of depression and sexual functioning have not been limited to desire. Other research has shown depression to be related to other aspects of sexual functioning, including arousal problems (Barlow, 1986; Frohlich & Meston,

2002; Kennedy et al., 1999; Nicolosi, Moreira, Villa, & Glasser, 2004; Shabsigh et al.,

1998), orgasm difficulties (Johnson, Phelps, & Cottler, 2004; Kennedy et al., 1999;

Laumann, Paik, & Rosen, 1999), sexual pain (Johnson, Phelps, & Cottler, 2004;

Laumann, Paik, & Rosen, 1999) and low levels of satisfaction (Frohlich & Meston, 2002;

Nicolosi et al., 2004).

Anxiety has been similarly linked to low levels of desire (Figueira, Possidente,

Marques, & Hayes, 2001; Johnson, Phelps, & Cottler, 2004; Katz & Jardine, 1999), arousal problems (Bradford & Meston, 2006; Johnson, Phelps, & Cottler, 2004), orgasm difficulties (Aksaray, Yelken, Kaptanoglu, Oflu, & Ozaltin, 2001; Corretti, Pierucci, De

Scisciolo, & Nisita, 2006; Johnson, Phelps, & Cottler, 2004), sexual pain (Johnson,

Phelps, & Cottler, 2004), and low levels of satisfaction (Aksaray et al., 2001). Though studies have consistently revealed associations between affective and sexual problems, examination of the body of research fails to reveal specificity of associations between depression and anxiety with various sexual problems.

In their recent and extensive review of sexual dysfunction, Laurent and Simons

(2009) conclude that depression may be associated with all phases of sexual responding, excluding the resolution phase. Additionally, the authors report that the relation between anxiety and sexual dysfunction, though present and harmful, is not as clear. They elaborate that different anxiety disorders (e.g., generalized anxiety, social phobia, obsessive-compulsive disorder, etc.) may be associated with different sexual problems.

However, they offer that low correlations between psychological and physiological measures of sexual arousal may play a role in the inconsistency of findings, which highlights the mistake of collapsing the psychological and physiological aspects of arousal into a unitary structure. Collectively, the literature shows that affective and sexual problems are related and, further, that depression and anxiety are similarly related with sexual problems. However, methodological aspects of past studies may have hindered the ability to detect potential specificity of associations between affective and sexual problems.

One possible explanation for the lack of potential specificity may regard how depressive and anxiety symptoms are typically measured in studies. Studies that have examined associations between affective and sexual problems routinely use measures of depression and anxiety that are highly correlated with one another (Maier, Buller,

Philipp, & Heuser, 1988; Maier et al., 1988). The high correlations are likely due to both a) high comorbidity between depression and anxiety, as well as b) cross-contamination of symptom items (i.e., anxiety items on depression inventories and vice versa). As the correlations between measures of depression and anxiety symptoms are high, associations

among affective and sexual problems in research may be artificially inflated. For instance, if a negative correlation is found between a depression measure and a measure of sexual desire, we cannot be sure that the relation is due to depression’s association with sexual desire, anxiety’s association with sexual desire, or due to both depression and anxiety being related to sexual desire, as the depression measure is highly correlated with symptoms of anxiety. Given the high correlations between measures of depression and anxiety, as well as high comorbidity rates between the two disorders, researchers have offered models detailing and explaining how the constructs relate.

Clark and Watson (1991) proposed a conceptualization of depression and anxiety such that they were related, but different, constructs. In this model, the features and characteristics of depression and anxiety are organized in a hierarchy of symptoms.

Specifically, the model portrays depression and anxiety as having shared symptoms they described as general distress. General distress symptoms may be slightly more characteristic of depression (e.g., sad mood) or anxiety (e.g., fearful mood), but nevertheless commonly occur in both affective problems; thus they are considered shared features (Clark & Watson, 1991; Watson et al., 1995a; Watson et al., 1995b). Further,

Clark, Watson, and colleagues provided evidence that though depression and anxiety share many features, both affective problems have their own unique aspects that distinguish the two from one another. They proposed that anhedonia and physiological anxious arousal differentiated the two affective disturbances. Anhedonia consists of two basic characteristics—buffered positive affect and loss of interest in activities once considered enjoyable—and is unique to depression. Physiological arousal, on the other

hand, is unique to anxiety and is said to consist of somatic complaints regarding physiological hyperarousal. Clark and Watson’s (1991) tripartite model conceptualization allowed for further understanding of how depression and anxiety are related, yet not identical, constructs, the implications of which allow for researchers to examine how the two affective disturbances may similarly and variously be related to different outcomes. Reflecting upon the shared symptoms of depression and anxiety, past research has been at a marked disadvantage to delineate any potential specificity among affective and sexual problems. That is, whether the similar relations of depression and anxiety with sexual problems reflect actual associations or an inability to differentiate remains unclear.

Another possible explanation for the lack of potential specificity among affective and sexual problems may pertain to iatrogenic effects of antidepressants that may result in sexual problems (Ferguson, 2001). Disturbances in sexual functioning have been tied to serotonin-norepinehephrine reuptake inhibitors and reversible inhibitors of monoamine oxidase A (Kennedy, Eisfeld, Dickens, Bacchiochi, & Bagby, 2000), as well as selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants (Ferguson, 2001). The aforesaid antidepressants have been linked with decreased sexual desire and arousal, performance and orgasm difficulties, and low levels of sexual satisfaction and pleasure. As the associations between antidepressants and sexual problems are well established, parceling out iatrogenic effects when examining the relation of depressive symptoms to sexual problems is important. However, the concern of antidepressant-induced sexual problems is not limited to people who suffer from

depression. As antidepressants are often used to treat anxiety (Feighner, 1999), the concern of iatrogenic effects in studies examining anxiety and sexual problems must be heeded. Given these considerations, many researchers exclude participants taking antidepressants from either participating or from being included in analyses when examining the associations of affective and sexual problems (e.g., Frohlich & Meston,

2002; Kennedy et al., 1999).

As research on sexual problems often utilizes samples of older adults, considerations relating to the investigation of sexual functioning in a sample of young adults are addressed. Lauman, Paik, and Rosen (1999) showed that sexual problems often increase with age. As age-related factors—such as heart disease, diabetes, and menopause—have been associated with sexual problems (Avis, Stellato, Crawford,

Johannes, & Longcope, 2000; Lewis et al., 2004), studies must take precaution to control for these potential confounds. Therefore, by recruiting a sample of young, healthy adults, the likelihood of the aforesaid factors confounding the results of our study will be minimal.

Another consideration when examining sexual problems using a sample of young adults pertains to item sensitivity. Because measures of sexual functioning are typically normed in heterogeneous samples of sexually functional and dysfunctional adults of various ages (e.g., McHorney et al., 2004; Rosen et al., 2000), investigation into whether or not items on measures of sexual functioning inventories are sensitive enough to detect sexual problems in populations with more robust sexual functioning (i.e., young, healthy adults) is warranted.

A third concern in sexual functioning research is the possibility that the structure of sexual functioning may change with age. Though sexual functioning measures are often validated using heterogeneous samples consisting of young, middle-aged, and older adults, the structure of sexual functioning should not be assumed to be the same throughout the lifespan. For instance, the relation between sexual desire and arousal may be unitary in early life, but two separate, related constructs in later life. Additionally, many sexual functioning measures are validated in female samples (e.g., McHorney et al., 2004; Rosen et al., 2000) and, as aspects of sexual functioning in males and females can be biologically and experientially different, the structure of sexual functioning should not be assumed to be identical between the sexes. As such, the validity for using existing sexual functioning measures in males must be examined. Having measures that are able to validly measure sexual functioning in both males and females allows for comparison of sexual problems between the sexes.

The present study explores the potential specificity between depression and anxiety with sexual problems. However, we must first examine the utility of commonly used measures of sexual functioning in our young, healthy, antidepressant-free sample of males and females. Specifically, we will investigate the factorial structure, reliability, and validity of the Female Sexual Function Index (Rosen et al., 2000) and the Profile of

Female Sexual Function (McHorney et al., 2004). Results from these analyses will allow us to compare the structure of the sexual functioning measures between the two sexes, as well as ensure that sexual problems are measured validly and reliably for both genders.

Second, using Clark and Watson’s (1991) tripartite model of depression and anxiety, we

will then examine the potential specificity of affective and sexual problems. Though we predict that affective and sexual problems will be related, our analyses are largely exploratory and we do not have detailed predictions regarding the potential specificity of associations that depression and anxiety may have with sexual problems.

METHOD

Participants

The sample consisted of 1258 undergraduate students (748 females) enrolled in introductory psychology at a large Midwestern university who completed questionnaires in exchange for course credit. Of these 1258 students, 731 participants (409 females) had been sexually active within 30 days prior to participating. The participants’ average family income was between $60,000 and $79,999, indicating a generally high standard of living. The sample’s ethnic breakdown was predominantly Caucasian (84.8%), however, some diversity was evident (6.7% African-American, 2.2% Latino or Hispanic, 2.1%

Eastern Asian or Pacific Islander, .6% Middle Eastern or Western Asian, .2% Native

American and 3.3% who did not indicate a specific ethnicity). Participant ages ranged from 18 years to 29 (M = 19.56, SD = 1.91). The sample largely reported being exclusively heterosexual (87.3%), though some participants reported some degree of bisexuality (10.7%), exclusive homosexuality (1.7%), or did not report their sexual orientations (.2%).

Procedure

Participants were recruited through an online research study pool offered to students at a large, Midwestern university and were provided the option of either completing the study questionnaires from their homes or in the laboratory; participants were compensated for their time with research credit toward their psychology classes.

Participants who completed the questionnaires from home were provided with an online link to the study surveys, whereas participants who completed questionnaires in the laboratory were randomly assigned to complete the questionnaires on a computer or using a paper and pencil survey format; all in-lab participants completed their questionnaires in a private, quiet room.

Measures

The Female Sexual Function Index (FSFI; Rosen et al., 2002) is a 19-item self- report measure of sexual functioning. The FSFI was originally validated in a sample of females with female sexual arousal disorder and matched controls for the assessment of various sexual problems. The FSFI measures sexual desire, psychological arousal, lubrication, pain, satisfaction, and orgasm achievement. Internal consistencies for the

FSFI individual factors were all high.

The Male Sexual Function Index (MSFI) is a 16-item self-report measure of sexual functioning that was created for this study by adapting the FSFI. Specifically, items assessing lubrication items (e.g., how often did you become lubricated "wet" during sexual activity or intercourse?) were replaced with items assessing erection difficulties

(e.g., how often were you able to produce an erection during sexual activity or intercourse?). Additionally, the pain scale of the FSFI was omitted for the MSFI.

However, the desire, psychological arousal, satisfaction, and orgasm achievement scales remained unchanged. Internal consistencies for the MSFI ranged from adequate to high.

The Profile of Female Sexual Functioning (PFSF; McHorney et al., 2004) is a 37- item self-report measure of sexual functioning. The PFSF was originally validated in a sample of postmenopausal females for the assessment of various sexual problems, including desire, psychological arousal, orgasm achievement, pleasure, responsiveness, concerns, and self-image. Because the PFSF does not contain gender-specific items, the measure was unaltered for administration to male participants. Internal consistencies for the PFSF were high for both males and females.

The Mood and Anxiety Symptom Questionnaire – Short Form (MASQ; Clark &

Watson, 1991) is a 62-item self-report measure of depression and anxiety. Individuals report their experience of various symptoms on a five-point scale from ―not at all‖ to

―extremely.‖ There are three main factors assessing the facets of the tripartite model: general distress (e.g., ―felt uneasy‖, ―felt discouraged‖), anxious arousal (―was short of breath‖, ―hands were shaky‖), and anhedonia (e.g., ―felt nothing was really enjoyable‖).

Internal consistencies for the general distress (=.93), anxious arousal (=.88), and anhedonia (=.92) scales were high in the present study.

Data analysis plan

Given sex differences regarding sexual functioning and problems, all analyses will be conducted separately for males and females. The first goal of the present study is to examine the utility of using the FSFI, MSFI, and PFSF in a sample of young, healthy adults. To accomplish this goal, we will examine the structure, reliability, and validity of said measures in the sample. To examine the structure of the measures, confirmatory

factor analysis will be used. Next, we will use Cronbach’s alpha to investigate the internal consistency of the scales of each measure. Lastly, we will employ correlations to examine concurrent validity among shared scales between the measures.

The second goal of the present study is to explore the associations of affective and sexual problems, and to examine any potential specificity. To accomplish this goal, we will first employ bivariate correlations to examine associations between affective and sexual problems. Then, we will re-examine the data using multiple regression, which will allow us to examine the unique effects of the predictors (i.e., general distress, anxious arousal, and anhedonia) in an attempt to reveal greater specificity and patterning of associations.

RESULTS

Factor structure

MSFI in males. We tested the five-factor structural model of the MSFI with all latent variable variances set to 1.01 and, based on Hu and Bentler’s (1999) recommendations, found poor model fit based on the chi-square [2(94)=440.82, p<.001] and additional fit indices (Comparative Fit Index, or CFI=.868, Tucker-Lewis Index, or

TLI=.809, Root Mean Squared Error of Approximation, or RMSEA=.086). To enhance model fit, we then decided to employ a multi-trait multi-method (MTMM) CFA (Kline,

2011) to model method variance due to item-valence. The MTMM approach allowed us to account for item covariance with both the constructs they tap as well as the valence in which they were worded. To create our MTMM CFA model, we created two exogenous latent variables: 1) Positive and 2) Negative. All positively-valenced items were loaded onto the Positive latent variable, whereas all negatively-valenced items were loaded onto the Negative latent variable; this was in addition to the already established loadings of the items onto their corresponding sexual functioning factors (see Figure 1 for a partial model). We then tested this MTMM CFA model, which produced good model fit

[2(78)=229.51, p<.001] (CFI=.942, TLI=.899, RMSEA=.062). Additionally, analyses showed that the MTMM CFA was a significant improvement over the initial model

1 All trait and method latent variables’ variances in all CFAs were set to 1.0. 15

Figure 1. Partial model of MSFI MTMM CFA.

Note. Error terms not shown in model.

Table 1. MSFI MTMM CFA factor loadings, standardized regression weights.

Item Number Factor Estimate 1 Desire .68 2 Desire .80 3 Arousal .49 4 Arousal .56 5 Arousal .62 6 Arousal .68 7 Erection .47 8* Erection .51 9 Erection .76 10* Erection .76 11 Orgasm .65 12 Orgasm .51 13* Orgasm .73 14 Satisfaction .78 15 Satisfaction .90 16 Satisfaction .81

Note.* = Negatively-valenced item

[2(16)=211.31, p<.001]. All items significantly loaded on their respective factors

(Table 1).

PFSF in males. We tested the seven-factor structural model of the PFSF and found poor model fit as indicated by the chi-square [2(608)=3495.86, p<.001] and additional fit indices (CFI=.834, TLI=.809, RMSEA=.097). Next, we tested a MTMM

CFA model, which produced good model fit. However, the responsiveness factor did not conform to a priori hypotheses. Upon examination, we found that the first two items produced high loadings (.709 and .599), whereas the latter five item loadings ranged from

.049 to .237. These data suggested that the first two items of the responsiveness scale were not measuring the same construct as the latter five items. Inspection of the scale items showed that the latter five items appeared to measure sexual avoidance (e.g., ―I avoided having sex.‖), whereas the first item appeared to measure sexual initiation (―I initiated sex.‖) and the second item measured responsiveness (―I welcomed the chance to have sex.‖). As the data suggested that the responsiveness scale was measuring more than one construct, we decided to remove the first two items of the scale, thus revising the responsiveness factor into an avoidance factor. After rerunning the MTMM CFA, our model yielded good fit [2(573)=2255.29, p<.001] (CFI=.904, TLI=.882,

RMSEA=.077). Additionally, analyses showed that the MTMM CFA was a significant improvement over the initial model [2(35)=1007.33, p<.001]. All item loadings were significant (Table 2).

FSFI in females. We tested the six-factor structural model of the FSFI and found adequate to good model fit based on the chi-square [2(137)=683.28, p<.001] and additional fit indices (CFI=.916, TLI=.884, RMSEA=.073). We then tested this MTMM

CFA model, which yielded very good fit [2(118)=303.01, p<.001] (CFI=.970, TLI=.952,

RMSEA=.047) and showed to be a significant improvement over the initial model

[2(19)=380.27, p<.001]. Item loadings on each factor were significant (Table 3).

PFSF in females. We tested the seven-factor structural model of the PFSF and found poor model fit as indicated by the chi-square [2(608)=4540.59, p<.001] and additional fit indices (CFI=.864, TLI=.843, RMSEA=.095). We then tested this MTMM

CFA model, which produced good model fit. However, the responsiveness factor once

Table 2. Males PFSF MTMM CFA factor loadings, standardized regression weights.

Item Factor Estimate 1 Desire .70 2 Desire .76 3 Desire .78 4 Desire .67 5* Desire .18 6 Desire .61 7* Desire .25 8 Desire .35 9 Desire .47 10* Arousal .61 11* Arousal .74 12* Arousal .67 13 Orgasm .28 14* Orgasm .68 15* Orgasm .84 16* Orgasm .64 17 Pleasure .58 18 Pleasure .61 19 Pleasure .55 20 Pleasure .65 21 Pleasure .51 22 Pleasure .64 23 Pleasure .66 24* Concerns .74 25* Concerns .55 26* Concerns .74 27* Responsiveness .68 28* Responsiveness .64 29* Responsiveness .47 30* Responsiveness .41 31* Responsiveness .41 32 Self-Image .75 33 Self-Image .74 34 Self-Image .61 35 Self-Image .44

Note.* = Negatively-valenced item

Table 3. FSFI MTMM CFA factor loadings, standardized regression weights.

Item Factor Estimate 1 Desire .78 2 Desire .86 3 Arousal .57 4 Arousal .59 5 Arousal .65 6 Arousal .63 7 Lubrication .65 8* Lubrication .76 9 Lubrication .67 10* Lubrication .77 11 Orgasm .79 12 Orgasm .85 13* Orgasm .83 14 Satisfaction .75 15 Satisfaction .91 16 Satisfaction .83 17 Pain .79 18 Pain .80 19 Pain .81

Note.* = Negatively-valenced item

again did not conform to a priori hypotheses. Specifically, the first two items had factor loadings of .567 and .630, whereas the last five items produced factor loadings that ranged from .023 to .185; this very phenomenon occurred in the male sample as well. As the data suggested that the responsiveness scale was measuring more than one construct, we decided to remove the first two items of the scale, thus once again modifying the responsiveness latent variable into an avoidance latent variable. After this modification, we reran the MTMM CFA and our model produced good model fit [2(573)=2488.53, p<.001] (CFI=.934, TLI=.919, RMSEA=.068) and was a significant improvement over

Table 4. Females PFSF MTMM CFA, factor loadings, standardized regression weights.

Item Factor Estimate 1 Desire .68 2 Desire .72 3 Desire .70 4 Desire .66 5* Desire .30 6 Desire .54 7* Desire .29 8 Desire .49 9 Desire .52 10* Arousal .65 11* Arousal .77 12* Arousal .71 13 Orgasm .41 14* Orgasm .83 15* Orgasm .95 16* Orgasm .80 17 Pleasure .51 18 Pleasure .55 19 Pleasure .53 20 Pleasure .58 21 Pleasure .53 22 Pleasure .57 23 Pleasure .60 24* Concerns .77 25* Concerns .71 26* Concerns .87 27* Avoidance .66 28* Avoidance .68 29* Avoidance .54 30* Avoidance .73 31* Avoidance .72 32 Self-Image .71 33 Self-Image .80 34 Self-Image .77 35* Self-Image .39

Note.* = Negatively-valenced item

the initial model [2(35)=2052.06, p<.001]. All item loadings were significant (Table

4).

Reliability

Internal consistency was examined for each measure to evaluate inter-item correlations within each measure’s scales. The MSFI yielded internal consistencies ranging from adequate (orgasm; =.66) to high (desire; =.85) (see Table 5). The PFSF for the male sample produced adequate (orgasm; =.71) to very high (pleasure; =.97) internal consistency (see Table 5). The FSFI produced high internal consistencies in each of its subscales (see Table 6), with Cronbach’s alphas ranging from .81 (lubrication) to

.89 (desire). Similarly, the internal consistencies in the PFSF for the female sample ranged from high (orgasm; =.84) to very high (pleasure; =.99) (see Table 6).

Validity

To examine concurrent validity, we correlated shared scales between the two measures while correcting for attenuation due to measurement error. For males, the MSFI and PFSF desire (r=.787, p<.01; disattenuated2 r=.901) and orgasm (r=.610, p<.01; disattenuated r=.891) scales showed high concurrent validity, whereas the arousal scales were only moderately correlated (r=411, p<.01; disattenuated r=.471). Similarly, the FSFI

2 Examination of concurrent validity necessitates correction for attenuation in the correlation that is due to measurement error. The disattenuation formula is: rxy/[(rxx*ryy)] where rxy represents the correlation between x and y, and rxx and ryy represent the internal consistencies of x and y, respectively.

Table 5. Male MSFI and PFSF internal consistencies and factor correlations.

Factor  MSFI MSFI – MSFI – MSFI – MSFI – PFSF PFSF – PFSF – PFSF – PFSF – PFSF – – Arousal Erection Orgasm Satisfaction – Arousal Orgasm Pleasure Concerns Avoidance Desire Desire MSFI – .85 Desire MSFI – .82 .46** Arousal MSFI – .76 .10 .53** Erection MSFI – .66 .15** .49** .52** Orgasm MSFI – .82 .12** .49** .30** .36** Satisfaction PFSF – .90 .79** .46** .19** .16** .08 Desire PFSF – .93 .16** .41** .61** .46** .201** .18** Arousal PFSF – .71 .10* .41** .41** .61** .15** .10* .55** Orgasm PFSF – .97 .40** .53** .29** .39** .34** .47** .14** .16** Pleasure PFSF – .89 .02 -.40** .29** -.34** -.45** -.04 -.43** -.25** -.34** Concerns PFSF – .91 -.11* -.28** -.46** -.42** -.21** -.16** -.56** -.48** -.03 .37** Avoidance PFSF – .86 .25** .46** .34** .21** .44** .35** .21** .14** .57** -.51** -.14** Self-image

Note. * Correlation is significant at the 0.05 level. ** Correlation is significant at the 0.01 level. MSFI = Male Sexual Function Index. PFSF = Profile of Female Sexual Functioning.

Table 6. Female FSFI and PFSF internal consistencies and factor correlations.

Factor FSFI – FSFI – FSFI - FSFI – FSFI – FSFI – PFSF – PFSF – PFSF – PFSF – PFSF – PFSF – Desire Arousal Lubrication Orgasm Satisfaction Pain Desire Arousal Orgasm Pleasure Concerns Avoidance FSFI – Desire FSFI – .61** Arousal FSFI – .33** .55** Lubrication FSFI – .20** .46** .34** Orgasm FSFI – .19** .50** .36** .40** Satisfaction FSFI – .12* .24** .48** .17** .19** Pain PFSF – .81** .60** .34** .20** .19** .15** Desire PFSF – .27** .48** .52** .27** .36** .40** .33** Arousal PFSF – .14* .36** .32** .82** .36** .18** .16** .40** Orgasm PFSF – .56** .70** .48** .47** .46** .26** .63** .29** .16** Pleasure PFSF – -.05 -.37** -.40** -.33** -.61** -.36** -.06 -.45** -.25** -.23** Concerns PFSF – -.19** -.41** -.53** -.24** -.39** -.51** -.24** -.45** -.48** -.21** .43** Avoidance PFSF – .40** .50** .36** .30** .49** .22** .47** .36** .14** .58** -.43** -.29** Self-image

Note. * = Correlation is significant at the 0.05 level;** = Correlation is significant at the 0.01 level; FSFI = Female Sexual Function Index. PFSF = Profile of Female Sexual Functioning.

and PFSF desire (r=.807, p<.01; disattenuated r=.880) and orgasm (r=.821, p<.01; disattenuated r=.958) scales showed high concurrently validity, whereas the arousal scales were only moderately correlated (r=.478, p<.01; disattenuated r=.532) for females.

Upon inspection of the arousal scale items, one explanation for the moderate correlations may be due to the MSFI and FSFI arousal items ask of one’s frequency of, level of, confidence in, and satisfaction toward their arousability, whereas the PFSF items ask about one’s difficulties experienced with their arousability. In other words, though both the MSFI/FSFI and PFSF measure the sexual arousal construct, the scales may tap slightly different aspects of, attitudes toward, or experiences with arousal. To view all correlations between the MSFI and PFSF, as well as the FSI and PFSF, see Tables 5 and

6, respectively.

Depression, Anxiety, and Sexual Problems

Given the large number of analyses that were run, we decided our statistical significance cutoff would be p=.01, whereas we would report findings that were .01> p

<.05 as trends. All p-values above .05 were deemed nonsignificant and not trends. This shifting of significance values to more conservative cutoffs were made in attempt to decrease the rates of Type I errors in our analyses, the presence of which increases as a function of the number of analyses run.

Bivariate correlation analyses. To explore the possibility of decreased item sensitivity in the sexual functioning measures among participants who were not in sexual

relationships, analyses exploring the associations of affective and sexual problems were conducted first for the entire sample, then again only including participants who had reported having been in a sexual relationship within 30 days of participating in our study.

If the sexual functioning measures’ items are not sensitive enough to detect sexual problems in people who are not in sexual relationships, then strengths in correlations between affective and sexual problems would be stronger among participants with sexual partners. Analyses for the entire sample and the subset revealed markedly similar findings suggesting that item sensitivity was not an issue, thus only results for the entire sample are reported.

MSFI in males. Analyses showed that general distress, anxious arousal, and anhedonia were associated with most measured sexual problems (see Table 7).

Specifically, general distress and anhedonia were related to lower psychological arousal, more erection and orgasm difficulties, as well as lower satisfaction. Anxious arousal significantly correlated with erection and orgasm difficulties, as well as lower satisfaction. However, affective problems were not associated with sexual desire.

Regarding specificity between depression and anxiety, anhedonia was particularly related to psychological arousal and satisfaction, whereas anxious arousal was particularly related to erection difficulties.

PFSF in males. Analyses showed that general distress, anxious arousal, and anhedonia were associated with most measured sexual problems (see Table 8).

Specifically, all three affective problems were associated with lower levels of subjective arousal and sexual self-image, as well as higher levels of orgasm difficulties, sexual

Table 7. MSFI and MASQ correlations among males.

Factor MSFI – MSFI – MSFI – MSFI – MSFI – Desire Arousal Erection Orgasm Satisfaction

MASQ - General .04 -.16** -.31** -.16** -.26** Distress MASQ - Anxious .08 -.09 -.32** -.19** -.20** Arousal

MASQ - Anhedonia -.04 -.29** -.23** -.19** -.29**

Note. * = Correlation is significant at the 0.05 level; ** = Correlation is significant at the 0.01 level; MSFI = Males Sexual Function Index; MASQ = Mood and Anxiety Symptom Questionnaire

Table 8. PFSF and MASQ correlations among males.

Factor PFSF – PFSF – PFSF – PFSF – PFSF – PFSF – PFSF – Desire Arousal Orgasm Pleasure Concerns Avoidance Self-Image

MASQ – -.005 -.234** -.159** -.136** .161** .324** -.290** General Distress MASQ – .037 -.276** -.243** -.033 .236** .270** -.152** Anxious Arousal MASQ - -.098* -.181** -.126** -.205** .133** .254** -.398** Anhedonia Note.* = Correlation is significant at the 0.05 level; ** = Correlation is significant at the 0.01 level; MSFI = Male Sexual Function Index; MASQ = Mood and Anxiety Symptom Questionnaire.

avoidance, and sexual concerns. Further, general distress and anhedonia were related to lower levels of sexual pleasure, whereas anxious arousal was not. Unlike the findings of the MSFI analyses, higher levels of anhedonia were correlated with lower levels of sexual desire; neither general distress nor anxious arousal was related to sexual desire.

Table 9. FSFI and MASQ correlations among all females.

Factor FSFI – FSFI – FSFI – FSFI – FSFI – FSFI – Desire Arousal Lubrication Orgasm Satisfaction Pain

MASQ- .07 -.13** -.20** -.12** -.31** .19** General Distress MASQ - .07 -.11* -.22** -.06 -.15** .30** Anxious Arousal MASQ - -.06 -.28** -.21** -.21** -.37** .17** Anhedonia

Note. * = Correlation is significant at the 0.05 level; ** = Correlation is significant at the 0.01 level; FSFI = Female Sexual Function Index; MASQ = Mood and Anxiety Symptom Questionnaire.

Table 10. PFSF and MASQ correlations among all females.

Factor PFSF – PFSF – PFSF – PFSF – PFSF – PFSF – PFSF – Desire Arousal Orgasm Pleasure Concerns Avoidance Self-Image

MASQ - .05 -.17** -.15** -.05 .30** .23** -.27** General Distress MASQ - .04 -.15** -.15** -.02 .20** .22** -.14* Anxious Arousal MASQ - -.11** -.23** -.19** -.17** .36** .26** -.39** Anhedonia

Note. * = Correlation is significant at the 0.05 level; ** = Correlation is significant at the 0.01 level; PFSF = Profile of Female Sexual Functioning; MASQ = Mood and Anxiety Symptom Questionnaire

Regarding specificity, anhedonia was especially related to desire, pleasure, and self- image. However, anxious arousal was particularly related to psychological arousal, orgasm difficulties, and concerns.

FSFI in all females. Analyses showed that general distress, anxious arousal, and anhedonia were associated with most measured sexual problems (see Table 9).

Specifically, general distress and anhedonia were associated with lower levels of psychological sexual arousal and sexual satisfaction, as well as higher levels of sexual pain and lubrication and orgasm difficulties. Anxious arousal was correlated with lower levels of psychological sexual arousal and sexual satisfaction, as well as higher levels of sexual pain and lubrication difficulties. However, affective problems were not associated with sexual desire. Regarding specificity between depression and anxiety, anhedonia was particularly related to lower levels of psychological arousal and satisfaction as compared to anxious arousal. However, anxious arousal, when compared to anhedonia, was especially associated with sexual pain.

PFSF in all females. Analyses showed that general distress, anxious arousal, and anhedonia were associated with most measured sexual problems (see Table 10).

Specifically, all three affective problems were associated with lower levels of subjective arousal and sexual self-image, as well as higher levels of orgasm difficulties, sexual avoidance, and sexual concerns. Further, anhedonia was related to lower levels of both sexual desire and pleasure, whereas general distress and anxious arousal were not.

Regarding specificity between depression and anxiety, anhedonia more strongly related to psychological arousal, pleasure, concerns, and self-image.

Multiple regression analyses. Though bivariate correlations were important to employ given the exploratory nature of these analyses, we then examined the data using multiple regression. By doing so, we were able to examine the unique effects of the

predictors (i.e., general distress, anxious arousal, and anhedonia) in an attempt to reveal greater specificity and patterning of associations. Similarly as with the bivariate correlation analyses, we conducted multiple regression analyses for the entire sample then again using only the participants who had been in sexual relationships within 30 days of participating. Once again, the analyses between the entire sample and the subset were markedly similar. As such, only the results of the entire sample are reported.

MSFI in males. Excluding the model predicting levels of sexual desire, all regression models showed significance (Table 11). Generally, findings show that anxious arousal and anhedonia are strongly associated with sexual problems and that their influences vary across sexual problems. With general distress, anxious arousal, and anhedonia in the multiple regression model, general distress was a nonsignificant predictor of all measures of sexual functioning on the MSFI. However, anxious arousal was exclusively and significantly associated with higher levels of erection difficulties.

Further, anhedonia was exclusively and significantly associated with lower levels of arousal and satisfaction. Both anxious arousal and anhedonia were related with orgasm difficulties.

PFSF in males. Excluding the model predicting levels of sexual desire, all regression models showed significance (Table 12). Once again, anxious arousal and anhedonia are more strongly related to sexual problems than general distress, though some specificity was revealed. With all three predictors in the model, general distress was exclusively and significantly associated with sexual concerns. Anxious arousal was exclusively and significantly associated with orgasm difficulties and higher levels of

Table 11. MSFI and MASQ, unique effects of predictors of sexual problems in males.

Outcome Variable Model Significance MASQ – MASQ – MASQ – and Effect Size General Anxious Anhedonia β Distress β Arousal β MSFI - Desire F=1.66, p=.18, .03, p=.74 .08, p=.21 -.08, p=.16 R2=.01 MSFI - Arousal F=11.96, p<.001, .01, p=.88 -.02, p=.82 -.30, p<.001 R2=.09 MSFI - Erection F=17.56, p<.001, -.07, p=.39 -.23, p<.001 -.12, p=.055 R2=.12 MSFI - Orgasm F=7.33, p<.001, .09, p=.33 -.20, p<.01 -.17, p<.01 R2=.06 MSFI - Satisfaction F=11.74, p<.001, -.09, p=.30 -.06, p=.47 -.21, p<.001 R2=.10 Note. MSFI = Male Sexual Function Index. MASQ = Mood and Anxiety Symptom Questionnaire.

Table 12. PFSF and MASQ, unique effects of predictors of sexual problems in males.

Outcome Variable Model Significance MASQ – MASQ – MASQ – General Anxious Anhedonia β Distress β Arousal β PFSF - Desire F=2.38, p=.07, .03, p=.74 .06, p=.38 -.13, p=.02 R2=.02 PFSF - Arousal F=15.14, p<.001, -.01, p=.93 -.24, p<.001 -.11, p=.05 R2=.09 PFSF – Orgasm F=11.12, p<.001, .09, p=.22 -.28, p<.001 -.09, p=.09 R2=.07 PFSF – Pleasure F=7.97, p<.001, -.11, p=.12 .10, p=.12 -.17, p<.001 R2=.05 PFSF – Concerns F=21.45, p<.001, .19, p<.01 .10, p=.10 .12, p=.02 R2=.12 PFSF – Avoidance F=10.55, p<.001, -.08, p=.28 .26, p<.001 .10, p=.07 R2=.06 PFSF – Self-Image F=31.87, p<.001, -.14, p=.04 .05, p=.41 -.34, p<.001 R2=.17 Note. PSFF = Profile of Female Sexual Functioning. MASQ = Mood and Anxiety Symptom Questionnaire.

Table 13. FSFI and MASQ, unique effects of predictors of sexual problems in females.

Outcome Variable Model MASQ – MASQ – MASQ – Significance General Distress Anxious Arousal Anhedonia β β β FSFI - Desire F=5.40, p<.001, .15, p=.01 .04, p=.47 -.17, p<.001

R2=.02

FSFI - Arousal F=15.90, .11, p=.11 -.05, p=.36 -.32, p<.001

p<.001, R2=.08

FSFI - Lubrication F=12.51, .02, p=.80 -.16, p<.01 -.17, p<.01

p<.001, R2=.07

FSFI - Orgasm F=7.86, p<.001, -.01, p=.89 .03, p=.61 -.21, p<.001

R2=.044

FSFI - Satisfaction F=29.13, -.20, p<.01 .08, p=.14 -.28, p<.001

p<.001, R2=.15

FSFI - Pain F=14.15, .11, p=.16 -.32, p<.001 -.12, p=.05

p<.001, R2=.09

Note. FSFI = Female Sexual Function Index. MASQ = Mood and Anxiety Symptom Questionnaire.

sexual avoidance. Additionally, anxious arousal was significantly associated with lower sexual arousal, whereas the relation between anhedonia and lower sexual arousal showed to be a trend. Further, anhedonia was exclusively and significantly associated with lower levels of sexual pleasure, and trends between anhedonia and diminished sexual desire, as well as between anhedonia and sexual concerns were found.

Table 14. PFSF and MASQ, unique effects of predictors of sexual problems in females.

Outcome Variable Model MASQ – MASQ – MASQ – Significance General Distress Anxious Arousal β Anhedonia β β PFSF - Desire F=8.58, .19, p<.01 .02, p=.72 -.24, p<.001

p<.001, R2=.04

PFSF - Arousal F=13.39, .02, p=.74 -.08, p=.11 -.21, p<.001

p<.001, R2=.06

PFSF – Orgasm F=10.08, .02, p=.78 -.09, p=.09 -.17, p=.001

p<.001, R2=.04

PFSF – Pleasure F=7.64, .09, p=.16 .02, p=.75 -.23, p<.001

p<.001, R2=.03

PFSF – Concerns F=35.05, .12, p=.04 -.01, p=.90 .28, p<.001

p<.001, R2=.14

PFSF – Avoidance F=19.27, .03, p=.62 .11, p=.04 .20, p<.001

p<.001, R2=.08

PFSF – Self- F=40.79, -.09, p=.14 .07, p=.18 -.13, p<.001

Image p<.001, R2=.15

Note. PFSF = Profile of Female Sexual Functioning. MASQ = Mood and Anxiety Symptom Questionnaire.

FSFI in females. All regression models were significant (Table 13). Unlike among males, anhedonia clearly showed to be most strongly be associated with sexual problems among females. Specifically, anhedonia was exclusively and significantly associated with lower levels of sexual desire and arousal, as well as more orgasm difficulties. However, anxious arousal was exclusively and significantly associated with

higher levels of sexual pain. Both anxious arousal and anhedonia were significantly related to lubrication difficulties. Also, general distress and anhedonia were significantly related to lower levels of sexual satisfaction. Interestingly, general distress was related to higher levels of sexual desire.

PFSF in females. All regression models were significant (Table 14). Similar to the FSFI analyses, the PFSF analyses once again clearly showed anhedonia to be the most important emotional factor regarding sexual problems. Anhedonia was exclusively and significantly associated with lower levels of, arousal, and pleasure, worse sexual self- image, as well as more orgasm difficulties. Anhedonia and anxious arousal were both significantly associated with higher levels of sexual avoidance. The relation between sexual concerns and anhedonia was significant, whereas the relation between concerns and general distress was a trend. Similar to the FSFI findings, general distress was related to higher levels of desire.

DISCUSSION

The first goal of the present study was to examine two commonly used measures of sexual functioning in a sample of young, healthy adults. Findings supported the structures of the FSFI and MSFI, the latter of which was modified for this study.

However, the structure of the PFSF required modification. Specifically, we revised the

PFSF responsiveness scale by removing the first two items, thus creating a sexual avoidance scale; this modification resulted in a supported structure of the PFSF in both males and females. Reliability analyses revealed adequate to very high internal consistencies among the scales of the MSFI, FSFI, and PFSF. Finally, the MSFI/FSFI and PFSF had high concurrent validity for the desire and orgasm scales. However, concurrent validity was low for arousal scales. Upon item inspection, the MSFI/FSFI and

PFSF appear to tap slightly different aspects, attitudes, and experiences regarding arousal, which may explain the low concurrent validity between the measures.

After determining the utility of using the MSFI, FSFI, and PFSF in our sample of young, healthy males and females, we then examined the potential specificity among affective and sexual problems. Given the exploratory nature of the analyses, we first ran a series of bivariate correlations. Broadly speaking, these analyses revealed that general distress, anxious arousal, and anhedonia were related to most sexual problems for both genders. Though a small degree of specificity was observed, the patterning of findings was unclear.

Multiple regression was then employed to examine the unique effects of general distress, anxious arousal, and anhedonia with sexual problems. These analyses revealed clearer specificity and patterning, as well as notable gender differences. For both genders, analyses revealed that general distress was the least influential predictor of sexual problems. For males, general distress was related to more sexual concerns and to worse sexual self-image. For females, general distress was related to higher desire and less satisfaction, as well as to more concerns. The relation of general distress predicting higher levels of general distress may seem counter-intuitive, but is consistent with

Frohlich and Meston’s (2002) self-soothing hypothesis.

The most striking gender differences regarded anxious arousal and anhedonia.

Specifically among males, the problematic associations of anxious arousal and anhedonia with various sexual problems were mixed. For instance, anxious arousal most strongly associated with erection and orgasm difficulties, as well as higher levels of sexual avoidance. Though post-hoc, we offer that given the physiological basis of anxious arousal, its association with physiological-based sexual difficulties (i.e., erection and orgasm difficulties) makes intuitive sense. Also, as avoidance is a common behavior among people who suffer from anxiety, its association with anxious arousal stands to reason. However, anhedonia was most strongly associated with lower levels of desire, arousal, pleasure, and self-image, as well as more sexual concerns. Some of these findings are instinctive as people who are not motivated to seek pleasurable activities and do not experience positive affect are unlikely to desire sexual activity (commonly thought of as a pleasurable activity) or to experience high levels of arousal and excitement, nor to

experience pleasure. However, post-hoc explanations of the associations of anhedonia with self-image and concerns are less intuitive, especially given that self-image and concerns seem to be more conceptually related to aspects of general distress (e.g., low self-worth).

Unlike males whose data showed various differing associations among anxious arousal and anhedonia with sexual problems, analyses clearly revealed that anhedonia was most strongly related to sexual problems among women. Anhedonia was associated with every measured sexual problem among females, with its weakest relation to sexual pain, which was a trend. Anxious arousal, however, was associated with lubrication, pain, and avoidance. We offer that, once again, perhaps the physiological nature of anxious arousal explains its relation to physiological sexual problems in women (i.e., lubrication and pain). Interestingly, anxious arousal was not associated with female orgasm. However, again similar to males, anxious arousal was associated with sexual avoidance. Nevertheless, findings in our study show that anhedonia is more deleterious than anxious arousal for female sexual functioning as its associations were ubiquitous.

Though the findings of the present study have been at times explained using a perspective in which affective problems influence sexual problems, the relation between affective and sexual problems is bidirectional. Given our cross-sectional design, we are unable to determine directionality. However, we propose that of the three aspects of affect that we measured, sexual problems may most likely to influence general distress, rather than anxious arousal or anhedonia. That is, we believe that sexual problems are more likely to directly lead to subjective feelings of sadness and anxiety, rather than

directly to blunted positive affect, diminished appetitive drive, and physiological agitation. For instance, we found associations between anhedonia and diminished sexual arousal. Having low sexual arousal may be unlikely to lead to either a loss of interest in other activities or blunted positive affect. However, having low sexual arousal may lead to sad mood, low self-esteem, or feelings of anxiety.

In summary, anxiety and depression both disrupt sexual functioning in both sexes.

For males, anxiety and depression are associated with various sexual problems, without either affective problem appearing to be particularly more detrimental to overall sexual functioning. For females, depression appears more problematic for sexual functioning, though anxiety also showed some relations to sexual problems.

The findings of the present study need to be interpreted in the light of certain limitations. First, the study’s cross-sectional design does not allow for determination of directionality nor potential reciprocity. Given that the relation between affective and sexual problems is potentially bidirectional, this limitation is especially important.

Additionally, the effect sizes obtained in the present study are small. Though we had previously discussed the benefits of using a sample of young, healthy adults, we believe that the nature of our sample resulted in a conservative test of the associations among affective and sexual problems as young, healthy adults boast robust sexual functioning.

These associations may be noticeably stronger in samples more prone to sexual dysfunction and affective problems. Also, the MSFI and FSFI desire scales consist of only two items, which results in little variance. A small amount of variance in a variable may attenuate the strength of relations in analyses, which may explain why significant

relations of desire were less frequent among the MSFI and FSFI scales than the PFSF scale.

Our findings extend the line of research on affective and sexual problems by revealing hitherto shown specificity among affective and sexual problems. Past research has suggested minimal specificity between depression and anxiety as they were associated with various sexual problems. This problem may be due to previous studies using depression and anxiety measures that predominantly tap the construct of general distress and thus suffer from a lack of discriminant validity, whereas the MASQ allows for a more nuanced approach as it allows for the examination of unique aspects of the two affective problems. Utilizing the tripartite model of anxiety and depression offers the benefit of inspecting whether the similar relations of depression and anxiety with sexual problems reflect either a) an inability to differentiate between the syndromes (i.e., affective measures that tap the shared general distress symptoms) or b) true associations between depression and anxiety with sexual problems that are similar. However, to allow for constant specificity, analyses allowing for the examination of unique effects among predictors are highly recommended. Past research has suffered from these aforesaid methodological concerns and, based on the results of the present study, we highly recommend utilization of the tripartite model of anxiety and depression for the examination of affective and sexual problems.

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