C 2006) Archives of Sexual Behavior, Vol. 35, No. 2, April 2006, pp. 179–190 (
DOI: 10.1007/s10508-005-9014-2

The Effects of Increasing Neutral Distraction on Sexual Responding of Women With and Without Sexual Problems Elske Salemink, M.A.,1,3 and Jacques J. D. M. van Lankveld, Ph.D.2 Received June 21, 2004; revision received April 26, 2005; accepted July 16, 2005 Published online: 26 April 2006

This study examined the influence of distraction on genital and subjective sexual responses of women with (N = 20) and without (N = 21) sexual problems. Female-produced erotic film fragments were presented to induce sexual response and a vaginal photoplethysmograph was used to measure genital sexual responding. Subjective sexual arousal was assessed in real time using a rotating button and, retrospectively, with visual analogue scales. Distraction load was manipulated through different verbal instructions on how to deal with pairs of digits. The results revealed an equally strong impeding effect of distraction on genital sexual responses and on subjective sexual responses when these were measured retrospectively in women with and without sexual problems. However, distraction did not affect subjective sexual responses when these were measured in real time. The implications of the finding that distraction equally affects women with and without sexual problems are discussed. KEY WORDS: female sexual response; sexual arousal; distraction; psychophysiology.

investigate the processing capacity of the sexual arousal system. Two experimental studies have been conducted to examine the role of attention in sexual arousal of women without sexual problems. Adams, Haynes, and Brayer (1985) had participants listen twice to a description of explicit sexual activity, paired either with or without a distractor task that consisted of a series of visually presented arithmetic tasks. Genital sexual responding was measured as vaginal pulse amplitude (VPA) and subjective arousal was measured repeatedly during the trial (by asking about genital sensations). An inhibitory effect of distraction on both genital and subjective responding was found. In the second study by Elliott and O’Donohue (1997), women without sexual problems listened three times to an erotic audiotape presented to one ear, paired with no distraction, a low level of distraction, or a high level of distraction presented to the other ear. In the low distraction task, participants were instructed to repeat aloud a neutral sentence and, in the high distraction task, participants were instructed to repeat a neutral sentence aloud and then to repeat it in reverse order. Genital sexual responding was measured as VPA and subjective arousal was measured retrospectively. Both genital and subjective sexual responses were found to vary as a

INTRODUCTION In the early 1970s, Masters and Johnson (1970) and Kaplan (1974) suggested that distraction during sexual activity is a pivotal factor in the etiology of sexual dysfunction. Masters and Johnson (1970/1981) stated that: The more the male strains the more distracted he becomes and the less input of sensual pleasure he receives from his partner . . . . Sexual input can be blocked by any negative influence in the psychosocial system that distracts the male. (pp. 189–190)

Barlow (1986) also emphasized the role of attentional resource limitations in the etiology and maintenance of sexual disorders. If sexual arousal depends on the processing of sexual stimuli, then it would be relevant in terms of basic knowledge about sexual patterns to 1 Department

of Clinical Psychology, Utrecht University, Utrecht, The Netherlands. 2 Pompe Kliniek, Nijmegen, The Netherlands and Department of Medical, Clinical, and Experimental Psychology, Maastricht University, Maastricht, The Netherlands. 3 To whom correspondence should be addressed at Department of Clinical Psychology, Faculty of Social Science, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlands; e-mail: [email protected].

179 C 2006 Springer Science+Business Media, Inc. 0004-000206/0400-0179/0


180 function of distraction level, with lower levels of genital and subjective responses found with higher levels of distraction. Thus, in women without sexual problems, neutral distraction has been found to impede genital as well as subjective sexual responding. To our knowledge, no study has examined the effects of distraction on sexual responding in women with sexual problems. The effects of distraction on sexual responding in participants with sexual problems were recently tested in men. In a parametric study, four levels of distraction were induced during presentation of erotic film excerpts. Genital sexual responding was measured with an electromechanical strain gauge and subjective responding was measured real time. A linear association of distraction and genital responding was found both in men with and without sexual problems (van Lankveld & van den Hout, 2004). Stronger distraction resulted in lower genital responding. No effects of distraction on subjective arousal were found. The present study attempted to extend these findings in men to female sexual functioning. Although several studies have emphasized gender differences in patterns of sexual responses and sexual behavior between men and women (Chivers, Rieger, Latty, & Bailey, 2004; Hamann, Herman, Nolan, & Wallen, 2004; Oliver & Hyde, 1993), in some domains of sexual responding, gender differences were absent (e.g., Spiering, Everaerd, & Laan, 2004). Because no previous studies using this attentional paradigm in female sexual problem samples were found in the literature, our predictions were based on research done in men (Abrahamson, Barlow, Sakheim, Beck, & Athanasiou, 1985; Geer & Fuhr, 1976; van Lankveld & van den Hout, 2004). We addressed the role of cognitive capacity in the maintenance of sexual arousal by assessing the effect of increasing neutral distraction on genital and subjective sexual responses of women with and without sexual problems. Neutral distraction, as opposed to distractor tasks with erotic connotations (see, e.g., Abrahamson, Barlow, & Abrahamson, 1989), was used to investigate the general association of sexual responsivity with modulation of attentional resources. It was the first attempt to compare response patterns in women with and without sexual problems under different loads of distraction. A parametric design was chosen to assess the potential dose–response relationship between cognitive resources and sexual responding. We used five levels of distraction to create divergent levels of the independent variable. It was hypothesized that genital sexual responding would decrease under increasing loads of neutral distraction in women both with and without sexual problems. Secondly, it was hypothesized that subjective sexual responding

Salemink and van Lankveld (both real time and retrospective) would not decline with increasing distraction in both women with and without sexual problems. Subjective arousal has been operationalized in different ways in previous experimental investigations. In some studies, it was defined as perceived level of genital responding (Adams et al., 1985), more specifically as perceived warmth in genitals, genital wetness, or genital feelings (Palace & Gorzalka, 1992). In other studies, subjective arousal was defined as the degree to which one felt sexually aroused or as an evaluation of the arousal quality of the sexual stimulus (Morokoff & Heiman, 1980) without reference to genital responding. Recently, Brotto and Gorzalka (2002) conducted a study in which these two different definitions were correlated with genital responding. VPA correlated significantly with selfperceptions of genital sensations but not with subjective sexual arousal. The significant correlation is likely to be the result of the conceptual similarity of subjective arousal, defined as perceived genital feelings, and actual genital responding. For the present study, we operationalized subjective arousal as the degree to which one feels sexually aroused. Subjective arousal was measured both in real time and in retrospect. In real time measurement, participants reported their subjective arousal during the experimental condition. In retrospective measurement, participants indicated their subjective arousal after termination of the condition. In previous studies, real time and retrospectively measured subjective arousal sometimes produced similar and sometimes divergent results (Adams et al., 1985; Laan, Everaerd, van Aanhold, & Rebel, 1993; Laan, Everaerd, van Bellen, & Hanewald, 1994; Morokoff & Heiman, 1980; Przybyla & Byrne, 1984; Steinman, Wincze, Sakheim, Barlow, & Mavissakalian, 1981). Summary of Hypotheses 1. Both women with and without sexual problems will show a decrease in genital sexual responding under increased distraction during erotic stimulus presentation. 2. Subjective sexual responding (both real time and retrospectively measured) will not be affected by distraction in women with and without sexual problems during erotic stimulation. METHOD Participants Participants without sexual problems (N = 21) were recruited through media advertisements and participants

Distraction Effects on Female Sexual Responding Table I.

181

Demographic Characteristics of Women with and without Sexual Problems Women without sexual Women with sexual problems (N = 21) problems (N = 20) Characteristic

M

SD

M

SD

Age (years)∗ Education (years) Has a partner (%) Duration of relationship (years)∗∗

23.3 14.9 71 1.7

7.1 1.8

29.4 15.8 85 7.5

8.6 2.3

Has experience with masturbation Has seen erotic films before Contraception Hormonal Condom Other (sterilization) No contraception ∗ p < .05,

0.2

% 86 71

95 80

81 19 0 0

55 15 5 25

7.5

two-tailed;∗∗ p < .001, two-tailed.

with sexual problems (N = 20) were recruited in a hospital sexology department (N = 10) and through media advertisements (N = 10). The advertisements announced a study of female physical sexual functioning in response to sexual stimuli. Women with and without sexual problems 18 years of age and older were invited to participate. Women with sexual problems (M, 29.4 years) were significantly older than women without sexual problems (M, 23.3 years) and had relationships of longer duration (see Table I). The groups did not differ significantly with respect to years of education, percentage having a partner, and percentage living in a steady relationship. All women had coital experience and 86% of the women without sexual problems and 95% of the women with sexual problems masturbated sometimes. The majority of participants had seen erotic films before participation (71% of the women without sexual problems and 80% of the women with sexual problems). Contraceptive use varied: 81% of the women without sexual problems used hormonal contraception, in comparison to 55% of the women with sexual problems. Condoms were used by 19% of the women without sexual problems and by 15% of the women with sexual problems. The husband of a woman with sexual problems was sterilized (5%) and 25% of the women with sexual problems used no contraceptives. Sexual problem status was established by means of sexual history taking. A graduate student with advanced training in the field (ES) performed this structured interview and she was supervised by a senior clinician (JvL) with 14 years of clinical experience in the field. Primary sexual disorders were: hypoactive sexual desire disorder or sexual aversion (N = 9), orgasmic disorder

(N = 6), and dyspareunia (N = 5), all according to DSMIV-TR criteria (American Psychiatric Association, 2000). These sexual disorders were included because sexual arousal difficulties have been implied in their etiology in theoretical (Basson et al., 2003; Hartman, Heiser, R¨uffer-Hesse, & Kloth, 2002; Segraves & Segraves, 1991) and empirical work (Basson, McInnes, Smith, Hodgson, & Koppiker, 2002; Berman et al., 2001; Meston, 2005). Ten women had comorbid sexual disorders. Three women with vaginismus according to DSM-IV-TR criteria were excluded for reasons of possible differences in the etiology of this disorder in comparison to the other female sexual disorders (van der Velde & Everaerd, 2001). One woman without sexual problems was excluded who had no sexual (coital and masturbation) experience at all. Applicants for participation in the study were screened for exclusive or predominant heterosexual orientation and use of medication known to affect sexual functioning. Excluded were four postmenopausal women and one woman with a diagnosis of current major depression (Fagan, Schmidt, Wise, & Derogatis, 1988; Lecrubier et al., 1997; Michael & O’Keane, 2000). Participants received Euro 22.70 for their participation and traveling expenses were reimbursed. Participants using hormonal and nonhormonal contraception as well as women who did not use contraceptives were allowed to participate. No significant differences in sexual responding were found between women using hormonal contraceptives and women using none or nonhormonal contraceptive devices (Laan et al., 1993; Laan, Everaerd, & Evers, 1995a; but see Slob, Ernste, & van der Werff, 1991). Participants using nonhormonal or

182 no contraceptives were all tested in the follicular phase of their menstrual cycle to avoid confounding due to differences in sexual responding between the phases of the menstrual cycle (Schreiner-Engel, Schiavi, Smith, & White, 1981; Slob, Bax, Hop, Rowland, & van der Werf ten Bosch, 1996; Slob et al., 1991). Testing took place 6–10 days after the first day of menstruation. Measures Stimulus Materials Sexual stimuli were 5 min excerpts of femaleproduced erotic color films with sound (Laan et al., 1994; Laan & Everaerd, 1995) that put emphasis on enjoyment on the part of the female actor. As low explicit film fragments may not evoke sufficient arousal thus creating floor effects, only highly explicit sexual film fragments were used. The stimuli depicted explicit heterosexual acts of cunnilingus, fellatio, and vaginal intercourse, including close-up shots of female and male genital areas. The distractor task consisted of five levels of increasing cognitive load that were presented while participants watched film fragments. The distractor task replicated that in Geer and Fuhr (1976), who found effects on genital responding with this task (for use in a nonerotic setting, see Posner & Rossman, 1965). The distractor stimuli were random pairs of digits, read aloud by a female voice at a normal speaking volume level and presented through loudspeakers. Digits within pairs were separated by 1-s intervals. Digit pairs were separated by 5-s intervals. The sounds of film and distraction stimuli were adjusted so that both were approximately at the same level. Participants were asked to perform tasks on the digits. During the first of five levels of distraction, the participants heard no digits and only watched a film fragment. During the second level, participants heard pairs of digits and were given the instruction to “do nothing with these digits.” For the third level, an instruction was given to repeat the digit pairs aloud. At the fourth level, an instruction was given to add the two digits of each pair and verbalize the result aloud, and, at the fifth level, the instruction was to classify the pairs according to a complex rule and verbalize the result aloud. The instruction for the classification rule was: “together the digits form a number; odd numbers under 50 are classified as A; even numbers under 50 are classified as B; odd numbers over 50 are classified as B; even numbers over 50 are classified as A.” Genital Measure of Sexual Responding A vaginal infrared photoplethysmograph was used to measure genital responses. The probe was connected

Salemink and van Lankveld to a vaginal pulse plethysmograph amplifier (Technical Support Group, Faculty of Psychology, University of Amsterdam) and an IBM-compatible computer. The AC component of the signal measuring VPA was used for analysis of the influence of distraction on genital responding. The AC component measures short-term changes and is considered a more sensitive indicator of change in sexual response than the DC component (Laan et al., 1995a). A software program to measure sexual responding was developed at Maastricht University in collaboration with the University of Amsterdam (in LabWindows). The probe was made of epoxy glass containing an infrared containing an infrared light emitting diode (LED). There was a 45-min warm-up period prior to insertion and was put in place by the participant without the experimenter’s help to allow for maximum privacy during the experimental session. Depth of placement and orientation of the light emitting diode were controlled by an acrylic plate (9 cm × 2 cm) attached to the cable of the photoplethysmograph. Participants were instructed to insert the probe such that the plate would touch their labia. After testing, the probe and acrylic plate were cleaned with antibacterial soap, disinfected in 70% ethanol (Segal, Pirnazer, Arens, & Pepose, 2001), rinsed with distillated water, and left to dry in room air. Before analyzing genital responses, measurement of heart rate (HR) was required to find valid HR peaks and troughs in the VPA signal, which were subsequently used as a reference. The electrocardiogram was measured with two disposable ECG electrodes placed on the chest of the participant, one at the sternum and the other at the left side of the body on the last rib, making sure that the heart was between both electrodes. The ECG signal was recorded by a Picker Schwarzer electro-encephalograph (encephaloscript ED 14). A 50-Hz filter was used to exclude interference.

Subjective Measures of Sexual Responding For the real time measurement of subjective responding, participants were asked to continuously indicate their subjectively experienced sexual arousal while watching the videotapes, with the aid of a rotating dial of a potentiometer mounted on a small plastic box that could be moved through a 180◦ arc along a sliding scale. The box was placed on the table in front of the participant at the side of the participant’s dominant hand. The position of the dial was directly shown to the participant using a bar of 20 red LED’s placed underneath the TV monitor. One end position, with the button rotated counter clockwise, signaled “I feel no sexual arousal at all” and

Distraction Effects on Female Sexual Responding corresponded with the LED burning at the extreme left of the bar. The other end position, with the button rotated clockwise, signaled “I feel maximum sexual arousal” and corresponded with the LED burning at the far right end. The endpoint labels were shown in writing on the bar. This technique was introduced to enable participants to indicate their level of subjective arousal without having to look away from the TV monitor. The signal was calibrated to a linear 0–100 scale with 0 indicating no feelings of sexual arousal and 100 indicating maximum feelings of sexual arousal. Real time measurement of subjective arousal has successfully been used in studies of sexual responsivity (Wincze, Venditti, Barlow, & Mavissakalian, 1980). It only interfered with genital responding at low levels of sexual stimulation. A software program was developed in LabWindows to collect data from the rotating button. Participants completed a 10-cm Visual Analogue Scale (VAS) after each stimulus presentation to retrospectively indicate their experienced subjective arousal. The left extreme of the scale indicated “I did not feel sexual arousal at all” and the right extreme “I felt maximum sexual arousal.” Questionnaires The Mini International Neuropsychiatric Interview (MINI; Lecrubier et al., 1997; Sheehan et al., 1997) was administered to screen for depressive disorders, psychotic disorders, alcohol abuse, and dependency. To validate diagnostic classification in the subsamples of women with and without sexual problems, it was tested whether both groups differed significantly in sexual functioning and especially in sexual arousal based on their questionnaire results. Participants completed four questionnaires in the following order: a General Satisfaction Questionnaire (GSQ; Fugl-Meyer, Branholm, & Fugl-Meyer, 1991), the Golombok Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 1985, 1986), the Female Sexual Function Index (FSFI; Rosen et al., 2000), and the Questionnaire for Screening Sexual Dysfunctions (QSD; Vroege, Zeijlemaker, & Scheers, 1998). 4 For all psychometric instruments, raw subscale scores and total scores were considered. The GSQ consisted of eight items and we selected two items that we considered relevant for the present study: “How satisfied are you with your sexual life?” and “How satisfied are you with the relationship with your partner?” The GRISS consisted of 28 items and covers the most frequently occurring sexual complaints of heterosexual persons with a steady partner. Seven factors are identified in women: infrequency, noncommunication, 4 Questionnaire

data are available from the first author upon request.

183 dissatisfaction, avoidance, nonsensuality, vaginismus, and anorgasmia (ter Kuile, van Lankveld, & Kalkhoven, 1999; van Lankveld & ter Kuile, 1999). The FSFI consisted of 19 items covering six domains: sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and pain (Rosen et al., 2000). The QSD is a multidimensional questionnaire that evaluates sexual functioning (van Lankveld, Weijenborg, & ter Kuile, 1996; Vroege et al., 1998). Factor analytically derived factors were “masturbation problems,” “pain and negative affect during masturbation,” “sexual aversion and low desire,” and “sex frequency.”

Procedure The same female experimenter tested each participant individually. Upon arrival at the laboratory, the experimental procedure, including the use of erotic film excerpts and the vaginal photoplethysmograph, was explained to the participant with sufficient detail to enable an informed decision. They were assured privacy, anonymity, and confidentiality. It was stressed that they could withdraw from the experiment at any time without penalty. An informed consent form was handed out and the participant was asked to read and sign it. During the next 30 min, participants completed the four questionnaires. The experimenter subsequently conducted a 30 min sexual history interview, in which sexual experience, sexual satisfaction, and possible sexual disorders were discussed. Then the experimenter explained how to insert the genital device and how to use the rotating button to report subjective arousal. Operationalization of subjective sexual arousal was clarified. After placing the electrodes on the participant’s chest, the experimenter left the room and subsequent contact was conducted over an intercom to ensure privacy. The participant removed her clothing as far as necessary and inserted the probe in private. Participants were then seated in a comfortable chair before a TV screen at a distance of 150 cm. Clothes could be put back on. Participants were asked to sit as still as possible to avoid movement artifacts. An adaptation period of 15 min began. First, a 10 min explanation of the distraction task was given, including practice trials. After this, a 5 min neutral video fragment was shown depicting archaeological excavations. During the next 60 s, quiet music was played while baselines for VPA and real time subjective arousal were established. Next, five 5 min erotic video fragments were shown, each combined with a different distractor task. A counterbalanced schedule for the film excerpts, distractor tasks, and consecutive presentations

184 was made, in which each film and each distractor task was presented equally often as the first, second, etc. Care was taken to eliminate sequences in which the load of the distractor tasks would increase or decrease stepwise. Random assignment to one of the five scheduled series of film fragments and distractor tasks was performed separately for groups with and without sexual problems before the start of the experimental session. Each sequence was completed by four women with sexual problems and four women without sexual problems (with one sequence being completed by five women of the latter group). The instruction was repeated for the following distractor task immediately preceding the start of a video fragment. Between erotic video presentations, participants watched a neutral archaeological film fragment for 5 min to allow the participant’s arousal to return to baseline. The VPA of each participant was visible for the experimenter and return to baseline was visually checked by comparing initial baseline to current response. When vasocongestion had not reached baseline after 5 min, the participant was asked to count backwards from 100 by 7 in a loud voice. The total time of the psychophysiological assessment was 90 min. The entire experiment lasted for 2.5 hr and was terminated with a short debriefing.

Data Reduction For the analysis of VPA data, all peak-to-trough amplitudes were identified and mean amplitude for each condition was calculated. First, a low-pass filter of 0.03 Hz was applied to the signal to delete noise and the filter was used as a reference to find the closest peak (or trough) in the raw signal. Then, the following criteria were used to judge whether a peak or trough was valid: minimum HR was set at 45 beats per min and maximum HR was set at 180 beats per min. Maximum decrease in HR between two heartbeats allowed was 55% and maximum increase allowed was 175%. Regarding the VPA amplitude, minimum amplitude was set to 35% of the mean block amplitude of the raw signal to determine small artifacts. Maximum amplitude was set to 300% of the mean block amplitude of the raw signal to determine invalid large artifacts. Artifacts were then removed from the signal. Further, maximum shift from the block mean value of the “VPA mid” ( = [peak amplitude + trough amplitude]/2) of the raw signal was set to three SDs. These criteria were tested in this order and when a VPA was rejected, new block means were calculated. When all the criteria were met, the peak to trough amplitude was considered valid and calculated for each remaining pulse. The amplitudes were averaged over 30 s, resulting in two

Salemink and van Lankveld points per baseline period. The first 60 s of responding after stimulus onset were not entered in data analysis with the purpose of focusing on the maintenance phase of genital responding, which is hypothesized to be governed by other etiological factors than the earlier phases of response preparation and deployment (Janssen, Everaerd, Spiering, & Janssen, 2000). Nine data-points per condition were thus included for analyses. VPA signals that went outside the set range were excluded from analyses. After this analysis, VPA pulses were visually inspected for artifacts caused by movements of the lower part of the body or agitated speaking. These artifacts were easily detected by visual inspection, because the corresponding pulse showed an extreme increase in amplitude and had a different shape. Those pulses were deleted. It is difficult to calculate between-subjects factors using VPA, because it lacks absolute reference points. We therefore compared VPA responses during the experimental conditions with each participant’s individual baseline scores. This also prevents influence of baseline shifts. VPA difference scores were calculated by subtracting baseline scores from scores during erotic stimulus presentation. Thus, mean VPA change scores in mV provided a measure of genital reactivity. Real time subjective sexual responding was collected continuously and then averaged per 30 s epoch. The first 60 s of every stimulus period were skipped to enhance comparison with the genital data. Two epochs per baseline and nine epochs per condition were included for the calculation of mean real time subjective sexual responding. Differences between baseline scores and erotic film scores were calculated and difference scores were used as a measure of subjective reactivity. The retrospectively measured subjective data (VAS) resulted in a score ranging from 0 to 100 for each distractor level and was used as a retrospective indication of experienced subjective responding.

RESULTS Sexual Functioning Characteristics Table II shows the sexual functioning characteristics of women with and without sexual problems. One-way MANOVA was performed with the sexual functioning scores entered as dependent variables and Group (with vs. without sexual problems) entered as a fixed factor. A main effect of Group was found, F(18,17) = 7.20; p < .001; η2 = .88. Post hoc univariate testing revealed that women with sexual problems were less satisfied with sexual life (GSQ, GRISS, and FSFI). Women with sexual

Distraction Effects on Female Sexual Responding

185

Table II. Responses to Questionnaires of Women With and Without Sexual Problems Women without sexual problems

GSQa Satisfaction with sexual life Satisfaction with partner relationship GRISSb Infrequency Noncommunication Dissatisfaction Avoidance Nonsensuality Vaginismus Anorgasmia Total FSFIc Desire Sexual arousal Lubrication Orgasm Sexual satisfaction Pain Total QSDd Masturbation problems Pain and negative affect Sexual aversion and low desire Sex frequency

Women with sexual problems

M

SD

M

SD

F

5.0 5.3

0.5 1.0

2.5 4.7

1.3 1.1

48.38∗∗ 2.83

4.6 4.6 6.1 5.0 5.0 4.3 9.2 46.1

1.4 1.5 1.6 0.8 1.3 0.5 2.6 6.4

7.1 5.5 9.9 8.5 8.6 8.8 13.9 75.7

2.0 1.6 3.5 3.6 3.1 4.4 5.0 12.0

18.60∗∗ 2.54 16.30∗∗ 14.86∗∗ 18.07∗∗ 17.37∗∗ 11.56∗ 76.69∗∗

4.2 5.5 5.9 5.4 5.4 5.4 31.8

0.7 0.5 0.2 0.6 0.5 1.5 2.3

2.8 3.3 3.9 2.9 3.1 2.2 18.2

1.2 1.8 2.1 2.3 1.7 2.2 8.4

16.58∗∗ 24.06∗∗ 14.03∗∗ 17.05∗∗ 26.55∗∗ 23.49∗∗ 39.50∗∗

9.1 5.1 −1.2 7.9

1.0 0.3 1.4 1.5

13.8 7.0 3.5 5.4

6.9 3.3 2.8 2.4

4.49∗ 1.00 15.31∗∗ 3.89

a Range

for both subscales: 1–6. for infrequency and noncommunication: 2–10; for dissatisfaction, avoidance, nonsensuality, vaginismus, and anorgasmia: 4–20. Range for total score: 28–140. c Range for desire: 1.2–6; for sexual arousal, lubrication, orgasm, and pain: 1.2–7.2; for sexual satisfaction: 1.2–6.4. Range for total score: 7.2–41.2. d Range for masturbation problems: 6–30; for pain and negative affect: 4–20; for sexual aversion and low desire: − 2.0–16; for sex frequency: 2–14. ∗ p < .05, two-tailed; ∗∗ p < .001, two-tailed. b Range

problems had also lower frequencies of sexual contact, avoided sexual contact more often, and experienced more sexual problems such as vaginismus and anorgasmia than women without sexual problems (all GRISS subscales). Compared to women without sexual problems, they had more problems with desire, arousal, lubrication, orgasm, and had more sexual pain (all FSFI subscales). During masturbation, women with sexual problems had more difficulties with sexual arousal and orgasm and more feelings of aversion than women without sexual problems (QSD). Genital Sexual Responding A 2 (Group) × 5 (Distraction) repeated measures ANCOVA was performed with mean VPA change from baseline entered as the dependent variable. Adjustments for between-group effects were made for age and duration

of relationship as covariates. A main effect of Distraction was found, F(4,36) = 3.00; p < .05; η2 = .25. Neither covariate was significant. Univariate post hoc comparisons revealed that VPA change was larger during the no distraction than during the classify condition, F(1,39) = 12.06; p < .001; η2 = .24, whereas intermediate conditions showed no differential effects (ps > .05). No main or interaction effects of sexual problem status were found. Re-analysis of the data with the addition of hormonal contraceptive use as an independent variable did not yield significant main or interaction effects. Subjective Sexual Responding First, a 2 (Group) × 5 (Distraction) repeated measures ANCOVA was performed on mean change from

186

Salemink and van Lankveld than after the no distraction condition, F(1,39) = 5.34; p < .05; η2 = .12, whereas intermediate conditions did not yield differential effects (for means and SDs, see Table III). No main or interaction effects of sexual problem status were found.

Table III. Genital and Subjective Sexual Responses to Distraction of Women with and without Sexual Problems

Level of distraction

Women without sexual problems (N = 21)

Women with sexual problems (N = 20)

M

M

SD

SD

1. No distraction 2. Listen only 3. Repeat 4. Add 5. Classify

Change in genital sexual arousal (in mV) 4.64 3.32 3.33 2.25 3.56 3.23 3.57 2.56 4.27 2.83 3.08 2.56 3.80 2.72 3.01 2.84 3.15 2.22 2.60 2.19

1. No distraction 2. Listen only 3. Repeat 4. Add 5. Classify

Change in subjective sexual arousal in real time 26.85 20.15 22.80 15.24 26.00 19.15 26.35 18.50 28.55 18.80 21.65 14.35 25.50 14.80 19.55 13.35 26.75 15.40 19.95 15.50

1. No distraction 2. Listen only 3. Repeat 4. Add 5. Classify

Subjective sexual arousal retrospectively measured 43.6 19.5 41.3 21.9 43.5 23.9 47.4 24.0 45.6 16.6 34.5 19.5 39.7 22.7 40.2 23.1 36.5 20.4 34.5 20.1

Differences in Level of Sexual Responding Between Women With and Without Sexual Problems One-way ANCOVAs were performed on mean change scores of genital and subjective sexual responding during the no distraction condition to test whether the responses of women with and without sexual problems differed when not being distracted. Data were adjusted for age and duration of relationship as covariates. No main effects were found on mean VPA change, real time subjective sexual responding, or retrospectively measured subjective sexual responding (ps > .05).

Concordance Between Genital Responding and Different Measures of Subjective Responding The degree of correspondence between genital (mean VPA change scores) and subjective sexual responses (mean change scores in real time and retrospectively measured subjective arousal) was examined by calculating Pearson product–moment correlations for each of the five distraction conditions and for each group separately (see Table IV). For women with and without sexual problems, correlations between genital and both subjective measures of sexual arousal were low and nonsignificant. An exception was found during the listen only condition, in which a significant positive correlation existed between mean VPA change and mean retrospectively measured subjective arousal for women with sexual problems (r = .48; p < .05).

baseline in real time recorded subjective responding, with age and duration of relationship entered as covariates. No main or interaction effects of distraction, sexual problem status, or covariates were found (for means and SDs, see Table III). Next, a 2 (Group) × 5 (Distraction) repeated measures ANCOVA was performed on retrospectively recorded subjective responses (VAS), with age and duration of relationship entered as covariates. A main effect of Distraction was found, F(4,36) = 2.84; p < .05; η2 = .24. The covariates were not significant. Post hoc comparisons revealed that subjective sexual arousal was significantly lower after the classify condition

Table IV. Correlations between Genital and both Measures of Subjective Sexual Responding of Women with and without Sexual Problems Real time measured Level of distraction 1. No distraction 2. Listen only 3. Repeat 4. Add 5. Classify ∗ p < .05,

two-tailed

Retrospectively measured

Women without sexual Women with sexual Women without sexual Women with sexual problems (N = 21) problems (N = 20) problems (N = 21) problems (N = 20) −.19 −.13 −.10 −.03 −.33

.08 .30 .28 .03 .21

−.02 −.05 −.15 .21 −.39

.14 .48∗ .16 −.12 .10

Distraction Effects on Female Sexual Responding Table V. Correlations between Real Time and Retrospectively Measured Subjective Sexual Arousal of Women with and without Sexual Problems

Level of distraction

Women without sexual Women with sexual problems (N = 21) problems (N = 20)

1. No distraction 2. Listen only 3. Repeat 4. Add 5. Classify ∗∗ p < .001,

.69∗∗ .80∗∗ .60∗∗ .73∗∗ .68∗∗

.94∗∗ .77∗∗ .74∗∗ .43 .66∗∗

two-tailed.

The degree of correspondence between the two different measures of subjective sexual responding was examined by calculating Pearson product–moment correlations for each of the five distraction conditions and for each group separately (see Table V). For women with and without sexual problems, the correlations between real time and retrospectively measured subjective arousal were positively significant for all distraction conditions. An exception was found during the add condition (p > .05).

DISCUSSION This is the first study that compared sexual responding to erotic stimuli under varying levels of neutral distraction in women both with and without sexual problems. It revealed the predicted impeding effect of distraction on genital sexual responding. Genital responses, measured as VPA, were significantly lower during the highest level of distraction than during the no distraction condition in both groups of women. Our findings correspond to earlier investigations in men (van Lankveld & van den Hout, 2004) and women without sexual problems (Adams et al., 1985; Elliott & O’Donohue, 1997). Retrospective ratings of subjective sexual arousal also decreased with increasing levels of distraction, confirming earlier results in women without sexual problems (Elliott & O’Donohue, 1997). Distraction had no effect on real time measured subjective arousal. Although this last result was in line with findings in men (van Lankveld & van den Hout, 2004), it contrasts with findings in women without sexual problems by Adams et al. (1985), who found that real time measured subjective arousal decreased with increasing cognitive load. This may be explained by differences in the operational definitions of subjective sexual arousal. Adams et al. used a genitally focused operationalization of subjective arousal with propositions such as “no genital sensations” and

187 “orgasm” as anchor points. In the present study, however, participants were asked to focus on their feelings of arousal with “I feel no sexual arousal at all” and “I feel maximum sexual arousal” as anchor points. VPA decreased under increasing loads of distraction in both studies. The distraction effect on real time subjective arousal in the Adams et al. study might therefore reflect their participants’ perception of decreasing genital responses. This strong association of genital responses and genitally focused conceptualizations of subjective arousal is reflected in the large effect sizes of correlations found in other studies (e.g., Brotto & Gorzalka, 2002). In the present study, retrospectively measured subjective sexual arousal decreased under increasing cognitive loads, but real time measured subjective arousal remained unaffected. Both measures employed an experiential focus on subjective sexual arousal. A possible explanation for this differential effect may be that participants to some extent used contextual cues to label their experience as erotic (see Everaerd, Laan, Both, & van der Velde, 2000; Laan et al., 1994; Laan, Everaerd, van der Velde, & Geer, 1995b). In this sense, the appraisals of the different video scenes may have become contextual determinants of their subjective sexual arousal, whose influence could have been higher during real time than during retrospective rating. During retrospective ratings, in contrast, participants might have relied on their perceived physical genital responses to rate their subjective arousal. Two other points should be made concerning real time measurement. First, the activity of turning a button to monitor one’s degree of subjective arousal may have become a distractor in and of itself (Wincze et al., 1980). Second, the responses on real time subjective sexual arousal were quite low level, even in the no distraction condition. Thus the absence of distraction effects on real time subjective reports thus might reflect a floor effect. In sum, the effect of distraction on subjective arousal in women appears to depend on the operational definition of subjective arousal, a result that was also found in previous studies in men (Abrahamson et al., 1985; Przybyla & Byrne, 1984; van Lankveld & van den Hout, 2004). The influence of neutral distraction on sexual responding—more in general, the reduction of available processing capacity for sexual stimuli—was found not to differ between women with and without sexual problems, despite large differences between both groups on sexual functioning questionnaires. Both groups did not seem to differ in general distractibility. However, caution is required in interpreting the meaning of this finding for the etiology of female sexual dysfunction. Note, that different sexual disorders were included in the present study, since they shared impaired sexual arousal problems (Basson

188 et al., 2002; Basson et al., 2003; Berman et al., 2001; Hartman et al., 2002; Meston, 2005; Segraves & Segraves, 1991). Due to the small sample sizes, it was unfortunately impossible to separately analyze each sexual disorder. In addition, our experimental manipulation might not have been effective in differentiating between both groups. The laboratory setting might not have activated differences in processing of sexual stimuli between women with and without sexual problems to the same extent that the more naturalistic situation at home would. Alternatively, distraction tasks with sexual connotations or tasks inducing high levels of performance anxiety might be better capable of distinguishing between women with and without sexual problems, compared with neutral distraction tasks (Laan et al., 1993). Genital and subjective responses to erotic stimuli did not differentiate between women with and without sexual dysfunction in the no distraction condition in this study. This result was in line with findings in genital (Laan, van Driel, & van Lunsen, 2003; Meston & Gorzalka, 1996; Morokoff & Heiman, 1980) and subjective responding (Meston & Gorzalka, 1996; Palace & Gorzalka, 1990; Wincze, Hoon, & Hoon, 1976), but also contradicts previous findings regarding genital (Palace & Gorzalka, 1990; Wincze et al., 1976) and subjective responding (Laan et al., 2003; Morokoff & Heiman, 1980). Again, one should be careful when interpreting this nonsignificant result. Wouda et al. (1998) found that differences in VPA between women with dyspareunia and women without sexual problems depended on the content of the erotic stimuli. The genital responses of the two groups in their study did not differ during a cunnilingus scene, but did during a penile–vaginal penetration scene. The effect of content of erotic stimuli was not part of the present study design and the subsample of women with sexual problems was heterogeneous with regard to dominant sexual disorder, despite the overall presence of problems with sexual arousal and lubrication. Studying more homogeneous groups of participants compared under stimulus conditions reflecting their different sexual problem types may clarify this issue. The present study revealed no correlation between genital and subjective measures of sexual arousal in women with and without sexual problems, which corresponded to earlier findings (Adams et al., 1985; Laan et al., 1994; Morokoff & Heiman, 1980, but see Przybyla & Byrne, 1984; Steinman et al., 1981). A limitation of this study concerns the VPA signal, which was found to become distorted by talking loudly or enthusiastically. The distractor tasks required the participants to speak and, when the task was difficult, participants reacted intensely when they found the answer.

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