Asking questions about sexual function in community surveys is challenging. This is partly because the parameters set by the research context are demanding. They include the need to minimize respondent burden, to ensure acceptability (Dunn, Jordan, Croft, & Assendelft, 2002), and to ensure relevance to diverse sections of the population. Where sexual function is measured within a larger questionnaire survey covering other aspects of health, brevity is vital; space often permits only one question per difficulty (Hayes & Dennerstein, 2005). Measures of sensitive behaviors have the potential to seem intrusive and even offensive (Loewenthal, 2001), particularly where they may be unexpected, as in a general health survey. The challenge is to achieve a balance between accuracy and acceptability. Community-based measures should also have public health utility, providing useful information on the likely burden of ill health and an indication of how many and who might require professional help. As far as possible, they should avoid including those with transient difficulties and those whose sexual difficulties represent an adaptive response to their particular situation.
The survey team of the British National Survey of Sexual Attitudes and Lifestyles (NATSAL) sought a measure of sexual function that covered the key domains and could be completed by all, regardless of gender, sexual orientation, recent sexual experience, and relationship status. It needed to be brief (<20 items); acceptable; have public health utility; and, ideally, be informed by the perceptions and experiences of men and women themselves.
We reviewed 54 psychometric measures (Mitchell, 2008), but did not find one that met our specific needs. For example, of three validated measures with male and female versions, two were too long (the Golombok-Rust Inventory of Sexual Satisfaction [GRISS]: Rust & Golombok, 1985; and the Derogatis Interview for Sexual Functioning-Self-Report: Derogatis, 1997), one was relevant only to couples in heterosexual relationships (the GRISS), and one omitted key domains and asked about function only over the past week (the Arizona Sexual Experience Scale: McGahuey et al., 2000). An inferior, but tolerable, option was to use a different measure for men and women. Among the extensively validated female measures, the Female Sexual Function Index (Rosen et al., 2000) is fairly brief (19 items), but does not measure the degree of personal unease related to symptoms. Among the extensively validated male measures, the International Index of Erectile Function (Rosen et al., 1997) is sufficiently brief (11 items), but is focused on erectile function, may be considered intrusive by a general population sample (e.g., "How often were your erections hard enough for penetration?"), is unsuitable for gay men, and does not ask about the degree of personal unease related to symptoms. In general, many measures are unsuited to community surveys because they have been designed as endpoints in clinical trials and, therefore, tend to focus on biomedical aspects of sexual dysfunction (Corona, Jannini, & Maggi, 2006), often to the neglect of relational and subjective aspects of the sexual experience. Finally, few of the existing validated measures have followed U.S. Food and Drug Administration guidelines about involving patients in their development (Dennerstein, 2010).
Having not found a suitable measure, we embarked on a program of development work to produce a tailor-made measure from first principles. A crucial first step was to identify the criteria that should be included within the construct of sexual function. An overriding concern was to ensure that the conceptual framework for the measure would reflect both biomedical and psychosocial perspectives, and would take account of the meaning and significance of sexual function for men and women themselves. In this article, we describe the research that generated the conceptual framework upon which the measure was designed. Elsewhere, we describe the psychometric development and validation of the subsequent measure (manuscript in preparation).
We carried out qualitative research aimed at exploring the meaning of sexual function in the context of the everyday lives of men and women. A literature review guided selection of discussion points for interviews and eventual decisions about inclusion or exclusion of elements in the conceptual framework.
Maximum variation sampling was used to include a wide range of sexual function experience. This was achieved by purposefully recruiting three groups of participants:
1. Those who self-identified as having sexual difficulties (consecutive patients attending a National Health Service sexual problems clinic in London; N = 6).
2. Those with conditions associated with sexual difficulties (individuals with diabetes and depression randomly selected from the diabetes patient list and depression patient list of a general practitioner [GP] clinic in London and invited to participate by letter [n = 13]; and individuals with HIV, selected via snowballing techniques from an HIV charity in a regional town [n = 3]).
3. A community group of consecutive attendees at the same GP surgery clinic, recruited from the waiting room by the first author (n = 10).
The first group comprised those with experience of sexual difficulties for which they had sought help; the second group comprised individuals who, because of underlying health problems (diabetes, depression, and HIV), might be expected to be experiencing some problems but had not necessarily sought help for themselves or self-identified as having difficulties (sub-clinical); the third group represented a proxy to a general population sample, with some individuals experiencing difficulties and others not. Non-English speakers and those under the age of 18 were excluded from the sample. Fieldwork was brought to an end when subsequent interviews began to yield little in the way of new information (saturation point).
Interviews were framed by a topic guide that sought to facilitate disclosure of personal experiences. Open-ended questions probed the range of criteria used by participants in assessing their sex lives and what they saw as problematic and non-problematic for themselves (see Figure 1). Detailed probing encouraged participants to describe and explain the criteria they considered important. For those who described any sexual concern or problem (n = 25), further discussion sought to explore the impact of that problem on their lives.
Interviews were undertaken by the first author (30 interviews) and the second author (two interviews), and lasted between 45 minutes and two hours. Interviews were recorded (with permission) and transcribed verbatim. Participants signed an informed consent form prior to being interviewed.
Use of the term sexual function was avoided during interviews so as to make no assumptions of its meaning for participants. Instead, we offered several plain-language terms (satisfactory/OK for you/ideal/good-enough), and asked participants to think in terms of what was realistic rather than ideal.
Interview transcripts were read and checked as part of the familiarization process. They were then read again and catalogued according to broad themes (such as orgasm, satisfaction, and frequency), and entered into a Microsoft[R] Excel spreadsheet, which served as a data retrieval tool.
As previously described (Mitchell, King, Nazareth, & Wellings, 2010; Mitchell et al., 2011), close examination of the narrative provided by each individual enabled participants to be categorized according to their experiences of sexual difficulties (see Table 1). Individuals who described no significant frustration or difficulty were categorized as "functional"; those who expressed minor frustrations or difficulties, but no significant concern about these experiences, were categorized as "dissatisfied"; and those who described significant problems, some level of distress, and had also either sought or considered clinical help were categorized as "problematic."
Once the data had been mapped, the analysis moved to an interpretative phase, drawing on principles of Grounded Theory (Charmaz, 2006; Strauss, 1987). This is an analytical approach particularly suited to generating dense theoretical accounts grounded in data (Green & Thorogood, 2009). We read the transcripts once more, undertaking line-by-line analysis (or open coding) to identify potential criteria of functional sex; we then used axial coding to explore dimensions of these criteria and relationships between them (see Strauss, 1987). For example, we identified dimensions of the criterion of compatibility as sexual role/identity, preference for sexual activities, and motive for sex. Throughout, we sought data (quotes/text) that would both confirm and challenge our emerging list of criteria. It was not possible to double code the transcripts, but reliability was enhanced via discussion between authors, both of whom are experienced qualitative researchers.
Prior to and during fieldwork, we undertook a comprehensive review of the literature, including a review of measures of sexual dysfunction. We searched key databases (Pubmed, BIDS, PsycINFO, Medline, IBSS, and PsychLIT), as well as reviewing the reference lists of key articles. We used a range of search terms related to the concept of sexual dysfunction: sexual function/ dysfunction, sexual satisfaction/dissatisfaction, sexual function disturbance(s), and sexual adjustment. We used the "or" operator to include specific terms within this concept (e.g., premature ejaculation and dyspareunia), as well as the "and" operator to combine the central concept with terms related to measurement (classif *, measure *, model, and psychometric), and with terms related to epidemiology and aetiology (aetiology, prevalence, and epidemiol *).
Building the Conceptual Framework
A conceptual framework outlines a preferred approach to a problem. In our case, the purpose of the framework was to describe the phenomenon we were setting out to measure (i.e., sexual function).
We based our framework on the World Health Organization's (WHO) definition of sexual dysfunction: "the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. Sexual response is a psychosomatic process and both psychological and somatic processes are usually involved" (WHO, 1992, p. 191). Given that we aimed to develop a population metric, rather than a clinical measure, we used the term sexual function, defining it as the converse of this WHO definition--the capability of an individual to participate in a sexual relationship as he or she would wish.
The development of the framework was guided by our psychosocial perspective and by our inductive approach (deriving criteria from participant accounts). Our review of the literature also urged the adoption of a number of key precepts. These included (a) the need to avoid equating vaginal intercourse and sex (Boyle, 1993; Sandfort & de Keizer, 2001), (b) to view subjective experience and physiological signs as equally valid (Bancroft, Loftus, & Long, 2003; Sugrue & Whipple, 2001), and (c) to regard the sexual relationship as integral to sexual function (Conaglen, 2001; Tiefer, Hall, & Travis, 2002).
Decision Rules to Guide the Inclusion and Exclusion of Criteria
From the outset of the qualitative analysis, it was clear that we would identify more criteria from the data than would be possible to include in the final conceptual framework. To help decide which criteria to keep, we set up three decision rules:
1. If two criteria overlap, exclude the criteria for which the evidence is weakest.
2. Exclude any criterion that interview respondents regarded as desirable, rather than essential.
3. Exclude any criteria that are associated with sexual function, rather than part of the construct itself.
With regard to the third decision rule, we defined associated factors as any criteria that could be construed as antecedent to, or an outcome of, a functioning sex life or criteria that were "a degree or so removed from explicit sexual behaviour" (Derogatis, 1997, p. 293); in other words, criteria that represented the context of a sex life (whether personal, relational, or physical) or criteria that might be viewed as aetiological agents. The decision was complicated by the fact that the same criterion may be considered part of the construct by some, and an associated factor by others. Whether a criterion belongs within or outside depends on the underlying concept of sexual function. The logic is somewhat circular; the conceptual framework is essentially determined by the criteria incorporated within it, yet the choice of criterion is determined by the underlying concept of sexual function.
The decision to exclude or include each criteria was guided by our qualitative data analysis, an examination of the existing literature, and the application of logic.
Results and Discussion
Through analysis of participant accounts, we identified 31 criteria of functional sex. By grouping together conceptually similar criteria, we identified four main aspects of sexual function: psycho-physiological, relational, functional sexual self (individual sexuality and ability to have positive sexual experiences), and self-rating/severity. This latter group of criteria measured the severity of problematic sexual experiences, as well as the quality of an overall sex life. We describe each group of criteria in turn, summarizing our evidence to support the inclusion or exclusion of criteria within that aspect.
The Psycho-Physiological Aspect
We examined the qualitative data to see whether aspects of sex associated with established diagnostic criteria (desire, arousal, orgasm, and lack of pain/ discomfort) were important to participants. We identified several further psycho-physiological criteria that were also considered important by participants. The evidence and decision for each criterion is summarized in Table 2.
The Relational Aspect
Unlike most health behaviors, sex is essentially dyadic in nature. Relationship factors--contingent on the sexual partner, as well as the interaction between partners--are, therefore, seen by many as fundamental to the aetiology and experience of sexual difficulties (Dennerstein, Lehert, Burger, & Dudley, 1999; King, Holt, & Nazareth, 2007; among others). The current classification systems (the Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.]: American Psychiatric Association, 2000; and the International Statistical Classification of Diseases and Related Health Problems [10th ed.]: WHO, 1992) do not adequately address the relationship dimension. Our qualitative data, supported by the literature, provided strong evidence for the inclusion of a relational dimension. Table 3 summarizes the evidence and decision for each criterion identified in our qualitative study.
The Self-Rating and Severity Aspect
Given that standard diagnoses correlate only moderately with individual assessment of their situation, particularly for women (King et al., 2007), and given the need to differentiate transitory difficulties from longer-term dysfunction (Mitchell & Graham, 2008), we wanted to ensure that a degree of self-assessment was included in the measure.
From the literature and from our qualitative data, we identified eight potential indicators of severity: duration since onset of symptoms, the frequency with which symptoms occur, level of distress caused by the symptoms, the extent to which an individual perceives that a problem exists, the overall level of distress, whether the person has sought professional help, the overall level of satisfaction, and avoidance of sexual activity. The final two were discussed earlier as potential criteria of the psycho-physiological aspect, but we opted to include them here (see Table 2). We have previously investigated the relative merits and limitations of these indicators (Mitchell, 2008), concluding that there is sufficient evidence to warrant the inclusion of these eight. Later psychometric testing may lead to the exclusion of some indicators from the final measure.
The Functional Sexual Self Aspect
From our qualitative data, we identified a number of criteria that could be grouped under the dimension functional sexual self. These criteria related to an individual's sexuality and capacity to enjoy positive sexual experiences. A majority view of sex emerged as an act carrying potential risk of rejection and, thus, creating feelings of vulnerability. Confidence and comfort, therefore, emerged as important to good-enough sex. We identified five characteristics of an ideal sexual self related to confidence and comfort: positive body image, ability to give and receive pleasure, positive sexual identity, confidence to communicate needs, and positive motivations to have sex (motivations that are not damaging to the individual or his or her partner). These can be construed as attributes, attitudes, and abilities brought to the sexual encounter, although they might also develop as an outcome of positive sexual experiences.
A second group of criteria relating to functional sexual self clustered around the concept of context, both physical and personal. Key aspects of the personal context were tiredness and stress. Physical context included privacy--a criterion particularly pertinent to those with children living at home.
These criteria are well established in the literature, but are usually examined in terms of their association with sexual dysfunction (e.g., see Laumann, Paik, & Rosen, 1999; Nazareth, Boynton, & King, 2003; Rosen & Althof, 2008; Sanchez & Kiefer, 2007).
In keeping with the established literature, we excluded all these criteria, assigning them as associated factors (or correlates), rather than part of the construct itself.
The Conceptual Framework
The selection process gave rise to a conceptual framework as depicted in Table 4.
The measure derived from this conceptual framework is computer-based and routes participants to sections relevant to their experiences. Those who have not been in a relationship for the whole of the past year, for example, will be routed past the relationship questions. This means that the measure can be completed by anyone, regardless of their recent sexual experience.
The methodological limitations of our study relate to qualitative approaches more broadly. Qualitative methods are suited to exploring phenomena from the perspectives of others. Semi-structured interviews provide rich and detailed descriptions; but because the data generated are cumbersome, the sample size is generally small. Sampling is often theoretical, rather than probabilistic, and so the aim is to generate ideas and concepts that are transferable to other contexts, rather than results that are statistically generalizable to a wider population.
Our framework is novel in that it is grounded in participant perceptions; provides opportunity for individuals to state the degree to which they see their sex life as problematic; and incorporates relational, psychological, and physiological aspects.
The framework provides a solid conceptual basis for a brief and acceptable measure of sexual function, specifically designed for use in community surveys. Just as we identified shortcomings in existing measures, so practitioners with different objectives will see drawbacks to ours. For example, sex therapists might point out that it contains nothing about intimacy in a relationship; experts on premature ejaculation and orgasmic dysfunction (Waldinger & Schweitzer, 2006a, 2006b) could consider the number of items on orgasm/ejaculation inadequate for precise measurement; practitioners who advocate on behalf of rare and specific conditions, such as persistent sexual arousal disorder (Leiblum & Nathan, 2001), might point out that these have been omitted; and various individuals (notably, the Working Group for a New View of Women's Sexual Problems, 2001) might criticize our attempt to put forward a normative list of difficulties. Whereas some will feel that we have strayed too far from the current classification, others will feel that we have not strayed far enough. In response, we would highlight the fact that most limitations of the measure stem directly from our design imperatives of brevity, user acceptability, relevance to all population subgroups and public health utility. Furthermore, given the general lack of agreement concerning the conceptualization and measurement of sexual dysfunction (Balon, 2008; Mitchell & Graham, 2008), it is simply not possible to meet all expectations. In contrast to many existing measures, we based our decisions on empirical evidence specifically collected for the purpose, thus giving our measure a strong claim to validity. Ultimately, the quality and utility of this conceptual framework and subsequent measure will be established by future community-based survey research.
Figure 1. Interview topic guide (excerpt).
* How would you describe a good-enough/satisfactory/ideal sexual relationship?
* What about a good-enough/satisfactory/ideal sexual act/sexual activity?
* How would you describe an unsatisfactory/unacceptable/not OK sexual relationship?
* What about unsatisfactory sex/sexual activity?
We are indebted to the participants who kindly gave of their time and views. We would like to thank Professors Anne Johnson, Michael King and Irwin Nazareth for their valuable scientific input into the study. The study was supported by an Economic and Social Research Council/Medical Research Council inter-disciplinary PhD studentship award. The views expressed in the article are those of the authors and do not necessarily reflect those of the funding bodies. Ethical approval for the study was obtained from Camden and Islington Local Research Ethics Committee and the London School of Hygiene and Tropical Medicine Ethics Committee. Governance approval was obtained from Camden and Islington Primary Care Trust and Camden and Islington Mental Health and Social Care Trust.
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Correspondence should be addressed to Kirstin R. Mitchell, c/o Rachael Parker, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. E-mail: firstname.lastname@example.org
Kirstin R. Mitchell and Kaye Wellings
Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine
Table 1. Characteristics of the Interviewees (n=32) Characteristic Functional Dissatisfied Problematic Total no. in group 7 9 16 No. of men/women 2/5 3/6 10/6 Mean age (range) 38.7 52.1 52.8 (23-62) (31-78) (33-70) Recruitment group Community 4 4 2 GP diabetes/depression 3 3 7 list HIV charity -- 2 1 Sexual problems clinic -- -- 6 Partnership status Single 2 5 5 Married/co-habiting 4 4 9 Non-cohabiting partner 1 -- 2 Sexual orientation Heterosexual 7 5 15 Lesbian -- 1 -- Gay -- 2 1 Bisexual -- 1 -- Note. Source: Mitchell, King, Nazareth, and Wellings (2010) and Mitchell et al. (2011). GP =general practitioner. Table 2. Summary of Evidence for Psycho-Physiological Criteria Criteria Findings From Evidence From Qualitative Study Literature Desire * Desire viewed as * Lack of interest important, not only is the most common for intercourse but female difficulty for maintaining (Laumann, Paik, & intimacy and Rosen, 1999; Mercer closeness. et al., 2003), but is also common in men. * Desire plays * Clinical patients important role often present with within relationship. loss of desire in * Experiencing a conjunction with period of reduced another problem desire is common. (Bancroft, 2009). * Most participants * Most existing expected and measures include accepted that desire desire as an item. would diminish in certain circumstances (e.g., being single, experiencing work- related stress, feeling depressed). * Loss of desire that turned into avoidance of sexual activity was considered highly problematic. It was construed as a form of denial or ignoring the problem (F50-54). (a) Subjective * Arousal viewed as * The DSM-IV-TR arousal, important. classifies arousal lubrication, & Difficulty becoming as erectile disorder erection aroused viewed as a for men and profound problem inadequate (M60-64). lubrication swelling response for women. * Arousal said to * Subjective contribute to assessment of greater enjoyment, arousal not as well as conveying currently included to a partner that in the DSM-IV TR, they are sexually although frequently attractive and asked in measures of wanted. sexual dysfunction- for example, the * Participants GRISS and the BISF- mentioned many W. subjective signs of arousal, including feeling excited, losing inhibition, tingling, and quickened heart rate. * Among women, lubrication (feeling wet [F60-64]; damp in the vagina [F70-74]) was regarded as the primary sign of arousal, although many other signs were mentioned. * Absence of lubrication perceived as easy to remedy; and because it was not considered so salient, its absence did not necessarily signify failure to become aroused. Vaginal dryness could become a problem if externally applied lubricant was not used or failed to work, leading to dry and painful sex. * For men, an erection (a springing to life [M50-54]) appeared to be the indication of arousal that mattered most. Many men, although not all, equated an erection with arousal. * Where penetrative intercourse was regarded as the only "proper" way of having sex, erectile failure precluded sex, or at least made it very, very difficult (M60-4). * Men with erectile difficulties said they experienced feelings of inadequacy, failure, and loss of self- esteem. It was difficult for them to convince their partner that they were finding sex pleasurable. * Partners are likely to interpret erectile failure as a lack of attraction toward themselves. Orgasm: Ability * Some participants * Inability to reach to reach, (women more than orgasm is the second timing, & men) held the view most frequently quality that orgasm helped reported female to complete sex, but problem (Meston, was more a bonus Hull, Levin, & than a necessity. Sipski, 2004). * Others viewed it * Premature as essential to ejaculation is the satisfaction: The most common problem definition of a good affecting men satisfactory, sexual (Barnes & Eardley, experience [is] that 2007). both of you would mutually enjoy, it * Orgasmic disorder equally... that both and premature of you would ejaculation are theref6re experience classified as orgasms... (M55- dysfunctions in the 59). DSM-117TR. * An orgasm was seen * Most existing as spanning a whole measures include gradient of items on premature different sexual ejaculation and experiences (F45- difficulty reaching 49), and could vary orgasm. in quality. * The male orgasm was considered fairly easy to achieve. So, if a man had difficulty reaching orgasm, his female partner might interpret his difficulty either as her failure to provide sufficient stimulation or as an indication that he was not sexually attracted to her. * The female orgasm was regarded by men as more exciting (like Everest compared to a molehill [M70-74]), but more elusive (like looking for a needle in a haystack [M55-59]). * There was a common view among heterosexual participants that an orgasm completed sex or rounded it qff (1740-34); thus, a sooner-than-desired orgasm was problematic. Pain & * Pain considered by * Dyspareunia is discomfort all to be at odds defined as genital with a good-enough pain associated with sex life. Most sexual intercourse participants felt it in the DSM-IV TR. would be awful (1720-24) and * Painful distressing (M60- intercourse is 64) to experience a reasonably common level of pain that (Mercer et al., precluded sex or 2003). prevented enjoyment. * Participants felt * Pain is included that pain might also as an item in signal a deeper several measures- underlying physical for example, the problem in need of GRISS, the SFQ, and attention. the BISF-W. * Three participants described pain during intercourse, and all had found it problematic. A woman in her 40 s, with vulvodynia, described how constant pain had dominated her life, directly leading to depression; unemployment; and, ultimately, the break-up of her relationship. Enjoyment, * Around one-third * Sexual novelty, & of participants dissatisfaction is satisfaction spontaneously significantly mentioned enjoyment, associated with novelty, excitement, physical dysfunction satisfaction, or (Dunn, Croft, & related terms when Hackett, 2000; asked to describe Qberg, Fugl-Meyer, & ideal or functional Fugl-Meyer, 2004), sex. but it is still possible to report * In long-term satisfaction relationships, with one's sexual maintaining relationship at the excitement was often same time as regarded as an reporting sexual important challenge. difficulties (Read, King, & * For several Watson, 1997). participants with sexual difficulties, * Subjective a key concern was pleasure is that they had particularly stopped enjoying important to sex. women (Bancroft, Loftus, & Long, * Participants used 2003). the term "excite" or "excitement" * Lack of enjoyment variously to was often cited as a describe a state of problem by female arousal (feeling attendees at sexual excited ), the problem clinics experience of orgasm (Warner et al., (crescendo of sexual 1987). excitement ), as well as a feeling * Lack of enjoyment/ of attraction (they satisfaction is not find you sexually currently exciting [M55]). included in DSM-IV- TR, although several * The term measures include it "satisfaction" was as an item. used in a range of ways: either interchangeably with orgasm, to describe a specific encounter, or to talk about sex life overall. * Lack of satisfaction was described in various ways: feeling empty (1730-34), not getting what you wanted (1735-39), and not feeling content and complete (1745-49). Anxiety * Several * Link between respondents anxiety and poor described finding it sexual function is difficult to relax well established and let go. This (Purdon & Holdaway, hampered their 2006; Rosen & ability to receive Althof, 2008). pleasure and, thus, precluded good- enough sex. * Anxiety viewed * Anxiety is not both as a cause and regarded as a sexual outcome of other dysfunction in the difficulties. One DSM-IV-TR. man described how anxiety about his * It is often ability to perform included in measures sexually was the of sexual source of his dysfunction--for difficulties. He example, the GRISS recalled how and the SSS-W. concentrating too hard on making sex work (this must work, this has got to happen) led to anxiety, rather than enjoyment (M30-34). * For other participants, anxiety arose from (and subsequently reinforced) another problem. For one man in his 60s, the anxiety associated with his erectile difficulties eventually became the core problem: [The anxiety is more distressing] because I think this is the cause of it. I could,-eel myself becoming nervous. When 1 was feeling anxious 1 knew wouldn't be able to [get an erection]. Once I got to that state 1 knew that that was it (M60- 65). Frequency: * Frequency of sex * Lack of frequency Actual & viewed as an is not classified as relative to indicator of the a dysfunction, but desired level health of the is important to relationship. satisfaction (Smith et al., 2011). * Regular sex viewed as important in * Frequency can be maintaining affected by factors emotional connection such as duration of and keeping passion the relationship, alive (M55-59). fertility intentions, * Sex less than once and contraception per month viewed as (Schneidewind- problematic: an Skibbe, Hayes, indication that a Koochaki, Meyer, & relationship was Dennerstein, 2008). going humdrum very fast (1730-34). * Items on frequency of intercourse are * Particularly often included in problematic was an measures of sexual unexplained decrease dysfunction for in frequency. example, the BSFQ. * Some participants were concerned about the level of frequency relative to what was usual and desired within a particular relationship. Others were concerned about actual frequency per se. Criteria Decision Desire Item on desire included based on strong evidence from qualitative study and literature. Subjective Strong evidence to arousal, include specific lubrication, & items on lubrication erection and erectile difficulties. Based on qualitative study, item on subjective arousal/ excitement included. Orgasm: Ability Strong evidence to to reach, support inclusion of timing, & items on difficulty quality reaching orgasm and early orgasm. Item on quality not included because it overlaps with item on enjoyment, and there is insufficient evidence from the qualitative study to suggest that it was essential. Pain & Strong evidence from discomfort qualitative study and literature to support inclusion of item on pain. Enjoyment, Items on enjoyment novelty, & and overall satisfaction satisfaction included, supported by literature and particularly by qualitative data. We excluded novelty because the qualitative data suggested that it was desirable, rather than essential. Anxiety Anxiety included mainly on strength of qualitative evidence. Frequency: There is some Actual & evidence to support relative to inclusion of desired level frequency, but logically, it is more appropriately conceptualized as an outcome or correlate of a functional sex life. Note. All participant quotes are italicized. DSM-IV-TR=Diagnostic-and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000); GRISS=Golombok-Rust Inventory of Sexual Satisfaction (Rust & Golombok, 1985); BISF-W=Brief Index of Sexual Function for Women (Taylor, Rosen, & Leiblum, 1994); SFQ=Sexual Function Questionnaire (Quirk et al., 2002); BSFQ=Brief Sexual Function Questionnaire (Reynolds et al., 1988); SSS-W=Sexual Satisfaction Scale for Women (Meston & Trapnell, 2005). "F =female; M =male; numerical range relates to age group of respondent. Table 3. Summary of Evidence for Relational Criteria Criteria Findings From Evidence From Qualitative Data Literature Compatibility: In * Three dimensions * Among women, motive, in of compatibility partner roles, & in were identified. incompatibility is preferences associated with * Compatibility in distress and most of motive implied the sexual wanting sex for the dysfunctions same reasons. (Witting et al., Participants 2008). perceived a gender disparity, with * Compatibility in women more often preferences or motivated by libido types is intimacy and men often the focus of more often motivated self-help guides by physical (see Pertot, 2007; pleasure. among others). * Compatibility in * Compatibility is roles/identities included in several particularly measures-for concerned gay example, the GRISS participants because and the SSS-W. roles within their partnerships were often more fluid and required negotiation. Incompatibility might arise if one partner was openly gay and the other was not. * Compatibility in sexual preferences implied that suggestions from a sexual partner would not come as a profound shock (M60- 64)." Participants talked of disparities occurring where one partner desired activities that the other found repellent, leading the latter to feel under pressure and the former to feel frustrated. * Incompatibility in preferences arose where one partner had a sexual difficulty or condition, such as HIV, and felt they could no longer give their partner what he or she wanted. It could also arise through simple inability to communicate preferences. Emotional * An emotional * Among women in connection and connection was particular, chemistry implied in a range relationship of descriptions of a criteria, such as good sex life: an emotional emotional connection, are identification (M75- linked to sexual 79); mentally in satisfaction tune (1735-39). (Bancroft, Loftus, & Long, 2003). * An emotional connection was about * Loss of "spark" feeling a real sort within a of bond or love for relationship is a that person ... common reason for [enabling you to] seeing a almost let yourself relationship go with the way you counsellor (see express yourself 2007; among others). physically (1735- 39). * Several existing measures include * Lack of connection items on Perel, viewed as connection and detrimental to closeness between sexual satisfaction. partners-for One woman described example, the FSFI feeling empty and and the SFQ. used when her partner failed to make eye contact during sex or had his own agenda (1730-35). * Within a relationship, a loss of connection implied a partner closing down and being withdrawn (1750-54), a loss of rapport, or a relationship that is not going to go anywhere (1720-24). * Participants frequently used the term "chemistry." It was described as an animal spark (M50- 54) that often occurred suddenly and inexplicably. Balance in levels * Equivalence in * Balance in levels of desire, level of sexual of desire considered reciprocity desire between important (Davies, partners commonly Katz, & Jackson, viewed as key to a 1999; Levine, 2003). good sexual relationship, but * It has even been difficult to suggested that achieve: one always sexual desire ought wants it more than to be re- the other (1745- conceptualized 49). primarily as a relational problem * Imbalance (Clement, 2002; recognized as a Zilbergeld & source of arguments Ellison, 1980). or difficulties in the relationship * Despite this, (1725-29). discrepancy in desire is rarely * Participants who included in measures wanted sex less than (exceptions include their partner the GRISS). described feeling pressure to have sex, or guilt: I sometimes feel ... a bit guilty afterwards .... I think that he thinks I'm still pushing him away (M50-54). There was also a fear that a partner would decide to go outside [the relationship] (M55- 59). * Participants who wanted sex more than their partner found it difficult not to interpret a partner's low desire as rejection: I would find it hard to feel the confidence that they were sexually interested in me (1730-34). * Reciprocity- willingness to give and receive (pleasure) in roughly equal measure was important for a good-enough sexual encounter. In the longer term, reciprocity-each partner working at the sexual relationship, taking turns to initiate- was considered important. Difficulties * Nine participants * Co-morbidity experienced by described between partners is a partner relationships in common; in up to which they perceived one-third of that their partner patients with sexual had the primary problems, the difficulty. partner also has a sexual dysfunction * Common themes in (Gregoire, 1999). these accounts included feelings of * Clinical rejection, loss of interviews usually confidence, ask about frustration, and a difficulties gradual erosion of experienced by a desire. partner. * In particular, two * This is rarely women described included in measures having partners who, (an exception is the due to sexual SFQ). difficulties, had declined to have sex for many years. Both women described the detrimental impact on their self- esteem, sexual identity, their relationship, and beyond. Trust, warmth, & * A group of * Relationship feeling wanted criteria were adjustment--an identified related absence of to psychological relationship security (a comfort difficulties--is an zone) within a important relationship: trust, contributor to warmth, feeling sexual function wanted. (Bancroft et al., 2003; King, Holt, & * These criteria Nazareth, 2007) were particularly important to those within long-term relationships and those prioritizing the interpersonal. Criteria Decision Compatibility: In Compatibility in motive, in sexual preferences roles, & in included based preferences mainly on qualitative evidence. Compatibility in motive for sex and compatibility in sexual roles/ identities both excluded. Logically speaking, they predispose or precipitate difficulties within a couple (i.e., they are associated factors). There is also some overlap between compatibility in roles/identities and compatibility in sexual preferences to the extent that agreement about what to do sexually requires prior agreement about individual roles and identities. Emotional Based primarily on connection and our qualitative chemistry data, an item on emotional connection was included. The term "chemistry" was excluded because, in our qualitative data, it was generally viewed as desirable, rather than necessary. The notion of chemistry might also overlap with the concept of arousal. Balance in levels Item on equal desire of desire, included based on reciprocity strong evidence from qualitative data, as well as the literature. Reciprocity excluded. Conceptually, reciprocity and equal desire overlap, but there is stronger evidence for equal desire both from our data and from the literature. Difficulties Item included based experienced by on qualitative data a partner and evidence from clinical literature. Trust, warmth, & All three items feeling wanted excluded on the basis that they are associated with sexual function, rather than part of the construct (i.e., they contribute to function, and may also develop from a functional sexual relationship). In addition, there is overlap between feeling wanted and balance in desire between partners (mutually desiring each other). Note. All participant quotes are italicized. GRISS=Golombok-Rust Inventory of Sexual Satisfaction (Rust & Golombok, 1985); SSS- W=Sexual Satisfaction Scale for Women (Meston & Trapnell, 2005); FSFI=Female Sexual Function Index (Rosen et al., 2000); SFQ=Sexual Function Questionnaire (Quirk et al., 2002). (a) F=female; M =male; numerical range relates to age group of respondent. Table 4. Conceptual Framework of Sexual Function Psycho-physiological aspect Relational aspect P1 Desire for sex R1 Compatibility in sexual preferences P2 Lubrication (F)/erectile R2 Emotional connection function (M) P3 Sexual arousal/excitement R3 Balance in levels of desire P4 Orgasm-ability to reach R4 Partner does not have sexual difficulties P5 Orgasm-not too early Overall self-rating aspect P6 Absence of discomfort/pain SR4 Overall satisfaction P7 P7 Enjoyment SR5 Not avoiding sex anxiety SR6 Perception that no problem exists Severity (if difficulty present) SR7 Overall lack of distress/worry SRI Duration since SR8 Not seeking onset of difficulty SR2 Frequency with professional help which symptoms occur SR3 Distress caused by symptoms Criteria excluded from the framework: Functional sexual self Relational Happy body feeling (AF) Trust (AF) Able to give and Warmth (AF) receive pleasure (AF) Positive sexual identity (AF) Feeling wanted (AF/OV) Confidence to Compatibility in communicate needs (AF) motive for sex (AF/OV) Positive motives to Compatibility in have sex (AF) sexual roles/ identities (AF/OV) Reciprocity (OV) Chemistry (PH/OV) Psycho-physiological Novelty (PH) Quality of orgasmic Contextual experience (OV/PH) Actual frequency Stress and tiredness (AF) relative to desired (AF) Actual frequency (AF) Privacy (AF) Note. AF=criterion is associated with sexual function, rather than belonging to the construct; OV=criterion overlaps with another criterion; PH=criterion does not represent public health burden (respondents viewed it as desirable, rather than essential); SR = self-rating.…