Love Hurts: The Description and Measurement of Sexual and Relationship Distress in Couples

Abstract

Sexual disorders are highly prevalent, yet under researched when compared to other DSM-5 diagnoses. Sexual desire, in particular, is the most prevalent sexual concern for women, and substantially impacts the individual with low sexual desire, as well as their partner and the relationship. While the symptom clusters that comprise sexual desire and other dysfunctions are heterogeneous, they all require the presence of ‘distress’ in order to meet diagnostic criteria (American Psychiatric Association, 2013). The construct of distress is receiving increasing empirical interest, although the research to date remains in its infancy, suffers from a number of methodological flaws, and has focused on the individual rather than the relationship. Along with the wave of research investigating sexual distress, has come the development of psychometric measures to assess the construct. Indeed, the International Consensus Development Conference on Female Sexual Dysfunction (Basson et al., 2000), and the Third International Consultation on Sexual Medicine (Clayton et al., 2010) have highlighted the need for new validated measures of sexual distress. Although a number of psychometrically validated measures have been developed, they have focused exclusively on the individual experiencing the distress, to the exclusion of the partner involved and the relationship more generally. This thesis is divided into two sections: a literature review and a series of papers that have been published or submitted for publication. Section 1 (Chapters 1-5) reviews the literature on sexual dysfunctions and disorders generally, and sexual desire more specifically, with a focus on sexual distress and its measurement. Chapter 1 provides a description of common sexual disorders within the context of models of the human sexual response, as well as their prevalence and risk factors. Chapter 2 focuses primarily on low sexual desire, providing a detailed overview beginning with a description of the construct of sexual desire and introducing the history of sexual desire disorders within the Diagnostic and Statistical Manuals. In Chapter 3, information pertaining to the epidemiology and aetiology of sexual disorders is presented, while Chapter 4 provides a review of treatment strategies for low sexual desire. Finally, Chapter 5 focuses on sexual distress and provides a review of the current gold standard measures available. Section 2 (Chapters 6-9) consists of a discussion paper and two research studies that have been submitted or accepted for publication. Chapter 6 (and Appendix S) presents a discussion paper published in the Journal of Sexual and Relationship Therapy (Frost & Donovan, 2015), that outlines the difficulties associated with operationalising the construct of sexual distress, and questioning whether we have the literature base to determine the differences between ‘normal’ and ‘abnormal’ levels of sexual desire in women, particularly when it appears to be a potentially normative response to a range of life circumstances. Given the movement within this field to view sexual desire from a couples perspective, and the difficulties experienced when treating low sexual desire in women, this paper concludes that sexual distress may in and of itself be an important research and treatment target. Chapter 7 outlines a qualitative study investigating the distress and consequences experienced by women with low sexual desire and their partners (submitted to the Journal of Sexual and Relationship Therapy). For this study, semistructured interviews were conducted with 26 participants (13 couples), and thematic analysis revealed 29 conceptually distinct forms of distress and consequence. Despite the complex and multi-faceted nature of distress, results of the study suggest that the nature of individual and relationship distress, as experienced by men and women, is strikingly similar. Chapter 8 outlines a study conducted to develop and psychometrically validate, a new measure of sexual and relationship distress. An initial pool of 73 items was created from the results of the earlier qualitative study outlined in Chapter 7, and administered using an online survey to 1,381 participants (462 men, 904 women and 14 who identified as ‘other’), along with measures for the purposes of psychometric evaluation including the FSDS-R, CSI-16, DASS-21, and questions relating to sexual function. Exploratory (EFA) and Confirmatory Factor analyses (CFA) in separate split-half samples were conducted, and resulted in a psychometrically sound 30-item, 14 factor measure of sexual and relationship distress. The SaRDS improves upon other available measures due to its ability to be administered to both men and women, as well as the partner of an individual with any perceived or diagnosable sexual dysfunction. It also includes both sexual and relationship distress, and has the ability to provide both subscale and total scores. This study has been accepted for publication by the Journal of Sexual Medicine (Frost & Donovan, 2018). The SaRDS has also been accepted for publication in the new edition of the Handbook of Sexuality-Related Measures (Frost & Donovan, 2019), the manuscript for which is presented in Chapter 9. The overall aim of these studies is to gain a deeper understanding of the distress and consequences experienced by both members of a couple when sexual difficulties are present within their relationship and to use these findings to create a new measure of sexual distress. While the first study recruited women with low sexual desire and their partners, the results showed equivalence in experience across gender and type of sexual difficulty. The measure created using the items developed from the first qualitative study supported these findings as it was developed and validated in a community sample who reported a wide variety of sexual difficulties. Chapter 10 provides a discussion of the overall findings from these studies, and presents the strengths and limitations of the program of research as well as clinical implications and suggestions for future research, for the program of research as a whole. This thesis makes a unique and valuable contribution to our understanding and measurement of sexual and relationship distress within the context of sexual difficulties, and provides a foundational platform from which future research can build.