The relationship between anxiety and sexual functioning in lesbians and heterosexual women

Sexual Satisfaction among Lesbian and Heterosexual Cisgender Women: A Systematic Review and Meta-Analysis

BACKGROUND

Sexual satisfaction is a complex, multifaceted, and broad concept that is influenced by several factors. The minority stress theory posits that sexual and gender minorities are at a particular risk for stress due to stigma and discrimination at the structural, interpersonal, and individual levels. The aim of this systematic review and meta-analysis was to evaluate and compare the sexual satisfaction between lesbian (LW) and heterosexual (HSW) cisgender women.

METHODS

A systematic review and meta-analysis were conducted. We searched the PubMed, Scopus, Science Direct, Websci, Proquest, and Wiley online databases from 1 January 2013 to 10 March 2023 to identify the published observational studies on sexual satisfaction in women according to their sexual orientation. The risk of bias in the selected studies was assessed using the JBI critical appraisal checklist for the analytical cross-sectional studies.

RESULTS

A total of 11 studies and 44,939 women were included. LW reported having orgasms during a sexual relationship more frequently than HSW, OR = 1.98 (95% CI 1.73, 2.27). In the same direction, the frequency of women reporting "no or rarely" for having orgasms during their sexual relationships was significantly lower in the LW than the HSW, OR = 0.55 (95% CI 0.45, 0.66). The percentage of the LW who reported having sexual intercourse at least once a week was significantly lower than that of the HSW, OR = 0.57 for LW (95% CI 0.49, 0.67).

CONCLUSIONS

Our review showed that cisgender lesbian women reached orgasm during sexual relations more often than cisgender heterosexual women. These findings have implications for gender and sexual minority health and healthcare optimization.

Validation of the adapted female sexual function index among Chinese cisgender heterosexual women and sexual and gender minority women

BACKGROUND

The Female Sexual Function Index (FSFI) remains the most widely used scale for assessing female sexual function. However, while an adapted version of the FSFI has been proven to be suitable for Western sexual minority women, it has yet to be used in China.

AIM

This study aimed to validate the Mandarin Chinese version of the adapted FSFI among Chinese cisgender heterosexual women and sexual and gender minority women, and evaluate its psychometric properties.

METHODS

A cross-sectional online survey was conducted. The modified scoring method related to zero responses was examined, and structural validity, internal consistency, internal reliability, convergent validity, and known-group validity were evaluated.

OUTCOMES

The primary measure was the adapted FSFI, and the Positive Sexuality Scale and the New Sexual Satisfaction Scale-Short Form were used to test convergent validity.

RESULTS

A total of 431 Chinese adult women were recruited, including 193 cisgender heterosexual women and 238 sexual and gender minority women. Confirmatory factor analysis using the original scores supported the original 6-factor model. Using both Cronbach's α and McDonald's ω, the results showed that the values of the total scale and 6 subscales were in the 0.76 to 0.98 and 0.83 to 0.98 ranges, respectively, indicating satisfactory reliability. Moderate-to-strong correlations among the total FSFI scores and positive sexuality and sexual satisfaction were found (r = 0.32-0.71), supporting good convergent validity.

CLINICAL IMPLICATIONS

The adapted FSFI facilitates the use of more inclusive language in the clinical setting, allowing for a more comprehensive and unbiased assessment of sexual function in all women.

STRENGTHS AND LIMITATIONS

This study recruited both cisgender women of varied sexual orientations and gender minorities who were assigned female at birth, demonstrating that the adapted FSFI could be suitably applied to sexual minority populations. However, from a fully inclusive perspective of sex and gender, there is no research on how to accurately evaluate transgender women with female external genitalia or appropriately assess those with a female reproductive system but who do not self-identify as female. Therefore, more in-depth research is needed to further revise the FSFI for better use in the wider female population.

CONCLUSION

This Chinese version of the adapted FSFI has good psychometric properties and is a reliable and valid instrument to assess female sexual function. Furthermore, the modified scoring method could be an effective alternative among samples of sexually inactive women.

Quality of Life and Mental Health of Chinese Sexual and Gender Minority Women and Cisgender Heterosexual Women: Cross-sectional Survey and Mediation Analysis

BACKGROUND

Health-related research on sexual minority populations in China is lacking, and research on sexual and gender minority women (SGMW, including transgender women and persons of other gender identities assigned female at birth of all sexual orientations, and cisgender women with nonheterosexual orientations) is even less. Currently, there are limited surveys related to mental health in Chinese SGMW, but there are no studies on their quality of life (QOL), no studies comparing the QOL of SGMW with that of cisgender heterosexual women (CHW), and no studies on the relationship between sexual identity and the QOL as well as associated mental health variables.

OBJECTIVE

This study aims to evaluate the QOL and mental health in a diverse sample of Chinese women and make comparisons between SGMW and CHW and then investigate the relationship between sexual identity and the QOL through the role of mental health.

METHODS

A cross-sectional online survey was conducted from July to September 2021. All participants completed a structured questionnaire containing the World Health Organization Quality of Life-abbreviated short version (WHOQOL-BREF), the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

In total, 509 women aged 18-56 years were recruited, including 250 (49.1%) CHW and 259 (50.9%) SGMW. Independent t tests showed that the SGMW reported significantly lower levels of QOL, higher levels of depression and anxiety symptoms, and lower self-esteem than the CHW. Pearson correlations showed that every domain and the overall QOL were positively associated with mental health variables, with moderate-to-strong correlations (r range 0.42-0.75, P<.001). Multiple linear regressions found that participants belonging to the SGMW group, current smokers, and women with no steady partner were associated with a worse overall QOL. The mediation analysis found that depression, anxiety, and self-esteem significantly completely mediated the relationship between sexual identity and physical, social, and environment domains of the QOL, while the relationship between sexual identity and the overall QOL and psychological QOL was partially mediated by depression and self-esteem.

CONCLUSIONS

The SGMW had poorer levels of QOL and a worse mental health status than the CHW. The study findings affirm the importance of assessing mental health and highlight the need to design targeted health improvement programs for the SGMW population, who may be at higher risk of a poor QOL and mental health.

Norwegian Data on Prevalence, Sexual Risk Behaviors, Sexual Problems, and Sexual Satisfaction in Women Who Have Sex Exclusively with Women, Women Who Have Sex Exclusively with Men, and Women Who Have Sex with Men and Women

Objective

The study explores the difference between Women Who Have Sex Exclusively with Men (WSEM), Women Who Have Sex Exclusively with Women (WSEW), and Women Who Have Sex with Women and Men (WSWM).

Method

The data were obtained from a survey of a probability-based web sample of 1967 Norwegian women.

Results

Most WSWM identified themselves as heterosexuals (76.3%), and three out of 10 used a condom when having sex with a new partner. The highest number of sex partners during the last year was reported by WSWM. More WSEW than the other categories reported premature orgasm.

Conclusions

WSWM should be targeted in health campaigns.

Sexual Wellness in Cisgender Lesbian, Gay, and Bisexual People

Cisgender sexual minority persons have sexual wellness needs that go well beyond disease prevention. Despite historical asymmetries in research and clinical attention to sexual wellness in cisgender lesbian, gay, and bisexual persons, a growing body of evidence exists on how to optimally care for these populations. Additional research and development is warranted.

Changes in Sexual Desire and Behaviors among UK Young Adults During Social Lockdown Due to COVID-19

This study examined self-reported changes in young adults' sexual desire and behaviors during the most significant social restrictions imposed to deal with COVID-19. Drawing on a survey of 565 British adults aged 18-32 collected at the peak of social lockdown restrictions, we document an overall decrease in sexual behaviors consistent with abiding by social restrictions. We found that the levels of sexual desire reported by women (but not men) decreased compared with reports of pre-lockdown levels. Participants in serious relationships reported more increases in sexual activity than people who were single or dating casually, and there were significant differences according to gender and sexual orientation. The perceived impact of subjective wellbeing of people with high sociosexuality scores was disproportionately associated with social lockdown but there was no effect for general health. Thus, the impact on sexuality and general wellbeing should be considered by policymakers when considering future social restrictions related to COVID-19 or other public health emergencies.

Measurement invariance of Female Sexual Function Index: a study with heterosexual and lesbian Portuguese women

The Female Sexual Function Index is a powerful screening tool for female sexual dysfunction extensively used worldwide. Nonetheless, its factorial structure and psychometric properties have been tested almost exclusively with heterosexual samples. The current study aimed to testing the original factorial structure, reliability and temporal stability in two samples of women (heterosexual and lesbian), and to assess the measurement invariance across sexual orientation. An online sample of 752 Portuguese women (376 lesbian women and 376 heterosexual women) recruited between May 2012 and 2013 participated in the study and completed a sociodemographic questionnaire and the FSFI. For temporal stability, 30 Portuguese women were recruited online in May 2017. Confirmatory factor analysis, reliability analysis and temporal stability were assessed independently for each sample. Measurement invariance (configural, metric, and scalar) was also assessed. Main findings for both samples corroborate the six-factor structure and revealed excellent levels of temporal stability, with Cronbach alphas and McDonalds Omega of .95 for heterosexual sample, and .96 for lesbian women sample. Results corroborate measurement invariance (configural, metric, and scalar) across sample type. Overall, the FSFI revealed a good-fit for the six-factor model in both heterosexual and women sample, with excellent levels of reliability and temporal stability, and showed measurement invariance across sexual orientation. These findings support the use of the FSFI with lesbian women.

Gender Similarities and Differences in Casual Sex Acceptance Among Lesbian Women and Gay Men

Popular wisdom and scientific evidence suggest women desire and engage in casual sex less frequently than men; however, theories of gender differences in sexuality are often formulated in light of heterosexual relations. Less is understood about sexual behavior among lesbian and gay people, or individuals in which there is arguably less motivation to pursue sex for reproductive purposes and fewer expectations for people to behave in gender-typical ways. Drawing from scripts theory and pleasure theory, in two studies (N₁ =  465; N₂ =  487) we examined lesbian and gay people's acceptance of casual sex. We asked participants who had been propositioned for casual sex whether they accepted the offer and to rate their perceptions of the proposer's sexual capabilities and sexual orientation. They also reported on their awareness of stigma surrounding casual sex. We found a gender difference in acceptance: Gay men were more likely than lesbian women to have accepted a casual sex offer from other gay/lesbian people, and this difference was mediated by participants' stigma awareness. We also found the proposer's sexual orientation played a role in people's acceptance. Lesbian women and gay men were equally likely to accept offers from bisexual proposers but expressed different acceptance rates with "straight-but-curious" proposers, which was mediated by expected pleasure. We discuss dynamics within lesbian and gay communities and implications for studying theories of sexual behavior and gender differences beyond heterosexual contexts.

Roles of Genital Self-Image, Distraction, and Anxiety in Women's Sexual Pleasure: A Preregistered Study

Women with negative genital self-image are more likely to experience sexual dysfunction , but the processes underlying this association are unknown. We theorized that this association is mediated by distraction from the arousing sexual cues that foster pleasure and orgasm . In a sample of 1,619 women who had sex in the previous four weeks, women with negative genital self-image were more likely to be distracted by self-critical concerns (i.e., appearance- and performance-based distraction and embarrassment) during sex, and in turn, experienced less sexual pleasure and worse sexual function. Additionally, this indirect effect via appearance-based distraction was strongest among women with trait-level anxiousness and social anxiety. We found a similar pattern of results when investigating the indirect effect of genital self-image on sexual function. Implications for understanding sexual function and therapeutic approaches are discussed.

A Structural Equation Model of Sexual Satisfaction and Relationship Functioning Among Sexual and Gender Minority Individuals Assigned Female at Birth in Diverse Relationships

While there is a sizeable literature on sexual satisfaction among male-female mixed-sex couples, research examining other types of relationships (e.g., same-sex) is limited. The current study aimed to broaden our understanding of sexual satisfaction across the diverse relationships of sexual and gender minority individuals assigned female at birth (SGM-AFAB) and inform models of sexual satisfaction for this population. We examined: (1) differences in sexual satisfaction and characteristics of sexual activity (frequency of sex, frequency of orgasm, duration of sex) by relationship type (same-sex, mixed-sex, gender-diverse) among SGM-AFAB; (2) a model of sexual satisfaction and its correlates; and (3) differences in this model by relationship type. Results indicated cisgender women in relationships with cisgender women (same-sex) reported higher duration of sex, frequency of orgasm, and sexual satisfaction compared to cisgender women in relationships with cisgender men (mixed-sex). There were few differences in characteristics of sexual activity between SGM-AFAB in gender-diverse relationships (involving one or more gender minority partners) and those in same- or mixed-sex relationships. Results indicated similarities across relationship types in a model of sexual satisfaction and its correlates. For all relationship types, more frequent and longer duration of sexual activity predicted higher orgasm frequency, more frequent orgasm predicted higher sexual satisfaction, and higher sexual satisfaction predicted better relationship functioning. Only the association between orgasm frequency and sexual satisfaction varied by relationship type. As one of the first studies examining sexual satisfaction among SGM-AFAB in mixed-sex and gender-diverse relationships, findings substantially further our understanding of sexual satisfaction in this population.

Are Women's Orgasms Hindered by Phallocentric Imperatives?

Women who have sex with women (WSW) are more likely to report experiencing an orgasm during partnered sex, compared to women who have sex with men (WSM). We investigated whether this difference can be partially accounted for by phallocentric imperatives-gendered sexual scripts that prioritize men's sexual experience. For example, these imperatives emphasize vaginal-penile intercourse (i.e., the coital imperative) and men's physical pleasure (i.e., the male orgasm imperative). We reasoned that a larger variety of sexual behaviors indicates less adherence to the coital imperative and that more self-oriented orgasm goals for women indicate less adherence to the male orgasm imperative. Consistent with previous work, we expected WSW to report higher rates of orgasm than WSM when taking frequency of sex into account. We also hypothesized that this difference in orgasm rates would dissipate when controlling for variety of sexual behavior and women's self-oriented orgasm goals. In a sample of 1988 WSM and 308 WSW, we found that WSW were 1.33 times (p < .001) more likely to report experiencing an orgasm than WSM, controlling for frequency of sex. This incidence rate ratio was reduced to 1.16 (p < .001) after taking into account variety of sexual behavior and self-oriented orgasm goals. Our findings indicate that certain sexual scripts (e.g., phallocentric imperatives) help explain the orgasm discrepancy between WSW and WSM. We discuss masturbation as another male-centered practice that may be relevant to this gap, as well as implications for intervention and future research.

Healthcare Mistreatment and Avoidance in Trans Masculine Adults: The Mediating Role of Rejection Sensitivity

Objectives

Given that prior mistreatment can lead to heightened vigilance to and perceptions of future rejection, the present study examined whether this heightened vigilance, known as rejection sensitivity, mediates the association between healthcare mistreatment and healthcare avoidance in trans masculine (TM) adults.

Method

Between 2015 and 2016, 150 TM adults completed a comprehensive survey assessing socio-demographics, sexual health, and healthcare experiences. A 5-item scale assessing participants' sensitivity to rejection in healthcare scenarios was administered and psychometrically evaluated. Structural equation modeling was used to test whether rejection sensitivity in healthcare mediated the relationship between lifetime mistreatment in healthcare and past 12-month healthcare avoidance among TM adults.

Results

Overall, 68% of participants had experienced some form of mistreatment in healthcare in their lifetime and 43% had avoided healthcare in the past 12 months. For 5% of the sample, healthcare avoidance in the past 12 months resulted in a medical emergency. Path analyses revealed that healthcare mistreatment was positively correlated with rejection sensitivity and sensitivity was positively correlated with past 12-month healthcare avoidance. Rejection sensitivity mediated the relationship between mistreatment and healthcare avoidance (all p-values < 0.05).

Conclusion

Rejection sensitivity may contribute to healthcare avoidance among stigmatized TM patients; however, longitudinal research is needed to establish the temporal ordering of these processes. Multilevel interventions to reduce healthcare discrimination and help TM adults cope with the psychological and behavioral consequences of stigma are recommended.

Sexual well-being of sexual minority women in dating relationships who have experienced childhood sexual abuse and/or adolescent and adult sexual victimization

Few studies have examined the sexual sequelae of child sexual abuse (CSA) for sexual minority women (SMW), particularly SMW in dating relationships. We examined the impact of CSA on several aspects of sexual well-being. Participants were 299 SMW in a non-cohabiting dating relationship who completed an online survey that assessed CSA, adolescent and adult sexual victimization (AASV) and their behavioural, motivational, and cognitive-affective sexual responses. Four groups were formed based on sexual abuse experiences before the age of 14: No lifetime sexual abuse (NSA Group); AASV only (AASV Group); CSA limited to fondling (CSAfon Group); and, CSA involving attempted/completed vaginal, oral and/or anal penetration (CSApen Group). Women in the CSAfon and CSApen groups were significantly more likely to report having experienced AASV (77% and 56%, respectively) than were women in the AASV and NSA groups (32%). Women in the CSApen Group reported significantly lower sexual desire and sexual satisfaction, and more frequent negative automatic sexual thoughts than women in the other groups but no differences in their frequency of sexual behaviours, sexual duration, sexual esteem, or sexual anxiety. The AASV Group did not differ from the NSA Group on any of the sexual well-being variables. Overall, women in all four groups generally reported positive sexual well-being. These results suggest CSA involving attempted/completed penetration with or without subsequent AASV negatively affects only some aspects of SMW's sexual well-being. They also suggest SMW who have experienced sexual abuse can and do enjoy healthy sexual well-being within the context of a dating relationship.

Differential Associations of Communication and Love in Heterosexual, Lesbian, and Bisexual Women's Perceptions and Experiences of Chronic Vulvar and Pelvic Pain

The literature on genital and pelvic pain has largely focused on heterosexual women. An online study examined characteristics of vulvar pain in 839 lesbian, bisexual, and heterosexual women 18-45 years of age and investigated associations between relationship qualities such as love and communication with participants' perceptions of pain's influence on relationships. Characteristics of vulvar pain were similar across groups. Groups differed in how they perceived pain to impact their relationships, such that better communication for same-sex couples and more love for mixed-sex couples was associated with the perception of their pain as having less of an effect on their relationship functioning.

Prevalence of sexual problems and associated distress among lesbian and heterosexual women

Prevalence studies on female sexual problems among heterosexual samples have been conducted extensively across different countries. However, relatively little is known regarding prevalence of sexual problems in lesbians. The present study aimed to assess and compare the frequency of self-perceived sexual problems and associated levels of distress in lesbians and heterosexual women. In all, 390 lesbians and 1,009 heterosexual women completed an online survey. The authors assessed the frequency of self-perceived sexual problems in lesbians and heterosexual women, over the past 6 months, as well as the associated levels of distress. Main results suggested that, after controlling for distress levels, sexual pain was the most frequent sexual problem reported by lesbians and heterosexual women. Also, when distress was considered a significant decrease on prevalence rates of sexual problems were found for both lesbians and heterosexual women. Current findings emphasize the role of associated levels of distress to self-perceived sexual problems in women, regardless of sexual orientation. In addition, results suggest that length of relationship play a major role on sexual problems. Overall, data indicated a relatively similar pattern in prevalence of sexual problems in lesbians and heterosexual women.

Non-erotic cognitive distractions during sexual activity in sexual minority and heterosexual young adults

The present study examined 100 lesbian and gay college students and 100 heterosexual students to determine whether group differences exist in frequency of a range of non-erotic cognitive distractions during sexual activity. Non-erotic cognitive distraction is a descriptive term for both self-evaluative cognitions related to physical performance and body image concerns, as well as additional cognitive distractions (e.g., contracting an STI or emotional concerns) during sexual activity. Participants were matched on gender (96 males and 104 females), age, and ethnicity, and completed questionnaires assessing frequency of non-erotic cognitive distractions during sexual activity, as well as measures of additional variables (trait and body image anxiety, attitudes toward sexual minorities, self-esteem, and religiosity). Results indicated that sexual minorities experienced significantly more cognitive distractions related to body image, physical performance, and STIs during sexual activity than heterosexuals. Regarding gender, men reported more distractions related to STIs than women. Interaction effects were observed between sexual orientation and gender for body image-, disease-, and external/emotional-based distractions. Implications of these findings are discussed.

An Internet survey of demographic and health factors associated with risk of sexual dysfunction in women who have sex with women

INTRODUCTION

There has been scant attention to predictors of sexual dysfunction in women who have sex with women (WSW).

AIM

To investigate the associations of high risk for sexual dysfunction in an Internet cohort of WSW.

MAIN OUTCOME MEASURE

A modified version of the Female Sexual Function Index (FSFI) was used to quantify each subject's sexual function.

METHODS

Women who have sex with women were invited to participate in an Internet-based survey by invitations posted on e-mail listservs and on social media sites catering to WSW. Ethnodemographic, health status, and sexual/relationship data were collected.

RESULTS

The study was completed by 2,433 adult women. Of these, 1,566 participants had complete data on the FSFI and comprised the study cohort; 388 (24.8%) met the FSFI criteria for high risk of female sexual dysfunction (HRFSD). On multivariable analysis, the following variables were found to be independently associated with the HRFSD; moderate or severe subjective bother regarding sexual function (OR 4.8, 95% CI 3.0-7.9 and 13.7, 95% CI 7.5-25.1, respectively), overactive bladder (OAB) (OR 2.1, 95% CI 1.0-4.5), having a nonfemale or no partner (OR 2.3, 95% CI 1.1-4.7 and 3.2, 95% CI 2.0-5.2, respectively). A history of pregnancy was associated with lower odds of HRFSD (OR 0.567, 95% CI 0.37-0.87). Mean FSFI domain scores for all domains except desire were negatively impacted by partner factors and OAB.

CONCLUSIONS

A single-item question on sexual bother is strongly predictive of potentially distressing sexual problems in the WSW. A number of health and social factors are associated with risk of sexual problems in the WSW. Assessment of sexual well-being in the WSW is a priority for practicing healthcare providers.

An assessment of body appreciation and its relationship to sexual function in women

Objectification theory posits internalization of an observer's gaze may negatively impact women's feelings about their bodies, which may subsequently affect their sexual function. Subjective body image and body size (i.e., body mass index [BMI]) have mixed relationships to women's sexuality, but assessment of positive body image as a sign of resistance to objectification has not been researched. This study explored relations between body appreciation and sexual function in women and assessed whether body size impacted this relationship. Cross-sectional data were collected online from 247 women, ages 18 to 58. Body appreciation scores were modestly negatively correlated with BMI, while BMI was not related to sexual function scores. After controlling for sexual orientation, partner status, and age, body appreciation predicted the arousal, orgasm, and satisfaction aspects of sexual function. Practitioners' encouragement of body appreciation may improve sexual function in a way that encouraging a reduction in body size may not.

Confirmatory factor analysis of the female sexual function index

The Female Sexual Functioning Index (Rosen et al., 2000 ) was designed to assess the key dimensions of female sexual functioning using six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. A full-scale score was proposed to represent women's overall sexual function. The fifth revision to the Diagnostic and Statistical Manual (DSM) is currently underway and includes a proposal to combine desire and arousal problems. The objective of this article was to evaluate and compare four models of the Female Sexual Functioning Index: (a) single-factor model, (b) six-factor model, (c) second-order factor model, and (4) five-factor model combining the desire and arousal subscales. Cross-sectional and observational data from 85 women were used to conduct a confirmatory factor analysis on the Female Sexual Functioning Index. Local and global goodness-of-fit measures, the chi-square test of differences, squared multiple correlations, and regression weights were used. The single-factor model fit was not acceptable. The original six-factor model was confirmed, and good model fit was found for the second-order and five-factor models. Delta chi-square tests of differences supported best fit for the six-factor model validating usage of the six domains. However, when revisions are made to the DSM-5, the Female Sexual Functioning Index can adapt to reflect these changes and remain a valid assessment tool for women's sexual functioning, as the five-factor structure was also supported.