Factors shaping women’s sexual satisfaction: a comparison of medical and social models

Since the introduction of Viagra in 1998, pharmaceutical giants have been scrambling to develop a similar drug to treat ‘sexual dysfunction’ in women. In 1999, female sexual dysfunction (FSD), an umbrella term for a variety of different sexual ‘dysfunctions’, became an official disorder. FSD is one example of the medicalization of female sexuality whereby problems are defined, conceptualized, and solved in medical terms while ignoring the social, cultural, and psychological factors that shape women’s sexual health. Based on a sample of 311 sexually active women, this work explores the influence of both social factors and sexual dysfunction on sexual satisfaction. Results show that social factors explain more of the variation in sexual satisfaction than sexual dysfunction alone.

Keywords: sexual satisfaction; sexual dysfunction; social factors; stress; women’s health

Introduction

Medicalization is a process that refers to the application of a medical perspective to

hitherto non-medical behaviors and phenomena. It includes medical definitions, medical

terminology, and medical solutions to previously non-medical issues (Conrad and

Scheider 1980, Conrad 1992, 2007). Non-medical issues become medical problems

through the interactions of scientific technology, scientism, advertising, and the

patient/medical community. The conditions are then treated through medical solutions

such as pharmacology. Contemporary examples of the transformation of everyday

experiences into medical problems include shyness to ‘generalized anxiety disorder’

(GAD), rambunctious children into those that suffer from ‘attention deficit hyperactivity

disorder’ (ADHD), and unpleasant menstrual symptoms as ‘premenstrual dysmorphic

disorder’ (PMDD) (Ridberg 2006, Conrad 2007). Conrad (2007) has noted that women

have been disproportionally medicalized, citing examples such as depression,

menstruation, and, now, female sexual function. All of these ‘disorders’ can be diagnosed

using the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition (DSM-IV-TR) (American Psychiatric Association 2000) and can be treated

with pharmaceuticals. In the current work, we explore how well women’s sexual

dysfunction, compared to social desire variables, explains sexual satisfaction. If social

variables significantly shape variation in reported sexual satisfaction, pharmaceuticals

would be of limited value.

q 2013 Taylor & Francis

*Corresponding author. Email: eturner@odu.edu

Journal of Gender Studies, 2014

Vol. 23, No. 1, 69–80, http://dx.doi.org/10.1080/09589236.2012.752347

Defining female sexual dysfunction

In 1998, the Consensus Conference on female sexual function (by the Sexual Function

Health Council of the American Foundation for Urological Disease) helped solidify the

official definitions of female sexual dysfunction (FSD) (Tiefer 2006). Sexual dysfunction

is defined by the DSM-IV-TR as ‘ . . . a disturbance in the process that characterize the

sexual response cycle or by pain associated with sexual intercourse’ (American

Psychiatric Association 2000, p. 535). FSD is an umbrella term that includes sexual issues

with desire (hypoactive sexual desire disorder, HSDD), arousal (female sexual arousal

disorder, FSAD), orgasm (female orgasmic disorder, FOD), and pain disorders

(dyspareunia) (American Psychiatric Association 2000).

Critiques of medicalization

Academics critical of the medicalized approach to female sexuality have argued that pills

will not be able to address the core issues of women’s sexual satisfaction (McHugh 2006).

Tiefer (2002) has argued that the biological reductionism promoted by the medical model

has substantial detrimental effects on women. Disadvantages include: overemphasizing

the importance of genital response while ignoring social and cultural issues that affect

women, the dangerous promotion of pharmaceutical answers as a panacea to women’s

sexual issues, and the increase in sexual insecurity by ‘disordering’ common sexual

difficulties (Fishman and Mamo 2002, Tiefer 2002, Moynihan 2003b, Hartley 2006, Canner

2008). Many researchers have argued that disease-mongering, or the pathologizing of

common experiences by convincing healthy people that they are ‘disordered’ or ‘diseased’,

allows the pharmaceutical industry to define, promote, and treat disorders and diseases to

their financial advantage (Payer 1992, Moynihan 2005, Dyer 2006, Tiefer 2008).

Sexual functioning has historically been defined in medical terms focused on the

physiological aspects of body response. Masters and Johnson (1966) contributed to

the development of medical treatments for female sexual dysfunctions through the

identification of four phases of the sexual response cycle: excitement, plateau, orgasm, and

resolution. These concepts are also reflected in the DSM-IV-TR which defines the four

phases of the sexual response cycle as: desire, excitement, orgasm, and resolution

(American Psychiatric Association 2000).

Female sexual functioning index

Researchers have developed a standardized measurement that reflects the diagnostic

criteria for FSD as outlined by the DSM-IV-TR. The Female Sexual Functioning Index

(FSFI) is a 19-item self-report measurement that is comprised of Likert scale response

options (Rosen et al. 2000). The FSFI covers the frequency and/or level of satisfaction of:

desire, arousal, lubrication, orgasm, and pain items – all physiological aspects of the

sexual response cycle. Although the FSFI cannot officially diagnose FSD, or any of its

subtypes, it is an accepted and widely used instrument in the study of female sexual

function.

Operationalizing sexual satisfaction and the sexual satisfaction scale

Measuring and operationalizing female sexual satisfaction has proved to be challenging.

Dundon and Rellini (2010) highlight the on-going difficulty in conceptualizing female

satisfaction, noting that there is a vast array of predictors. Sexual satisfaction is even more

70 C. Pronier and E. Monk-Turner

complex than the physiological underpinnings of sexual functioning because it includes

physical, emotional, psychological, and relational variables. To date, clinical trials have

often used orgasm as a simple quantitative way to measure sexual satisfaction in women

(Canner 2008). This is problematic as Nicolson and Burr (2003) argue that orgasm is

extremely limiting in understanding sexual satisfaction among heterosexual women.

Further, Galinsky (2009) argues that the ability to communicate and understand another

person’s emotions as well as self-esteem and autonomy are better measures of sexual

health and satisfaction than orgasm.

Recently, a scale to address the complexity of female sexual satisfaction has been

developed. The Sexual Satisfaction Scale – Women’s version (SSS-W) is a 30-item self-

report instrument that has been tested for reliability, both internal and test-retest, and

validity (Meston and Trapnell 2005). This scale measures satisfaction based on a five-

factor model with subscales covering contentment, communication, compatibility,

relational concern, and personal concern.

Besides dysfunction, predictors of female sexual satisfaction focus on age, race,

relationship satisfaction, general well-being, and lifestyle factors. Relationship

satisfaction and relational variables such as emotional closeness have been shown to be

significantly related to sexual satisfaction in women (Philippsohn and Hartmann 2009).

Philippsohn and Hartmann found, in a sample of German women, that sexual satisfaction

was ‘ . . . intricately and inextricably interwoven with relationship factors’ (2009, p. 1008).

Likewise, Carpenter et al. (2009) found that women in midlife associated emotional

closeness more with sexual practices than with relational factors. Witting et al. (2008)

concluded that overall relationship satisfaction was positively associated with sexual

satisfaction and inversely related to the presence of sexual functioning problems. The

subjective experience of emotional closeness before, during, and after sexual activities is

also positively related to sexual satisfaction (Bancroft et al. 2003, McHugh 2006).

Notably, extant work in sexuality focuses on Caucasians (Dobkin et al. 2006, Huang

et al. 2009). Huang et al. (2009) purposefully oversampled minority respondents to

explore possible differences and argued that sexual satisfaction did vary according to race

and ethnicity independent of other variables. Age has varying effects on sexual satisfaction

in women (Davison et al. 2009).

Lifestyle factors and sexual satisfaction

Time restraints have been identified as a primary issue in shaping sexual satisfaction.

A study of 519 French women, aged 35 years and older, found that lack of sexual desire

was directly related to time restraints as experienced by the individual woman (Colson

et al. 2006). Qualitative research conducted by McHugh (2006), on a college-aged

population, also identified time as a crucial factor in sexual satisfaction. Additionally,

McHugh (2006) identified seven themes in her content analysis of 2000 þ sexuality journals in response to the question, ‘What do women want?’ These themes are:

consensual sex, mutually satisfying sex, sexual agency, relationships, self love, time and

rest, and sexual health and liberation (emphasis ours).

McHugh (2006) conceptualized ‘self love’ as a love of one’s own body, finding that

body image and self-esteem were integral factors in shaping young women’s sexual

selves. Holt and Kogan (2001) found that college women who reported dissatisfaction

with their sexual relationships were also more likely than others to be dissatisfied with

their body image. Likewise, Pujols et al. (2010) link body image and sexual satisfaction.

How media shape body image concerns has been the focus of much research. In a meta-

Journal of Gender Studies 71

analysis of past work, Grabe et al. (2008) write that the mass media ideal of female

‘thinness’ shapes body image disturbances. Media images of ideal bodies, and ideal body

parts (Holt and Kogan 2001), shape self-esteem which in turn is associated with sexual

satisfaction (McHugh 2006).

The role pornography plays in women’s sexual pleasure has received some research

attention. Heider and Harp (2002) argue that pornography objectifies women and depicts

them as willing to engage in any sexual act. Likewise, Gorman et al. (2010), utilizing free

internet pornography sites, found that women were typically depicted in such media as

submissive and enjoying this role in sexual activity. Notably, Dines and Jensen (1998)

maintain that pornography is primarily produced and used by men for male pleasure. In her

work, Attwood (2005, 2006, 2012) explores the sexualization of culture focusing on how

media, via images, sex products, and fashion, shape how we perceive body pleasure and

sexuality. The proliferation of pornography and how this shapes self-esteem, perceived

sexual roles, and sexual satisfaction merits further work.

Past work on exploring the relationship between survivors of childhood sexual abuse

(CSA) and adult sexual satisfaction shows mixed results. For example, Rellini and Meston

(2007) reported little difference in sexual functioning between survivors of childhood

sexual abuse compared to others. Likewise, Valentine and Feinauer (1993) write that

female survivors of sexual abuse may become sexually resilient as adults. On the other

hand, Wyatt et al. (1992) and Finkelhor and Hotaling (1989) found that adult survivors of

sexual abuse are less likely to report satisfaction in their sexual relationships. We posit that

social factors are important in shaping women’s reported sexual satisfaction; however, the

medical model generally fails to take these into account.

Feminism and the new view campaign

In 1999, in response to the resurgence of the medicalization of female sexuality, Tiefer

formed an activist group titled the New View Campaign (Tiefer 2001a, Moynihan 2003a).

Launched in 2000, the New View Campaign provides an alternative to the medical model

of female sexuality and challenges the assumptions of this approach. The New View

Campaign highlights the influence of social factors in relation to women’s sexuality.

Instead of focusing on a physiological etiology of female sexual dysfunction, the New

View Campaign argues that sexuality should be understood based on experiences of

women themselves (McHugh 2006). The New View Campaign offers an alternative sexual

problem classification system for women to that of the medical and pharmaceutical

industries. This understanding focuses on sexual desire and includes measures of non-

consensual sex, relationship intimacy, sexual agency (how often one’s feelings of sexual

desire and pleasure were acknowledged), emotional closeness, body love, stress (which

may be caused by family/work responsibilities resulting in not enough time or rest to take

care of self needs), and sexual liberation (or knowledge about one’s own sexuality). The

current work posits that sexual satisfaction is primarily shaped by sexual desire (as

informed by the New View Campaign). In other words, sexual dysfunction may play a part

in shaping sexual satisfaction; however, sexual desire will be critical in shaping self-

reported sexual satisfaction among sexually active heterosexual women.

Method

The sample consists of female respondents from a large urban university who had access to

the online announcement board and a university email address during the spring of 2010.

72 C. Pronier and E. Monk-Turner

Respondents included students, faculty, and other members of the university community.

Thus, our sample represents a diverse university population rather than a student sample,

which allows us to control for the possible effects of education and age. It has been noted

by previous researchers who have used the announcement page to recruit survey

participants that females are much more likely than males to participate in online surveys

for educational purposes, which provided a strong reason to use this recruitment method.

The participant’s information remains anonymous and cannot be traced back to them. Due

to the length of the survey (20 minutes) a small incentive for participation was offered

(a drawing for a gift card). The survey was composed in Survey Monkey (an online survey

development tool and data collection manager).

The dependent variable is sexual satisfaction, which was operationalized as the

respondents’ composite Sexual Satisfaction Scale-Women’s version (SSS-W) score. In

order for respondents to be eligible to complete the two standardized survey measurements

(SSS-W and FSFI, both validated instruments), they needed to be recently sexually active.

In order to determine their sexual activity the definition outlined in the FSFI was provided

to adhere to the instrument’s standardization. This definition of sexual activity included

caressing, foreplay, masturbation, and/or vaginal intercourse. Respondents were asked if

they had participated in any of these activities within the past four weeks. When asked

about their recent sexual activity, 81% of respondents were sexually active.

The (SSS-W) is a 30-item self-report measurement that was used to measure sexual

satisfaction (Meston and Trapnell 2005). The scale includes subscales covering the

following: contentment, communication, compatibility, relational concern, and personal

concern. Sexual function was measured using the FSFI, a 19-item questionnaire that

utilizes a five-point Likert scale where higher scores indicate higher sexual functioning.

The FSFI covers the frequency and/or degree of satisfaction of: desire, arousal,

lubrication, orgasm, and pain items (Rosen et al. 2000). Finally, female desire was

measured with seven overarching themes that were developed from a previous qualitative

analysis: consensual sex, intimacy (mutually satisfying sex), sexual agency, relationships,

self love, stress (time and rest), and sexual health/liberation (McHugh 2006).

Respondents were asked if they had engaged in non-consensual sex within the past

four weeks (yes ¼ 1; no ¼ 0). Non-consensual sex was defined as being forced, pressured, or coerced into unwanted sexual activity. Intimacy was a Likert-scaled variable where

respondents were asked how satisfied they were with the quality of sexual interactions

during the relationship (including intimacy and affection) (coded as 1 ¼ very satisfied, to 6 ¼ very dissatisfied). Sexual agency measured whether sexual desire and pleasure were acknowledged within the relationship (coded as 1 ¼ all of the time, to 5 ¼ not at all). Emotional closeness was captured by asking how often one experienced satisfying

emotional closeness during and after sexual activities (coded as 1 ¼ all the time, to 5 ¼ not at all). Respondents were asked this statement to capture self/body love: ‘I love my body’ (coded as 1 ¼ strongly agree, to 6 ¼ strongly disagree). Stress was operationalized by asking respondents how often stress negatively affected their relationship (stress could

be caused by responsibilities resulting in not enough time to take care of self) (coded

1 ¼ all the time, to 5 ¼ not at all). Sexual knowledge/liberation was captured by asking respondents about knowledge of their own sexuality (including self-awareness of sexual

orientation, sexual rights, sexual feelings/desires, and sexual/reproductive health) (coded

as 1 ¼ strongly agree, to 6 ¼ strongly disagree). Age is a continuous variable measured in actual years. Race is a dummy variable and

was coded as white (1) compared to others (0). Education was measured as some high

school, high school graduation, trade school, some college, bachelor’s degree, and

Journal of Gender Studies 73

graduate degree. This was re-coded as a dummy variable where (1) included those with at

least some college compared to others (0). Respondents were asked how important

religion was to them (coded as (1) for very important; (0) all others). Respondents were

asked about general life satisfaction – (1) was very happy versus all others (0).

Relationship status compared those who were married (1) to others (0). Respondents were

asked if they had been diagnosed with a sexually transmitted disease (Yes ¼ 0; No ¼ 1). Respondents were asked whether they were being treated for a medical condition (or a

psychological condition) (No ¼ 1; Yes ¼ 0).

Results

In total, 515 female respondents completed the survey instrument. Of these respondents,

72% (or 389) were sexually active. Fifty-eight percent of respondents identified as white

(21% as black/African American). Age ranged from 18 to 61; however, most respondents

(75%) were 25 years of age or younger, with a mean age of 24 (see Table 1). Perhaps

because our respondents are so young, relatively few (3%) can be classified (on FSFI

scale , 26.5 composite score) as officially sexually dysfunctional. For this reason, in our work the FSFI scale will be used instead of a dummy variable capturing sexual

dysfunction.

When asked about their current relationship status, almost half of all respondents

(48%) were in a relationship, 15% were married, and 37% were single. When asked to

identify their sexual orientation the vast majority (91%) identified as heterosexual (3%

identified as homosexual, 6% identified as bisexual, and 1% identified as ‘other’). In light

of past work, our work restricts the sample to heterosexual individuals.

Among our restricted sample, 29% indicated that they were survivors of sexual abuse

and/or assault at some point in their lives. Respondents were asked if they had been diagnosed

or treated for an STD/STI, other medical condition, or a psychological condition within

the previous 12 months. Few respondents (11%) had been diagnosed with an STD/STI.

Twenty-three percent of the sample had been diagnosed or treated with a medical condition