Abstract
Decreased sexual functioning is prevalent among female survivors of sexual violence yet psychological factors that contribute to sexual impairments in this population are understudied. To extend research in this area, the current study examined two psychological factors as they relate to sexual functioning concerns among 148 female survivors of sexual violence: severity of posttraumatic stress symptoms (PTSSs) and sexual self-schemas. Four domains of sexual functioning were examined: sexual desire, sexual arousal, sexual satisfaction, and orgasm functioning. It was predicted that PTSSs would be associated with a more negative sexual schema, which in turn, would be associated with decreased sexual functioning across the four domains. Using path analysis, PTSSs were found to be indirectly associated with decreased sexual satisfaction (b = −.08, SE b = .04, p = .035), sexual arousal (b = −.01, SE b = .001, p = .02), and reduced orgasm functioning (b = −.01, SE b = .001, p = .002). Results also supported significant direct paths from PTSS to all sexual functioning variables. These results support that negative sexual self-schemas may be relevant to the co-association of PTSSs and reductions in sexual functioning and satisfaction.
Sexual violence against women is widespread; the Centers for Disease Control (CDC) indicate that over one in three women experience sexual violence in her lifetime (Smith et al., 2017). Sexual violence encompasses a number of nonconsensual sexual experiences, including rape, attempted rape, use of coercion for sex, and unwanted sexual contact (Smith et al., 2017). Survivors of sexual violence can experience a vast array of negative mental and physical health consequences, yet additional research is needed to more fully understand the aftermath of sexual violence. Although understudied, many survivors of sexual violence experience reductions in sexual functioning and sexual satisfaction (e.g., Becker et al., 1986); psychological factors that may contribute to these reductions are not well-understood. To begin to address this gap, the present study examined two potentially relevant psychological factors, posttraumatic stress symptoms (PTSSs) and sexual self-schemas as they related to sexual functioning and satisfaction.
Female sexual functioning is comprised of several domains including sexual arousal, sexual desire, lubrication, orgasm, and sexual pain (Rosen et al., 2000). As many as 58% of female sexual violence survivors report impairment in one or more of these domains (Becker et al., 1986; Laumann et al.,1999; Nappi et al., 2016). Studies note that relative to women who have not experienced sexual violence, survivors of sexual violence report reduced sexual desire, increased problems with arousal or achieving orgasm, and decreased sexual satisfaction (e.g., Kelley & Gidycz, 2019; Leonard & Follette, 2002; Polusny & Follette, 1995; Rellini & Meston, 2011; Turchik & Hassija, 2014). Research with female veterans has documented that relative to nonsexual trauma, sexual trauma history (including military sexual trauma) showed a stronger association with reduced sexual satisfaction (e.g., DiMauro et al., 2018) and an increased likelihood to meet diagnostic criteria for a sexual dysfunction (Turchik et al., 2012).
In both veterans and civilians, research also has noted a high co-occurrence between symptoms of posttraumatic stress disorder (PTSD) and sexual dysfunctions. In a review, Yehuda and colleagues (2015) highlighted the co-occurrence of PTSD and reduced sexual functioning across a range of trauma-exposed populations. These authors hypothesize that several potential mechanisms may undergird the association between PTSD symptoms and sexual functioning problems including hormonal changes preventing normal sexual function and shared neural circuitry undergirding both PTSD symptoms and sexual dysfunction (c.f., Yehuda et al., 2015). Other authors (e.g., Laurent & Simons, 2009) have speculated that sexual dysfunctions may be maintained by similar cognitive-behavioral factors as PTSD, as both are internalizing in nature. Although these possibilities remain difficult to test empirically, identification of psychological processes that are associated with the presence of both PTSD symptoms and sexual functioning problems represents a useful step forward in this direction.
Previous studies have highlighted the potential relevance of cognitive factors in the co-association between PTSS and sexual dysfunctions (Blain et al., 2011). Individuals with PTSS often experience negative self-referential cognitions (e.g., “The trauma has changed me forever”) or thoughts of self-blame (“The trauma happened because of how I acted”; Foa et al., 1999), which can increase negative self-referential affect, such as shame or guilt (Beck et al., 2011; Leskela et al., 2002). Following sexual trauma, negative cognitions and emotions about the self may become integrated into one’s concept of themselves sexually, referred to as their sexual self-schema (Andersen & Cyranowski, 1994). An altered sexual self-schema may impair one’s ability to fully experience intimacy or satisfying sexual activities. In addition, the presence of other PTSS may negatively impact one’s sexual self-schema. For example, during sexual activity, experiencing recurrent intrusive thoughts of the trauma, may interfere with one’s sexual experience and also negatively impact one’s sexual self-schema. To date, there has been a relative lack of emphasis on sexual self-schemas among women with elevated PTSD symptoms who have experienced sexual violence.
In the initial development of a sexual self-schema scale for women, three schema subscales were derived: passionate-romantic, open-direct, and embarrassed-conservative (Andersen & Cyranowski, 1994). The passionate-romantic scale was associated with increased sexual arousal during sexual activity and feelings of love toward a romantic partner. The open/direct scale was associated with more positive attitudes regarding casual sex and increased number of sexual partners. The embarrassed/conservative subscale was associated with increased guilt related to sexual behavior, lower sexual arousal during sexual activity, and reduced feelings of love toward a romantic partner. Based on the associations between the subscales and sexual attitudes and behaviors (e.g., guilt, measures of sexual arousal), the passionate-romantic and open-direct subscales were labeled “positive” sexual schemas, and the embarrassed-conservative subscale was labeled a “negative” sexual schema. It was also determined that an overall sexual self-schema could be derived by combining these three subscales. Several studies have noted that less positive schemas are associated with increased negative affect in response to sexual stimuli, in addition to decreased sexual satisfaction, sexual aversion, decreased sexual self-efficacy, and sexual pain (Meston et al., 2006; Mueller et al., 2016; Reissing et al., 2005; Rellini & Meston, 2011). Furthermore, positive sexual self-schemas among gynecologic cancer survivors are associated with increased frequency of sexual activity, higher sexual satisfaction, and increased sexual arousal (e.g., Andersen & Cyranowski, 1994; Carpenter et al., 2009), which suggests that sexual self-schemas may play an important role in sexual functioning.
Empirical work on the sexual self-schemas of women exposed to sexual violence has focused primarily on survivors of childhood sexual abuse (CSA; C. M. Meston et al., 2006), with less attention to those who have experienced sexual violence in adolescence and early adulthood. Sexual self-schemas of CSA survivors have been found to differ from nonexposed control groups. For example, CSA survivors tend to score lower on positive schema subscales and higher on negative schema subscales (Meston et al., 2006; Niehaus et al., 2010) though some findings have not noted significant differences (e.g., Rellini & Meston, 2011). Although mixed, these findings suggest that sexual schemas may be impacted by sexual violence exposure. Importantly, research is needed to examine the association between sexual self-schema and sexual dysfunctions in women who experienced sexual violence in adolescence or adulthood, as findings for CSA survivors may not generalize to this sample (Seehuus et al., 2015). Moreover, few studies to date have examined the association between PTSS and sexual self-schemas following sexual violence exposure. Blain et al. (2011) examined the sexual self-schemas of women with histories of adult sexual trauma and found that PTSD-related negative self-referential cognitions about the self were significantly associated with more negative sexual self-schemas. Thus, it is possible that components of PTSD may alter a survivor’s sexual self-schema, which may in turn, reduce sexual functioning or satisfaction.
The Current Study
The present study extended available findings regarding PTSS and sexual self-schemas as they relate to impaired sexual function among survivors of sexual violence occurring in late adolescence/early adulthood. The present study aimed to examine whether the associations between PTSS and the four domains of sexual functioning were partially accounted for by sexual-self schemas. Given the multidimensional nature of female sexual functioning, the present study sought to consider these associations across the following domains: sexual desire, sexual arousal, orgasm functioning, and sexual satisfaction. Findings from Ruscio and colleagues (2002) note significant distress and impairment can occur even at subdiagnostic levels of PTSD, thus the present study examined PTSD dimensionally (i.e., PTSSs). Using path analysis, the present study examined the direct paths between PTSS and each sexual functioning domain as well as the indirect paths between PTSS, sexual self-schemas, and each sexual functioning domain. To allow for the potential that differences in association may exist for differing domains of sexual functioning, paths were tested for each of the sexual outcomes in a single model. It was predicted that more severe PTSS would be significantly associated with more negative sexual schema, which in turn, would be associated with decreased sexual functioning across each of the four sexual function domains. Although we were interested in exploring potential differences of association for the four sexual outcome variables, these differences were considered exploratory given a lack of prior research in this area.
Method
Participants
Participants were selected from a larger study of 201 female undergraduate students who had experienced sexual violence, recruited from introductory psychology courses in exchange for course credit. Participants self-identified as women, were at least 18 years old, English-speaking, and had experienced one or more unwanted sexual experience in their lifetime. Women who had negative sexual experiences that fell outside of the definition of sexual violence (Smith et al., 2017) or who experienced sexual abuse only prior to 14 years of age were excluded (n = 45) from this report, given its focus. In the present study, eight individuals were removed from the analysis due to lack of sexual activity in the past month, resulting in a total n = 148 following guidelines for examining sexual functioning by Rosen and colleagues (2000), who caution that inclusion of nonsexually active women has the potential to produce artificially low scores on sexual functioning measures. The mean age of the sample was 22.4 years (SD = 6.89); participants were predominantly Black/African American (46.6%) or White (42.5%), and the majority identified as straight/heterosexual (80.4%). Additional demographic information is presented in Table 1.
Sample Demographics.
Note. Participants reported on the frequency of each unwanted event, and participants were grouped based on the most severe event experienced. Not all categories add up to 100% due to rounding.
Measures
Trauma history
The Sexual Experiences Survey-Short Form Victimization (SES-SFV; Koss et al., 2007) is a seven-item measure that assesses unwanted sexual experiences, using specific behavioral descriptions (i.e., “Someone had oral sex with me or made me have oral sex with them without my consent”), as well as tactics used by the perpetrator (e.g., assault while the victim was incapacitated by drugs or alcohol, physical or emotional threat). The behaviorally anchored questions were designed to avoid subjective interpretation or emotionally charged language (i.e., “rape”) to capture a broad range of unwanted sexual experiences. Respondents in this study indicated the frequency of each experience in the past 12 months, as well as the frequency of each occurrence since 14 years of age. Previous research supports the reliability of the SES-SFV (α = .92; Johnson et al., 2017). In the present study, the SES-SFV was used to screen for experiences of sexual violence since 14 years of age.
Scoring procedures were used to determine the prevalence and frequency of the following types of sexual violence as outlined by Koss et al. (2007): rape, attempted rape, coercion, attempted coercion, and unwanted sexual contact (i.e., sexual touching). Participants reported on the frequency of each unwanted event and each participant’s experience was coded based on the most severe event experienced, for descriptive purposes. Approximately one half of the sample (53.4%, n = 79) were identified as having experienced rape (see Table 1).
PTSSs
Post-Traumatic Checklist for DSM-5 (PCL-5; Weathers et al., 2013) is a 20-item self-report measure of PTSD wherein symptoms are rated on a 5-point Likert-type scale (0 [Not at all] to 4 [Extremely]). The PCL-5 was anchored to the participant’s worst experience of sexual assault (e.g., participants were instructed to think of the worst sexual assault experienced since 14 years of age when filling out the PCL-5). A total severity score was calculated by summing the items (range 0–80), with higher scores indicating more severe PTSS. A cutoff score of 33 has been identified in veteran samples as indicative of probable diagnosis of PTSD (Bovin et al., 2016). In the current sample, 47 individuals had a PCL-5 score of 33 or higher (31.1%). Past research has supported the internal consistency, test–retest reliability, and convergent and discriminant validity of the PCL-5 (Weathers et al., 2013). In the current study, coefficient alpha for the PCL-5 was .96.
Sexual self-schemas
The Sexual Self-Schema Scale for Women (SSSS-W; Andersen & Cyranowski, 1994) is a 50-item scale that assesses for cognitive representations of one’s sexual self. Participants are asked to rate themselves on a list of 50 adjectives on a scale from 0 (Not at all descriptive of me) to 6 (very descriptive of me). The SSSS-W is comprised of three schema profiles: open-direct, passionate-romantic, and embarrassed-conservative. A sexual self-schema total score, used in the current study, was derived by adding the scores of the two positive schema scales and subtracting the negative schema scale, wherein higher scores reflected more positive schemas. Cronbach’s alpha for the SSSS-W total score in the current sample was .72.
Sexual function
Sexual satisfaction
The Sexual Satisfaction Scale for Women (SSS-W; C. Meston & Trapnell, 2005) is a 30-item self-report measure that assesses for current levels of sexual satisfaction (i.e., “I feel content with my present sex life”) on a scale from 1 (strongly disagree) to 5 (strongly agree). Negatively worded items were reverse coded. In the present study, a sexual satisfaction total score was calculated, with possible scores ranging from 24 to 120; higher scores indicate higher satisfaction. Support for the internal consistency (α = .94) and test–retest reliability (r =.58–.79) of the scale has been found in previous studies (C. Meston & Trapnell, 2005). In the current sample, Cronbach’s alpha for the total score was .87.
Female Sexual Function Index (FSFI)
FSFI (Rosen et al., 2000) is a 19-item self-report measure that assesses sexual functioning during the prior 4 weeks. Participants rate the frequency (e.g., “Over the past four weeks, how often did you feel sexually aroused?”) and degree of sexual functioning (e.g., “Over the past four weeks, how satisfied were you with your ability to reach orgasm during sexual activity or intercourse?”). Lower scores indicate more problematic sexual function. Results from a factor analysis as well as clinical considerations supported a six-factor model (Rosen et al., 2000), comprised of desire, arousal, lubrication, orgasm, satisfaction, and pain. Internal consistency of factor scales have been found to range between .79 and .86. The present study utilized three factor scales from the FSFI, with adequate to good internal consistency: arousal (α = .95), desire (α = .93), and orgasm (α = .74).
Procedure
All procedures were approved by a university institutional review board. Following provision of informed consent, participants were provided a link to complete questionnaires online, utilizing SurveyMonkey. Upon completion or discontinuation of study participation, participants were debriefed. Women indicating high levels of distress were contacted by phone to ensure safety and to provide additional assistance, if necessary. All participants were given a list of mental health resources at the time of withdrawal or completion. In addition to the study measures, participants provided demographic information.
Data Analytic Approach
Data screening procedures and analyses were conducted utilizing SPSS version 23, and path analysis was conducted with MPlus statistical software v.8 (Muthén & Muthén, 2015). Data were evaluated for patterns of missing data and evidence of non-normality (e.g., skewness and kurtosis), as well as univariate and multivariate outliers (i.e., values exceeding 3.29 standard deviations above or below the mean), utilizing procedures outlined by Tabachnick and Fidell (2012). No outliers were observed. Skew and kurtosis values were within normal limits for all continuous variables according to limits outlined by Kline (2011). Upon examining outcome variables for normality, the PCL-5 total appeared to be non-normal based upon visual inspection and an inverse square root transformation was used for this scale. Eleven of the 148 participants had missing data on one or more outcome variables. Of the 1,208 possible data points, 84 were missing (6.9%). Missing data were handled utilizing Maximum Likelihood Estimation when applicable. Correlations between proposed model variables revealed no evidence for potential problems with multicollinearity. Correlations of the following demographic variables and model variables were conducted: age, race, dichotomous racial identity (White vs. non-White), and dichotomous sexual orientation (straight, coded as 1 vs. nonstraight, coded as 0), dichotomous romantic relationship status (0 = in a relationship, 1 = not in a relationship; see Table 2). Sexual orientation and relationship status were found to correlate with one or more model variables, and were entered as covariates in the final path model.
Descriptive Statistics and Bivariate Correlations.
Note. PTSD = posttraumatic stress disorder, measured by the PCL-5. Sexual self-schema was measured by the Sexual Self-Schema Scale. Sexual satisfaction measured by the Sexual Satisfaction Scale for Women. FSFI= Female Sexual Function Index. Sexual orientation was dichotomized to distinguish heterosexual orientation and nonheterosexual orientation, coded as heterosexual = 1, nonheterosexual = 0. Relationship status was dichotomized as 0 = in a relationship, 1 = single. Point bi-serial correlations are shown for dichotomous variables (i.e., sexual orientation and relationship status). Inverse square root transformation was performed for PTSD severity prior to path analysis.
p < .01. **p < .001.
Path Analysis
Path analysis was used to examine simultaneous associations between PTSS, sexual self-schema, and four sexual functioning domains; path analysis was used given four outcome variables. A single model was run, comprised of PTSS severity, sexual self-schema, and the four dependent variables. Path coefficients were computed from PTSS to each domain of sexual function. In addition, the indirect effects of PTSS to each functioning domain through sexual self-schema were computed, to assess whether sexual self-schema partially accounted for variance explained by PTSS to any of the four domains. Bias-corrected bootstrapping procedures were conducted in the event of any significant indirect effects.
Evaluation of model fit was assessed utilizing recommendations by Kline (2012). Evidence of a significant chi-square statistic (p < .05) indicates evidence of poor model fit. The comparative fit index (CFI; Bentler, 1990) compares the specified model fit to that of a model assuming no covariance between observed variables; values above .95 are indicative of good fit. Next, the Steiger-Lind root mean square error of approximation (RMSEA; Steiger, 1990) serves as an indicator of poor model fit; values greater or equal to .10 indicate poor fit, .08 to .10 indicate mediocre fit, .05 and .08 indicate adequate fit, and values less than or equal to .05 indicate close approximate fit. Finally, the standardized root mean square residual (SRMR) compares the correlations between the predicted and actual covariances. SRMR values that are favorable are less than .10, and good values are less than .08 (Hu & Bentler, 1999).
Results
Overall Path Model
The overall path model included PTSS severity and sexual self-schema, four dependent variables: sexual satisfaction, sexual desire, sexual arousal, and orgasm functioning, and two covariates: sexual orientation and relationship status. Model fit indices suggested good-to-adequate model fit, χ2 (3) = 6.1., p =.11; CFI = .99; RMSEA = .084, SRMR = .04. Significant path coefficients are displayed in Figure 1. In examining the relation between PTSS severity and sexual self-schema, a significant negative association was found (b = −.17, SE b = .06, p = .003, β = −.25), indicating that more severe PTSS were associated with a less positive sexual schema.
Path model examining the relationship between PTSD severity, sexual self-schema, and four domains of sexual functioning, with unstandardized coefficients.
Sexual Satisfaction
For sexual satisfaction, all three paths coefficients were significant (R2 = .20, p = .009). PTSD severity was directly associated with decreased sexual satisfaction (b = −.28, SE b = .08, p = .001, β = −.25). The indirect effect from PTSS to sexual satisfaction via sexual self-schema was also significant (b = −.08, SE b = .04, p = .035; 95% confidence interval [CI] = [−.18, −.02]); more severe PTSS by way of negative sexual self-schema were associated with decreased sexual satisfaction. Finally, the combined effect of PTSS and sexual self-schema to sexual satisfaction was also significant (b = −.36, SE b = .09, p < .001).
Sexual Desire
For sexual desire, a significant amount of variance was explained by the model (R2 = .13, p = .02). PTSS was significantly and directly associated with decreased sexual desire (b = −.02, SEb= .01, p = .005, β = −.23). However, sexual schema did not significantly account for any shared variance between PTSS and sexual desire.
Sexual Arousal
For sexual arousal, all three paths coefficients were significant (R2 = .13, p = .02). PTSD severity was directly associated with decreased sexual arousal (b = −.02, SEb= .01, p = .045, β = −.16). The indirect effect from PTSS to sexual arousal via sexual self-schema was also significant (b = −.01, SE b = .001, p = .02; 95% CI = [−.05, −.01]); more severe PTSS by way of negative sexual self-schema were associated with decreased sexual arousal. Finally, the combined effect of PTSS and sexual self-schema to arousal was also significant (b = −.03, SE b = .01, p =.004).
Orgasm Functioning
For orgasm functioning, all three paths coefficients were significant (R2 = .15, p = .01). PTSD severity was directly associated with decreased orgasm functioning (b = −.02, SE b = .01, p = .026, β = −.19). The indirect effect from PTSS to orgasm via sexual self-schema was also significant (b = −.01, SE b = .001, p = .002; 95% CI = [−.05, −.01]); more severe PTSS by way of negative sexual self-schema were associated with decreased orgasm functioning. Finally, the combined effect of PTSS and sexual self-schema to orgasm functioning was also significant (b = −.03, SE b = .01, p =.002).
Covariates
Results indicated that relative to a nonheterosexual orientation, a heterosexual orientation was associated with a more negative sexual self-schema (b = −1.18, SE b = .09, p = .009). Results indicated that being in a romantic relationship was significantly associated with higher sexual satisfaction (b = −2.74, SE b = .85, p = .001) and greater sexual arousal (b = −.24, SE b = .09, p = .01).
Discussion
The present study examined the concurrent associations of four dependent sexual functioning variables (sexual desire, sexual arousal, sexual satisfaction, and orgasm functioning) with two independent variables, PTSS severity and sexual self-schema. Path estimates revealed that more severe PTSS were associated with a less traditionally positive sexual schema, which in turn, was associated with decreased sexual satisfaction, sexual arousal, and decreased orgasm functioning. PTSS’s association with reduced sexual satisfaction, arousal and orgasm functioning remained significant after accounting for variance explained by sexual self-schema.
The current results suggest that among sexually active college women who had experienced sexual violence after 14 years of age, the severity of PTSS negatively impacts sexual functioning, including sexual self-schema, sexual satisfaction, sexual arousal, and orgasm functioning. The significant paths that were noted (more severe PTSS is associated with a more negative sexual schema, which in turn, predicted reductions in satisfaction, arousal and orgasm functioning) is consistent with theoretical conceptualization of sexual self-schema and supports assertions that these schema influence sexual perceptions and behaviors (Cyranowski & Andersen, 1998; Rellini & Meston, 2011). These findings offer a potential path wherein one’s sexual schema may be altered by the presence of PTSS which may then interfere with sexual functioning and reduce sexual satisfaction. For example, negative affect in response to a trauma cue during sexual activity may induce feelings of embarrassment or shame that become integrated into one’s self-concept which then negatively affects sexual behavior and functioning. In a larger sample, it may be useful to investigate associations between specific PTSS clusters and sexual self-schemas to determine whether certain symptoms show greater relevance to sexual self-schemas than others. Importantly, the present study was not able to examine temporal relations between these variables as it was a cross-sectional sample. Indeed it is possible that these variables have a bi-directional relation to one another, wherein reductions in sexual functioning and satisfaction may serve to reinforce PTSS and negative sexual schemas. The use of longitudinal designs may help to clarify these possibilities.
Although sexual self-schema accounted for part of PTSS’s association with decreased sexual satisfaction, arousal, and orgasm, it did not fully account for this association. Additional factors may play a role in the association between PTSS and reductions on sexual satisfaction and desire. For example, previous research supports the relevance of depressive symptoms (Dunlop et al., 2015), the severity of sexual trauma that was experienced (Neilson et al., 2017; Peter-Hagene & Ullman, 2015), and decreased levels of social support (e.g., Hakimi et al., 2018; Wyatt et al., 2017) in understanding co-occurring PTSS and sexual functioning concerns. In light of the present findings, it will be important for future research to examine these possibilities with consideration for potential differences across dimensions of sexual function and satisfaction.
The present study also found that a heterosexual sexual orientation was associated with more negative sexual self-schema and decreased sexual arousal when compared with a nonheterosexual orientation. This finding is difficult to contextualize, in light of the relative lack of information about factors that are associated with sexual problems following sexual violence in sexual minority women. Given the relatively small sample of sexual minority participants in the current study (19.6%, n = 29), we were unable to perform a multi-group analysis to examine model equivalency between the heterosexual and nonheterosexual groups. It would be informative to explore further the nature of associations between PTSS, sexual self-schema, and sexual dysfunctions in heterosexual and sexual minority women, particularly given the relatively high level of risk for sexual violence in the sexual minority community (Friedman et al., 2011). Work that is inclusive of sexual minority samples can expand our understanding of the impact of sexual violence, with relevance to knowledge of both PTSD and sexual dysfunction.
One strength of the present study was inclusion of a large percentage of the sample who identified as Black or African American (46.6%). Related reports have documented notable differences between Black or African American and White women following sexual violence, noting links between assault severity and depressive symptoms and physical health problems, and between PTSD symptoms and drinking episodes among African American survivors, but not in White survivors (Pegram & Abbey, 2019). Hakimi and colleagues (2018) noted that race moderated the association between negative social reactions and mental health outcomes, noting that African American women experienced higher PTSD and depressive symptoms at low to moderate negative social reactions relative to White women. Importantly, Black or African American women have been shown to be less likely to utilize crisis centers and mental health services (Weist et al., 2014). Continued efforts are needed to better understand the mental and physical health needs of survivors of sexual violence who identify as Black or African American, in an effort to reduce health disparities.
Limitations
It is important to note the limitations of the current study. First, the present study relied on a cross-sectional sample, which does not permit causal or temporal interpretation of the findings. Given the lack of preliminary research on the proposed associations, reliance on a theoretical framework and cross-sectional data were considered an appropriate first step in exploring this research question. Future research should strive to employ longitudinal designs or laboratory analogue studies to further examine the role of PTSS, sexual self-schemas, and sexual functioning impairment in survivors of sexual violence.
The present study relied on a sample of relatively young female college students who had experienced sexual violence. The small effects noted in the model may be reflection of the use of a relatively healthy sample and may therefore not generalize to older women or to help-seeking samples of women with sexual dysfunction. The present study did not include male survivors of sexual violence. The decision to focus on women survivors of sexual violence was made based on prior research demonstrating high rates of PTSD in this sample (e.g., Faravelli et al., 2004; Turchik et al., 2012) as well as a dearth of literature in examining the association between PTSS and sexual dysfunctions in women exposed to sexual violence in late adolescence/adulthood. It should be noted that studies that have compared sexual versus nonsexual traumatic events have found higher rates of sexual dysfunction and PTSS in those with a sexual traumatic event (Bird et al., 2018; DiMauro et al., 2018). Thus, it appears that survivors of sexual violence may be particularly vulnerable to both PTSS and sexual dysfunctions, and therefore these findings may be specific to female survivors of sexual violence and may not generalize to other trauma samples or to PTSS’s association with sexual dysfunctions more generally.
The present study also excluded individuals who did not endorse any sexual activity within the past month, as the sexual functioning measures would not necessarily be accurate (Rosen et al., 2000). There are a host of reasons why a woman may not be sexually active, such as cultural or religious beliefs. High levels of PTSS could also account for sexual inactivity. Measures aimed at assessing potential reasons for current sexual nonactivity would be helpful in future studies. Future work needs to address the limitations of the current study’s sample, through inclusion of a wider age range of participants, examination of women from different cultures outside of the United States, and considering the role of religious differences as these impact sexual functioning following sexual violence.
Another notable limitation was the inability to distinguish the percentage of individuals who had experienced CSA in our sample. Although all of our participants endorsed at least one sexual trauma since 14 years of age, it is unclear how many individuals had also experienced sexual abuse earlier in childhood or early adolescence (aged 11–14 years), owing to measures using differing age cutoffs and descriptions to operationalize CSA. This reflects a larger issue within the CSA literature, as a clear consensus regarding at what age sexual violence should be considered CSA versus adulthood sexual assault (ASA) has yet to be determined. As noted, previous studies have found differences between CSA survivors and nonexposed control participants with regard to sexual schemas and sexual functioning problems. However, to our knowledge, there has not been research comparing sexual schemas and sexual functioning concerns between CSA and ASA survivors, or between ASA survivors with and without histories of CSA. As such, future work in this area would benefit from greater specificity in documenting the age(s) at which sexual violence exposure occurred.
Overall, the current findings contribute to available studies examining PTSS and sexual functioning among trauma samples. The findings highlight the relevance of sexual self-schemas in the association between PTSS and reduced sexual arousal, orgasm functioning and satisfaction. It may be useful for clinicians to consider sexual self-schemas in the treatment of PTSS following sexual violence, as this may contribute to sexual distress. This study also highlights a need to further dismantle aspects of PTSS that may account for both reductions in sexual functioning and the presence of more negative sexual self-schemas in survivors of trauma. Understanding which specific PTSS symptoms impact sexuality could shape selection of treatment interventions among women presenting with elevated PTSS symptoms and certain sexual functioning complaints.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially supported by the Lillian and Morrie Moss COE position (J. Gayle Beck, PhD).
