1. Background
Sexual function is a crucial aspect of human life, impacting mental and physical health, social behavior, and quality of life (1). It encompasses factors like sexual desire, sexual excitation (SE), and orgasm, which occur regularly and continuously in individuals or couples (1, 2). In women, sexual function is a complex interplay of psychosocial, physical, and biological factors, significantly affecting their mental, physical, and social health (3).
Various factors can influence sexual function, with SE and sexual inhibition (SI) being crucial predictors (4). SE involves sensitivity and stimulation in sexual situations, while SI is linked to recognizing danger and suppressing the sexual response (5). The dual control model, introduced by Bancroft (6), suggests that different levels regulate performing or not performing various sexual behaviors. It posits two neurophysiological systems: One activated by arousing signs and the other inhibited by avoidance signals. The sexual response emerges from a balance between excitatory and inhibitory processes in a given situation (7).
Moreover, the dual control model suggests that an individual's level of SI and SE influences their engagement in extramarital sex and risk-taking behavior (8). Higher SI levels are associated with sexual distress, sexual problems, sexual dysfunction, depression, and anxiety, while higher SE levels correlate with more frequent masturbation, more lifetime sexual partners, and better relationship quality and satisfaction (9). In general, SI predicts sexual problems in women (10), and satisfactory sexual response hinges on a balance between SE and SI (11).
While several psychological and biological factors have been proposed as underlying causes of women's sexual deviations (12), recent research suggests a limited correlation between biological phenomena and women's sexual deviations. Instead, the influence of psychological factors as mediating variables appears more pronounced (13).
Cognitive factors are recognized to play a significant role in the development and maintenance of sexual problems (14). In recent decades, there has been growing interest in studying the impact of cognitive dimensions on women's sexual performance (15).
Emotional-cognitive models have emerged to explain sexual dysfunction (16). According to this model, dysfunctional beliefs regarding sexual relationships serve as a vulnerability factor for sexual function (17). These beliefs encompass insights, attitudes, behaviors, and stereotyped beliefs concerning sexual performance, potentially leading to problems and undermining couples' sexual relationships (18). Sexual beliefs are among the vulnerable factors influencing sexual development and leading to various cognitive distortions. Research has shown a higher prevalence of dysfunctional sexual beliefs among women with sexual dysfunction (19).
Furthermore, women with sexual disorders exhibit a higher prevalence of dysfunctional beliefs, which also impact SI and SE. These women demonstrate significant differences in their inclination towards SI and SE, as well as the content of their thoughts during sexual activity, compared to women without sexual problems (20). Thus, factors related to processing sexual issues are crucial and determine the persistence of these problems over time (21). In summary, sexual performance can be predicted based on SI, SE, and dysfunctional beliefs.
2. Objectives
Few studies have investigated the mediating role of sexually dysfunctional beliefs in the relationship between research variables, with most focusing solely on direct paths in separate research. Therefore, the present study aims to assess the mediating role of sexually dysfunctional beliefs in the relationship between SI and SE with women's sexual function. Figure 1 depicts the hypothetical model used in this research.
The hypothetical research model
3. Methods
The current study employed a descriptive-correlational research design. The statistical population consisted of female employees working in the administrative departments of Tehran and Tabriz universities in Iran. Participants with a history of traumatic experiences and those with medical conditions related to sexual function, such as Diabetes mellitus and Hypothyroidism, were excluded. Additionally, participants needed to meet the criteria of being 18 years or older and not identifying as homosexual. The study was conducted using the convenience sampling method from April 2023 to November 2023.
After receiving an explanation of the research process and purpose, participants were invited to voluntarily cooperate in the study. Those who provided their consent through a signed written form were given the questionnaires to complete. Participants filled out the anonymous questionnaires on the campuses of their universities. A total of 467 individuals answered the questionnaires, and after removing incomplete ones, a sample of 402 participants was selected for data analysis.
3.1. Research Instruments
3.1.1. Sexual Inhibition and Excitation Questionnaire
The Sexual Inhibition and Sexual Excitation Questionnaire, designed by Graham et al. (22), assesses women's stimulating and inhibiting responses along with its psychometric characteristics. This widely used questionnaire comprises 36 items and demonstrates good validity. Respondents rate each item on a 4-point Likert scale. The questionnaire consists of 8 subscales, with 5 related to SE and the remaining 3 related to SI. The internal consistency of the SE factor, measured by Cronbach's alpha, is 0.70, while the average internal consistency of SI is 0.55. Abdolpour et al. translated this questionnaire into Persian. Its internal validity was 0.85 for SE and 0.79 for SI, indicating acceptable internal consistency (15).
3.1.2. Female Sexual Function Index Questionnaire
The Female Sexual Function Index (FSFI), designed and validated by Rosen et al. (23), consists of 19 items that measure sexual feelings over the last four weeks in six areas. Each item is scored on a scale of 0 to 5, with higher scores indicating better sexual function. The questionnaire demonstrates good validity and reliability, with Cronbach's alpha reported as 0.89 or higher in the study by Rosen et al. (23). The test-retest reliability of the scale is 88%, and the subscales range from 79% to 86%. Fakhri et al. confirmed the validity and reliability of the questionnaire in Iran, reporting a Cronbach’s alpha coefficient of 0.83 for the total scale (24).
3.1.3. Sexual Dysfunctional Beliefs Questionnaire
The Sexual Dysfunctional Beliefs Questionnaire (SDBQ), developed by Nobre et al. (16), assesses beliefs related to sexual relations across six areas. The scale comprises 40 items. Participants rate their level of agreement with each statement on a 5-point Likert scale (0 = completely disagree to 4 = completely agree). This questionnaire has demonstrated good reliability and validity, with a retest reliability score of 73% and Cronbach's alpha of 93%, indicating strong internal consistency and stability. Abdolmanafi et al. translated this questionnaire into Persian, reporting an internal validity of 0.82, which indicates acceptable internal consistency (25).
3.2. Data Analysis
In the initial phase, the primary analysis of research variables was conducted, which included descriptive indices such as mean, standard deviation, skewness, and kurtosis. The fit of the hypothesized model was tested using structural equation modeling (SEM). To analyze the mediation effect, the bootstrap method was employed to estimate the indirect effect, and 95% confidence intervals were calculated based on 200 bootstrap samples. SPSS 22 and LISREL 8.85 statistical software packages were utilized to classify, process, analyze data, and test research hypotheses.
4. Results
A total of 402 participants took part in this study, with a mean age of 33.84 (SD = 6.84), ranging from 18 to 55 years. Regarding the participants' educational level, 34 individuals (5.11%) reported having under a high school diploma, 126 (18.94%) reported having a high school diploma, 305 (45.86%) reported having a bachelor's degree, 190 (28.57%) reported having a master's degree, and 10 (1.50%) reported having a doctoral degree. Detailed descriptive statistics for each variable are presented in Table 1.
The Correlation Matrix, Mean, and Standard Deviation of the Research Variables
Before evaluating the measurement model and structural model, essential assumptions of structural equation modeling were examined, including univariate and multivariate normality and the absence of multiple collinearities. Assessing the normality of individual variables is typically done by calculating their skewness and kurtosis. In this study, the assumption of multivariate normality was assessed by computing the relative multivariate kurtosis index, which yielded a value of 1.103. Additionally, the absence of multicollinearity was verified by examining the correlation matrix among the observed variables, revealing no evidence of multicollinearity. According to Table 2, all fit indices indicate that the model fits well.
| Variable | NFI | CFI | RFI | SRMR | RMSEA | χ2⁄df | df | Chi-square |
|---|---|---|---|---|---|---|---|---|
| Structural model | 0.96 | 0.98 | 0.95 | 0.063 | 0.08 | 4.13 | 160 | 79.661 |
Fit Indices of the Structural Model of the Research
The structural model was evaluated using structural equation modeling with maximum likelihood estimation. The fit indices of the hypothetical model were found to fall within the optimal range, as displayed in Table 2 and Figure 2 illustrates the conceptual structural model and its standard coefficients.
The structural model of the research
In the present study, mediating relationships were evaluated using the bootstrap test. The results of the bootstrap test, presented in Table 3, indicate that the paths from SE and SI to sexual function through the mediation of sexual dysfunctional beliefs were significant, with effect sizes of 0.09 and 0.20, respectively, at the P value < 0.05 level.
| Independent Variables | Mediating Variables | Dependent | About Bootstrap | Estimation Error | Effect Size | Significance Level | |
|---|---|---|---|---|---|---|---|
| Upper Line | Lower Line | ||||||
| Sexual excitation | Dysfunctional beliefs | Sexual function | 0.183 | 0.033 | 0.037 | 0.091 | 0.005 |
| Sexual inhibition | Dysfunctional beliefs | Sexual function | -0.115 | -0.407 | 0.059 | -0.205 | 0.002 |
Results of the Bootstrap Test for Mediating Relations
5. Discussion
The present study aimed to evaluate the predicted model of sexual function based on SI, excitation, and sexual dysfunctional beliefs in women. The results revealed that SI and SE significantly influence women's sexual function through the mediating role of sexually dysfunctional beliefs. However, the direct effect of SI on sexual function was found to be insignificant. These findings align with the dual control model of sexual function (26) and previous research (10, 15) that has demonstrated a relationship between SE and women's sexual function. Nevertheless, the lack of a significant relationship between SI and sexual function is inconsistent with previous studies.
It can be posited that women who report a high level of sexual function also report higher levels of sexual responsibility and are more easily excited by sexual thoughts or external sexual stimuli. They may also experience greater sexual arousal in response to power dynamics in sexual relationships, such as when they are with a dominant sexual partner (27). Conversely, women who score higher in certain components of SE, such as the strength of sexual dynamics, may be more dependent on their partner's behavior or require specific stimuli to become aroused. If these conditions for excitation are not met, they may experience sexual problems and a greater likelihood of orgasmic difficulties (28).
Furthermore, previous studies have shown that individuals who score higher in SE also exhibit higher levels of impulsive sexual behavior and are more prone to engaging in risky sexual behaviors. In this regard, SE is considered an important factor in predicting sexual impulsivity (29). Physiologically, sexual arousal leads to the formation of vaginal lubrication, and by regulating the cellular processes in the vaginal tissue, estrogen increases and facilitates the growth and optimal function of nerve cells, blood vessels, smooth muscles, and cells inside the endothelium and epithelium (30). Improving the structure and thickness of the vaginal epithelium is expected to enhance blood flow in the genital tract, as the filled tissue contains a higher density of capillary beds, which increases blood supply to the genital organs and enhances lubrication.
The present study demonstrated that the direct impact of the SI factor on sexual function was insignificant, suggesting that a complete mediating mechanism was involved in influencing sexual function. The influencing mechanism in this study was found to be sexual dysfunctional beliefs. There is considerable evidence supporting the existence of a set of false sexual beliefs and sexual myths related to sexuality and SE, which are typically held by men and tend to overemphasize women's sexual function and pleasure. This study suggests that dysfunctional sexual beliefs can facilitate specific negative cognitive schemas and SI, leading to poor sexual performance in individuals with high inhibition. Additionally, it is important to consider the possibility that a high tendency for SI may precede and contribute to the development of negative cognitive schemas and sexual beliefs (31).
Repeated experiences of variable and inconsistent sexual response may increase the perception of anticipatory threat in sexual situations. Consequently, individuals may intensify efforts to prevent sexual failure through strategies such as monitoring their sexual response. Paradoxically, this can lead to improved anxiety performance and cause further negative sexual experiences.
Moreover, studies have demonstrated that individuals with negative basic sexual beliefs, including beliefs regarding the frequency and variety of sexual activities and partners, tend to report less frequent and shorter sexual encounters throughout their life (32). Therefore, it can be expected that if a woman has a positive sexual schema, the sexual stimulus may trigger the sexual meaning in the memory system, and reproductive/mental responses are activated.
Conversely, women with negative sexual schemas are more likely to perceive sexual stimuli as predominantly asexual or negative, inhibiting their genital and mental responses to sexual stimulation. Depressive mood and negative schemas have generally been shown to induce negative sexual schemas, which can further hinder sexual response (28). It has been suggested that depressed individuals may be vulnerable to misinterpreting sexual cues, as they may not have the same capacity to respond to these cues as non-depressed individuals (33).
Overall, the present study highlights the significance of SI and SE in the sexual function of women and provides further empirical support for the dual control model of sexual response. However, a set of limitations of the study should be acknowledged. Firstly, the cross-sectional design and correlational nature of the study prevent the establishment of causal relationships. Therefore, future longitudinal studies or controlled experiments are recommended to comprehensively determine the causal relationship between SI, SE, and cognitive factors with sexual performance. Secondly, the employed self-report evaluation method to collect data in the current research is susceptible to social desirability bias, which may cause inflated correlations between research variables. Despite these limitations, the current study represents a significant advancement in our understanding of the nature of sexual performance.
