Abstract
The present study aimed to investigate associations of automatic and controlled cognition with sexual functioning, and moderation of these associations by working memory capacity in a community sample of heterosexual women (N = 65) and men (N = 51). Participants performed two single-target Implicit Association Tests (ST-IATs) to assess implicit liking and wanting of erotic stimuli. The Sexual Opinion Survey (SOS) was used to assess explicit liking of sex. The International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) were used to assess sexual function. Working memory capacity was assessed using the Towers of Hanoi task and mood using the Hospital Anxiety and Depression Scale (HADS). In female participants, higher levels of sexual functioning co-occurred with stronger implicit associations of erotic stimuli with wanting, whereas implicit sex liking was unrelated to level of sexual functioning. In male participants, higher levels of sexual functioning co-occurred with lower implicit liking of erotic stimuli, whereas implicit sex wanting was unrelated to sexual functioning. Higher erotophilia scores were related to higher levels of sexual functioning in both women and men, but anxiety and depression symptoms were unrelated to sexual functioning. Working memory capacity did not moderate the associations between erotophilia and sexual functioning.
Conceptual models of sexual arousal in women and men have postulated the involvement of both controlled (or deliberate) and automatic cognitive processes (Barlow, 1986; Janssen, Everaerd, Spiering, & Janssen, 2000; van Lankveld et al., 2015). The cognitive interference model of sexual arousal (Barlow, 1986) assigned, along with affective factors, major roles to interfering thoughts and biased attentional processing in dysfunctional sexual performance. With regard to controlled, deliberate cognitive processing, Barlow proposed that, compared with nonsymptomatic men, men with erectile dysfunction expect to experience sexual difficulties when facing a potential sexual encounter. Conscious expectations are examples of controlled cognitions. Recurrent problems with sexual performance reinforce the person’s negative expectations, resulting in chronic sexual dysfunction. In contrast, asymptomatic men expect successful erectile performance, experience positive feelings, and focus adequately on erotic stimuli. Barlow based his model on a number of experimental studies among men (Abrahamson, Barlow, & Abrahamson, 1989; Bach, Brown, & Barlow, 1999; Barlow, Sakheim, & Beck, 1983; Beck & Barlow, 1986a, 1986b; Mitchell, DiBartolo, Brown, & Barlow, 1998; Weisberg, Bach, & Barlow, 1995). Manipulation of participants’ expectations of successful versus unsuccessful sexual performance was found to affect erectile performance in men with and without erectile dysfunction (Bach et al., 1999; Stone, Clark, Sbrocco, & Lewis, 2009). In more recent years, the model has also been applied to women (Laan & Everaerd, 1995; Wiegel, Scepkowski, & Barlow, 2007). In an experimental study among women, false positive feedback, presumably leading to positive expectations, was found to result in higher subjective sexual arousal, and false negative feedback resulted in lower subjective arousal in women with and without sexual arousal dysfunction (McCall & Meston, 2007). False positive feedback, however, did not lead to higher genital sexual arousal in healthy women but resulted in lower genital arousal in sexually dysfunctional women. Genital arousal in both groups was not affected by false negative feedback. Cross-sectional questionnaire studies have provided further support for the model. Men and women with sexual dysfunctions were found to harbor more negative deliberate cognitions than nonsymptomatic individuals before, during, and following partnered sexual activity, including certain types of negative sexual thoughts, sexual attitudes, and sexual self-schemata (Andersen, Cyranowski, & Espindle, 1999; Nobre & Pinto-Gouveia, 2009a, 2009b).
The information processing model of Janssen et al. (2000) postulated a crucial role for automatic appraisal of erotic stimuli as a determinant of sexual arousal. A central assumption in this model is that stimuli, upon being perceived, are coded as sexual or nonsexual, which results in, respectively, facilitation or inhibition of genital and subjective sexual responses. Initially, encoding and evaluation of erotic stimuli are automatic processes, of which the individual may be unaware, although conscious awareness may emerge in later stages of processing (Nisbett & Wilson, 1977; Schneider & Shiffrin, 1977). According to the model, stimuli that are coded as having sexual meaning automatically initiate genital sexual response. Awareness of the stimulus is not required for this purpose. Empirical support for this model has begun to emerge from experimental research in both men and women (Macapagal & Janssen, 2011; Spiering, Everaerd, & Janssen, 2003; Spiering, Everaerd, Karsdorp, Both, & Brauer, 2006).
More recently, dual-process theory (Corr, 2010; Evans & Frankish, 2009; Olson & Fazio, 2008) has been proposed to explain the fluctuating relative contributions of controlled and automatic processing of erotic stimuli to the generation of sexual arousal (van Lankveld, 2010; van Lankveld et al., 2018, 2015). Dual-process models, crucially, hypothesize that the relative impact of automatic and controlled cognizing on behavioral outcomes is determined by both situational and dispositional boundary conditions (Hofmann & Friese, 2008; Strack & Deutsch, 2004) (see Figure 1). A pivotal role among these conditions is assigned to working memory capacity (WMC; Baddeley, 1992; Dehaene, 2014). Situational factors, such as fatigue, alcohol intoxication, unpleasant emotional state (Figueira et al., 2017), and anxiety (Moran, 2016), impede the functioning of working memory. Individual differences in WMC are found to be significantly related but not identical to both crystallized and fluid intelligence (for a meta-analysis, see Ackerman, Beier, & Boyle, 2005). The moderating effect of boundary conditions is due to the different operating characteristics of the two types of information processing. The automatic process is permanently active during an individual’s waking state. It is able to simultaneously process multiple bits of information from a broad perceptual field and different sensory modalities and requires minimal WMC. Controlled processing, in contrast, occurs serially and is slower. It is able to override automatic (impulsive) responses (Hofmann & Friese, 2008; Strack & Deutsch, 2004), but its operation crucially depends on the availability of WMC. Decreases in WMC, therefore, impair the regulatory function of controlled cognizing, and allow automatic processes to dominate behavioral and physiological outcomes. When applied to sexuality, dual-process theory predicts that low or decreased WMC will augment the impact of (negative) automatic appraisals and lessen that of (positive) controlled appraisals on sexual functioning. Automatic associations are assumed to reflect general cultural stereotypes that are conveyed through socialization (Nosek et al., 2009; Steffens & Buchner, 2003) and the individual’s learning history (Gonzalez, Dunlop, & Baron, 2017). They are learned by frequent pairings of stimuli with an emotional state (Gawronski & Bodenhausen, 2006).
Different elements of the dual-process model of sexual functioning have been empirically tested. The first group of studies that will be reviewed focus on the aspect of limited cognitive processing capacity. In several experimental studies among men and women, using double-task or distraction paradigms, genital sexual responses were found to vary depending on the availability of information processing capacity (Adams, Haynes, & Brayer, 1985; Anderson & Hamilton, 2015; Elliott & O’Donohue, 1997; Geer & Fuhr, 1976; Salemink & van Lankveld, 2006; van Lankveld & Bergh, 2008; van Lankveld & van Den Hout, 2004). Note that these studies, at the time when they were performed and published, were not framed as tests of predictions derived from the dual-process model. Instead they were framed, for example, as testing the effects of distraction, increased cognitive load, and decreased attentional capacity on genital and subjective sexual arousal. Genital responses to erotic stimuli were found to decrease when a second, simultaneously executed, cognitive task captured incrementally larger parts of the available processing capacity, although some studies, in contrast, found that cognitive distraction facilitated erectile responses (Abrahamson, Barlow, Sakheim, Beck, & Athanasiou, 1985; Janssen, Everaerd, Van Lunsen, & Oerlemans, 1994).
In a small number of studies, the Implicit Association Test (IAT) paradigm (Greenwald, McGhee, & Schwartz, 1998) was used to test another element from the dual-process model, namely, the relative contribution of automatic and controlled cognitive associations with erotic stimuli to sexual functioning. The IAT aims to measure the strength of automatic associations in memory between two pairs of concepts (termed target pairs and attribute pairs). To do so, participants are instructed to assign stimuli that appear on a computer screen to categories by pressing designated keys on their keyboard. The IAT index is calculated from differences in reaction times between stimulus onset and key-press responses to different combinations of the concept pairs. We refer to the underlying cognitive process as “automatic versus controlled” when we discuss conceptual issues and to the measured cognitive outcomes as “implicit versus explicit” when we discuss data and findings. In the present study, the Single-Target Implicit Association Test (ST-IAT) was used, which is a single-target modification of the IAT (Bluemke & Friese, 2008). In the IAT, two opposing target categories are included that represent naturally occurring opposites (e.g., men versus women, animate versus inanimate). Such opposing categories are not readily available for sexual stimuli, and sexual stimuli were therefore used as a single-target category.
In an observational study, implicit associations of vaginal penetration stimuli with disgust and threat were assessed (Borg, de Jong, & Weijmar Schultz, 2010) using two ST-IATs. Women with sexual pain disorder or vaginismus were found to exhibit stronger implicit associations between sex and disgust than were nonsymptomatic women. In a study among healthy young adults, implicit sex–disgust ST-IAT associations were not strongly related to sexual functioning nor to genital or subjective sexual arousal responses to erotic stimuli (Grauvogl et al., 2015). In another ST-IAT study (Brauer et al., 2012), women who were diagnosed at the time with hypoactive sexual desire disorder (HSDD) exhibited less positive (but not more negative) implicit associations of vaginal penetration stimuli with positive valence, compared with sexually functional women.
Valence plays a role in both affective (“liking”) and motivational (“wanting”) appraisals that may have differential effects on sexual functioning (Dewitte, 2015). Both appraisal types are conceptualized in emotion theory (see Frijda, 1993) as determining the level of appreciation (liking) of stimuli and the tendency to approach or avoid stimuli (wanting). Recently, these constructs have been applied to a neuroscience model of sexual functioning (Georgiadis, Kringelbach, & Pfaus, 2012). In this model, wanting is a motivational phase of the sexual response that can be consciously experienced as increasing sexual desire, whereas liking plays a predominant role in the consummatory phase and is reflected in subjective and genital sexual arousal. Distinctions between liking and wanting were demonstrated in patient samples with illegal drug addictions (Robinson & Berridge, 1993, 2008) and eating disorders (Tibboel et al., 2011). Therefore, next to implicit sex-liking associations, sex-wanting associations might be of interest, reflecting automatic motivation for sex.
Implicit associations of erotic stimuli with both liking and wanting were examined in female gynecological patients with and without sexual problems (van Lankveld, Bandell, Bastin-Hurek, van Beurden, & Araz, 2018). In both groups, stronger implicit associations of erotic stimuli with wanting were associated with higher levels of sexual functioning. Compared to nonsymptomatic women, women with sexual problems were found to show more negative implicit associations of erotic stimuli with wanting, indexing automatic sexual motivation. In addition, higher positive explicit ratings of erotic stimuli were associated with lower levels of sexual distress in both groups. The two groups did not differ with regard to the implicit associations of sexual stimuli with liking.
Automatic liking and wanting associations, measured using ST-IATs, were also investigated in male urological patients with and without sexual dysfunction (van Lankveld et al., 2015). Although the two groups differed regarding the implicit association of erotic stimuli with liking, the direction of the observed difference was unexpected: Sexually dysfunctional men were found to harbor more positive implicit associations with erotic stimuli than healthy men. The two groups did not differ with regard to implicit wanting. In a second study among male urological patients with and without sexual problems this finding was replicated, with participants with lower levels of sexual functioning exhibiting a stronger automatic sex-positive association. This effect was largest in the younger age group (van Lankveld et al., 2018). In a nonclinical student sample, several aspects of the sexual behavior of men were predicted best from their implicit sex-liking scores, whereas the sexual behavior of women was best predicted using implicit sex-wanting scores (Dewitte, 2015).
In all previously reviewed studies of automatic cognitive associations with erotic stimuli, individuals with and without sexual dysfunction were compared, presuming a discontinuity between healthy and disordered sexual functioning, based on different underlying processes (e.g., Barlow, 1986). In contrast with such medical or categorical models of sexual functioning and dysfunction (for a discussion, see Pronier & Monk-Turner, 2014), the dimensional model of psychopathology (Anderson, Huppert, & Rose, 1993) postulates the existence of a continuum of psychopathology symptoms in the population, ranging from total absence in nonsymptomatic individuals to full-scale symptom constellations in persons suffering from severe mental disorders (Kessler, 2002). Evidence for the existence of a dimensional, continuous distribution of symptoms in the population has been found to vary among mental disorders (e.g., Fraley & Spieker, 2003; Haslam, 2003a; Haslam, 2003b; Solomon, Haaga, & Arnow, 2001; Thewissen, Bentall, Lecomte, van Os, & Myin-Germeys, 2008). Forbes, Baillie, and Schniering (2016) proposed a dimensional model of sexual dysfunction as part of an internalizing disorder dimension, together with depressive and anxiety disorders. Using latent profile analysis and structural equation modeling (SEM), women’s data were found to fit better with the dimensional model than men’s data (Forbes et al., 2016). Men’s data fit better with the categorical model. Consistent with a dimensional perspective, for the present study participants were recruited from the general population to investigate the relationships between sexual functioning and automatic and controlled wanting and liking associations with erotic stimuli and the moderation of these relationships by WMC. To the best of our knowledge, the central assumption in the dual-process model of sexual arousal—that the effects of automatic and controlled cognitive associations on sexual functioning are moderated by WMC—has not yet been tested. In the current, cross-sectional study, we aimed to perform a first test in the general population of this assumption that sexual functioning is determined by both automatic and controlled cognitive appraisals, and that the relative influence of these appraisal types is modulated by WMC. Given that currently available cognitive-behavioral interventions in the treatment of sexual dysfunctions focus predominantly on consciously available cognitive factors (Berner & Gunzler, 2012; Fruhauf, Gerger, Schmidt, Munder, & Barth, 2013; Gunzler & Berner, 2012; Ter Kuile, Both, & van Lankveld, 2010), testing the assumptions of a dual-process model of sexual function may have important clinical implications.
We tested the following hypotheses:
H1: In women, level of sexual functioning will be significantly associated with implicit associations of erotic stimuli with wanting: strong implicit sex-wanting scores will be associated with higher levels of sexual functioning.
H2: In men, level of sexual functioning will be significantly associated with implicit associations of erotic stimuli with liking: higher levels of implicit sex-liking will be associated with higher levels of sexual functioning.
H3: In both women and men, levels of sexual functioning will be significantly associated with explicit cognitions with regard to sexuality: stronger positive attitudes toward sex (erotophilia) will be associated with higher levels of sexual functioning.
H4: Anxiety and depression symptom levels will be negatively associated with levels of sexual functioning.
H5: Level of WMC will differentially moderate the relationship between automatic and controlled associations and sexual functioning, showing stronger associations between controlled sex liking and sex wanting and levels of sexual functioning at higher levels of WMC.
Method
Participants
Interested individuals were eligible if they were 18 years of age or older, self-identified as heterosexual, had any sexual experience with a partner, reported having had sexual contact in the last four weeks, and were sufficiently proficient reading Dutch to answer the study questions and to perform the computer tasks. Undergraduate students recruited study participants in their personal circle of acquaintances. Interested people received a personal invitation by e-mail in which the purpose and procedures for participation were explained. Participation was voluntary and no compensation was offered. Individuals who responded and indicated their interest and willingness to participate received personal log-in codes and a URL linking to an online research platform.
Measures
Sexual Functioning
After completing a short demographic questionnaire, participants answered an initial question asking whether they currently were experiencing any sexual problems. If they responded that they were, a follow-up question asked for the type(s) of sexual problems they experienced.
Female Sexual Function Index (FSFI). The FSFI (Rosen et al., 2000) is a self-report questionnaire that assesses female sexual functioning with 19 items organized in six subscales measuring sexual desire, sexual arousal, lubrication, orgasmic function, sexual satisfaction, and sexual pain. Our theoretical framework postulates crucial links between cognitive appraisal processes and sexual arousal. To investigate these predictions, the subscales indexing sexual desire, sexual arousal, vaginal lubrication, and orgasm were selected to represent these aspects of female sexual functioning. Summated subscale scores form a global index of sexual functioning (FSFI total score). Answers are provided on five- and six-item scales, with higher scores indicating better sexual functioning. The original factor structure was replicated in the Dutch-language version (Ter Kuile, Brauer, & Laan, 2006). The internal consistency of the FSFI was found to be excellent (Cronbach’s αs > 0.82). Its test–retest reliability ranged from satisfactory to high for all subscales (r = 0.79 to 0.86) as well as for the total scale (r = 0.88; Rosen et al., 2000). In the present study, the internal consistency ranged from satisfactory to excellent (sexual desire subscale: Cronbach’s α = .77; sexual arousal: Cronbach’s α = .94; lubrication: Cronbach’s α = .96; orgasm: Cronbach’s α = .92).
International Index of Erectile Functioning (IIEF). The IIEF (Rosen et al., 1997) is a self-report questionnaire to assess male sexual functioning. It has 15 items organized into five subscales measuring erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction. The subscales indexing sexual desire, erectile function, and orgasmic function were selected to represent these aspects of male sexual functioning. Participants provided answers on five- and six-item scales, with higher scores indicating better sexual functioning. A sum score is calculated to provide a global index of sexual functioning (IIEF total score). The internal consistency of the IIEF was found to be excellent in previous research (Cronbach’s α between 0.92 and 0.96), and test–retest reliability was high (r = .84; Rosen et al., 1997). In the present study, the internal consistency ranged from good to excellent (erectile function: Cronbach’s α = .95; orgasmic function: Cronbach’s α = .96; sexual desire: Cronbach’s α = .84).
Depression and Anxiety
The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) was employed to assess the severity of depression and anxiety symptoms. The HADS is a 14-item self-report questionnaire with two subscales for anxiety and depression. High scores represent higher levels of anxiety and depression. Satisfactory to high internal consistency was demonstrated in Dutch samples, with Cronbach’s α ranging from .71 to .90 (Spinhoven et al., 1997). In the present study, the internal consistency was good for the anxiety subscale (Cronbach’s α = .81) and satisfactory for the depression subscale (Cronbach’s α = .77).
Implicit Associations With Sexual Stimuli
Single-Target Implicit Association Test. The ST-IAT is a modified version of the IAT (Greenwald et al., 1998) and was used in the present study to measure implicit appraisals of erotic stimuli. The psychometric aspects of both the IAT (Houben & Wiers, 2008; Nosek, Greenwald, & Banaji, 2005) and the ST-IAT (Bluemke & Friese, 2008; Karpinski & Steinman, 2006) have been found satisfactory. Previous studies found that online and on-site performance of the IAT did not vary systematically (Houben & Wiers, 2008).
The ST-IAT contained one target category (erotic) and two conceptually opposite attribute categories. The erotic target in the liking and the wanting ST-IATs was represented by four images of heterosexual interaction selected from the International Affective Picture System (Lang, Bradley, & Cuthbert, 1999).1 Each showed a female and a male actor engaging in explicit sexual activity, but no full close-up shots of the genitals were shown. Female breasts were fully visible. The attribute categories for the liking ST-IAT were “positive” (represented by the words humor, health, gift, and peace [in Dutch: humor, gezondheid, kado, vrede]) and “negative” (represented by the words hatred, war, disease, and pain [in Dutch: haat, oorlog, ziekte, pijn]). The attribute categories for the wanting ST-IAT were “I want” (represented by the verbs “long for,” “want,” “wish,” and “desire”; in Dutch: hunkeren, begeren, wensen, verlangen) and “I do not want” (using the verbs “ward off,” “avert,” “avoid,” and “stop”; in Dutch: afweren, ontwijken, vermijden, stoppen).
The attribute category labels were permanently shown in the upper-left (label “positive” or “I want”) and upper-right (label “negative” or “I do not want”) corners of the screen. Their position remained the same throughout the test. The target category (“sex”) switched position and was shown either above the left or the right attribute category label, depending on the instructions for each block.
Participants received instruction to categorize each word or picture, appearing in the center of a laptop computer screen, into either the target category or one of the attribute categories by pressing the z and m keys on a QWERTY keyboard. After a correct response, the next stimulus was presented. When an incorrect response was given, error feedback was presented as a red X that replaced the stimulus in the center of the screen; the red X remained on the screen until the correct response was given.
Table 1 shows the ST-IAT setup that was identical in the liking and wanting versions and gives examples of the instructions for participants. The ST-IAT started with a practice block using only attribute stimuli. Subsequently, there were two identical blocks, first a practice block of 16 trials in which both erotic pictures and positive and negative attribute words were presented, followed by a test block of 48 trials (see Table 1). Within the practice and test blocks, the numbers of key presses on both response keys were kept equal to prevent the development of response bias (de Jong, 2015). The same stimuli were used in practice and test trials (Nosek et al., 2005). The target and attribute stimuli were presented in quasi-random order, ensuring that each target stimulus was both preceded and followed by an attribute stimulus. No more than two attribute stimuli were presented in a row between two target stimuli. In the first practice and test block erotic pictures and positive words were mapped on the same response key (sex-positive combination), whereas in the second practice and test block erotic pictures and negative words shared the same response key (sex-negative combination). One of the combinations (sex positive or sex negative) was expected to result in briefer reaction times. This expectation is based on the assumption that key presses are faster when the association between target and attribute is stronger within the participant’s representational network, compared with when this association is incongruent.
Table 1. Target and Attribute Key Mapping in Subsequent Blocks in the Liking and Wanting ST-IAT
No error correction procedure was used in the wanting ST-IAT, to emphasize the more personalized nature of this ST-IAT version (Olson & Fazio, 2004). The order of performance of the liking and wanting ST-IATs was fixed, with the liking ST-IAT used as the first task. Previous studies found that online and on-site performance of the IAT did not vary systematically (Houben & Wiers, 2008).
Explicit Associations With Sexual Stimuli
Sexual Opinion Survey (SOS). The SOS (Fisher, Byrne, White, & Kelley, 1988) was used to measure the participant’s explicit liking of sexual stimuli. It is composed of 21 items and contains a single scale that assesses the participant’s position on a erotophilia–erotophobia dimension, a “disposition to respond to sexual cues along a negative-positive dimension of affect and evaluation” (Fisher et al., 1988, p. 123). The psychometric characteristics of the SOS were satisfactory, with Cronbach’s α ranging from .82 to .90) in male and female samples (Fisher et al., 1988). In the present study the internal consistency was good, with Cronbach’s α = .81. No measure of explicit wanting was used.
Working Memory Capacity
Revised Tower of Hanoi (ToH-R). To measure the participant’s WMC, the ToH-R (Welsh & Huizinga, 2001) was used. This is a problem-solving task purportedly measuring executive functioning. ToH-R performance was found to correlate highly with working memory characteristics, especially with the visuospatial element (Handley, Capon, Copp, & Harper, 2002). Computerized administration of the ToH-R did not differ from performance using the wooden version (Mataix-Cols & Bartres-Faz, 2002). Comparisons of on-site and online computerized Tower of Hanoi tasks have not been published. An online digital version of the TOH-R was used. Three vertical pegs, identical in height and diameter, and evenly spaced, were placed on a flat base. Four disks with different diameters had to be placed onto the pegs, allowing for different configurations. The ToH-R contained 22 trials (see Welsh & Huizinga, 2001). At the beginning of each trial both the start configuration and the goal configuration were displayed on the computer screen. Participants were instructed to transform the start configuration into the goal state in the smallest possible number of moves by relocating the disks. The moves were constrained by three rules: (1) only one disk could be moved at a time; (2) a disk had to be placed onto one of the pegs before the start of the next move; and (3) a disk should not be placed on top of a disk with a smaller diameter. Further instructions were to attain the goal in one attempt, using the required number of moves, but no time limit was imposed. These rules were explained prior to the start of the first trial. They require the participant to plan a series of moves before making the first move and to monitor and adjust this plan during execution of the task. Because of this the ToH, and other object-transfer tasks, such as the Tower of London, are considered to be sensitive to differences in frontal lobe functioning, working memory (Goldman-Rakic, 1987), inhibition (Goel & Grafman, 1995), or both aspects of executive functioning (Zook, Davalos, DeLosh, & Davis, 2004). Each trial result was scored as 0 (incorrect solution) or 1 (correct solution), resulting in a total score of correctly solved problems with a possible range of 0 to 22. High scores indicate high WMC.
Procedure
A fixed order of tests was chosen to avoid priming effects of the completion of questionnaires on sexual issues that might impact subsequent performance of implicit testing and to avoid fatigue effects of test completion on the measure of WMC. Thus, first, the ToH-R was performed; next, the ST-IAT liking and wanting tasks were done; finally, the online questionnaires (demographic questions, FSFI/IIEF, HADS, and SOS) were completed. Together, all tasks took about 45 minutes to perform. Ethical clearance for the study was obtained from the university’s ethical review board.
Statistical Analysis
To index the implicit associations of erotic stimuli with liking and wanting, an improved D600 computation algorithm of Greenwald, Nosek, and Banaji (2003) was employed. Combined data of practice and test phases were used to calculate the D600 ST-IAT index. Conforming to standard practice, in this measure, reaction times (RTs) below 400 ms were discarded, RTs above 2,500 ms were replaced with 2,500 ms, and, only in the liking ST-IAT, incorrect trials were replaced by the mean RT with an added penalty of 600 ms before calculation of the mean RTs. The wanting ST-IAT was designed as a personalized IAT (Dewitte, 2015; Olson & Fazio, 2004); for this purpose, no faulty responses were defined. The D600 index score was calculated as the difference score between the mean reaction times to the sex-positive/I want and sex-negative/I don’t want combination blocks, divided by the standard deviation calculated across all blocks with the exception of the attribute practice block. Lower D600 scores indicated that erotic stimuli were more strongly associated with liking and wanting. Using d = 0.65 as a conservative mean effect size estimate of IAT differences, based on group comparison studies (Nosek et al., 2005), we required 60 participants to obtain 80% statistical power of an independent-samples t test, using p < .05. To test hypotheses 1 through 3, Pearson product-moment correlations were calculated. To test hypothesis 4, a series of hierarchical linear regression analyses was performed with sexual functioning scores (standardized FSFI/IIEF subscale scores) as dependent variables. Effect sizes and their 95% confidence intervals (CIs) were calculated (Steiger, 2004). Analyses were performed using SPSS Version 24.
Results
The sample was composed of 116 participants, of whom 65 were women (56%, Mage = 31.6 years; SD = 10.1), and 51 men (44%, Mage = 37.0 years; SD = 12.0). In all, 77% of female participants and 73% of male participants reported being in a committed relationship. Relationship length varied widely, with averages of 10.1 and 12 years for female and male participants, respectively. More than 50% of the participants reported a college or university-level education. Sexual problems were reported by 3% of female and 2% of male participants. Relationship characteristics, other demographics, and means and standard deviations of the variables of interest are shown in Table 2.
Table 2. Demographic, Medical, Sexual, and Psychological Functioning Characteristics of Participants (N = 116)
Pearson correlation analyses were performed separately for female and male participants (see Table 3). In female participants significant correlations were revealed between implicit wanting and self-reported levels of sexual arousal (r = −.26, p < .05) and orgasm (r = −.35, p < .01). Stronger implicit sex-wanting associations were correlated with higher levels of sexual arousal and orgasmic functioning. Implicit sex-liking associations were not significantly correlated with sexual functioning indices. In male participants significant correlations were revealed between implicit liking and self-reported levels of orgasm (r = .33, p < .05). Specifically, stronger sex-liking associations were correlated with lower levels of orgasmic functioning.
Table 3. Bivariate Correlations in Female and Male Participants Between Automatic Associations of Erotic Stimuli With Liking and Wanting, Erotophilia, Anxiety and Depression Symptoms, and Sexual Functioning Indexes
In female participants significant correlations were revealed between erotophilia and self-reported levels of sexual desire (r = .25, p < .05), sexual arousal (r = .40, p < .001), vaginal lubrication (r = .32, p < .01), and orgasm (r = .31, p < .01). In male participants a significant correlation was found between erotophilia and self-reported level of sexual desire (r = .30, p < .05). Stronger erotophilia was correlated with better functioning on these aspects of sexuality in both women and men. In male participants higher erotophilia scores were correlated with higher implicit sex wanting (r = −.31, p < .01). Explicit and implicit measures of sex liking and wanting were not significantly correlated in female participants.
Moderation by WMC of the associations of implicit and explicit sex-liking and sex-wanting associations was investigated by performing two series of hierarchical multiple linear regression analyses (Enter method) with sexual desire, sexual arousal, vaginal lubrication, and orgasm (all FSFI subscale measures) as criterion variables in the female participants, and sexual desire, erectile function, and orgasmic function (all IIEF subscale measures) as criterion variables in the male participants. In the first step, implicit sex-liking, implicit sex-wanting, and erotophilia scores were entered. In the second step, the interaction term of erotophilia and WMC was entered. In the third step, HADS anxiety and depression scores were added. Among the female participants, four univariate outliers were excluded from the analyses. Two participants had extremely high scores on the ToH-R, one had an extremely low score on the HADS anxiety scale, and one had an extremely low score on the HADS depression scale. Among the male participants, two univariate outliers were excluded. Both had extremely high scores on the ToH-R. No multivariate outliers were identified.
In the female subsample, the regression model using sexual arousal scores as criterion variable and implicit sex-liking, implicit sex-wanting, and erotophilia scores as predictor variables in the first step was significant when compared to a constant-only model, R2 = .23, F (3, 52) = 5.18, p = .003 (see online Supplementary Table 1). Erotophilia (β = .456, p = .001) significantly contributed to the model. In the second and third steps, no additional explained variance was revealed. The regression model using orgasmic function scores as criterion variable and implicit sex-liking, implicit sex-wanting, and erotophilia scores as predictor variables in the first step was significant when compared to a constant-only model, R2 = .18, F (3, 52) = 3.90, p = .014. Implicit sex wanting (β = −.313, p = .021) and erotophilia (β = .327, p = .014) contributed to prediction. In the second and third steps, no additional explained variance was revealed. Regression models with sexual desire and vaginal lubrication scores as criterion variables were not significant.
In the male subsample, the regression model using erectile function scores as criterion variable and with implicit sex-liking, implicit sex-wanting, and erotophilia scores as predictor variables in the first step was significant when compared to a constant-only model, R2 = .20, F (3, 40) = 3.26, p = .03 (see online Supplementary Table 2). Implicit sex liking (β = .319, p = .035) and erotophilia (β = .321, p = .038) significantly contributed to the model. Lower implicit sex-liking associations and stronger erotophilia were associated with higher levels of erectile functioning. In the second and third steps, no additional explained variance was revealed. The regression model using orgasmic function scores as criterion variable and implicit sex-liking, implicit sex-wanting, and erotophilia scores as predictor variable in the first step was significant when compared to a constant-only model, R2 = .19, F (3, 40) = 3.17, p = .03. Implicit sex liking (β = .407, p = .008) significantly contributed to the model. Again, low implicit sex-liking associations were related to higher levels of orgasmic functioning. In the second and third steps no additional explained variance was revealed. The regression model with sexual desire as criterion variable was not significant.
Discussion
In this study we investigated the relationships between sexual functioning and automatic and controlled wanting and liking associations with erotic stimuli and the moderation of these relationships by WMC in a nonclinical community sample. Our results partly supported the hypothesized gendered pattern of associations of aspects of sexual functioning on one hand and implicit liking and wanting of sex on the other. Whereas in female participants higher levels of sexual functioning (sexual arousal and orgasm) were associated with stronger implicit associations of erotic stimuli with wanting, implicit sex liking was not associated with any aspect of sexual functioning. The fully opposite finding was revealed in male participants. In men, better orgasmic functioning was associated with lower levels of implicit liking of erotic stimuli, but implicit sex-wanting associations did not correlate with any aspect of sexual functioning. These starkly contrasting findings, nevertheless, replicated results in previous studies of our research group in female and male patient samples with and without self- and clinician-diagnosed sexual dysfunctions (van Lankveld, Bandell et al., 2018; van Lankveld, de Jong, et al., 2018; van Lankveld et al., 2015), using similar methodology. The present findings in female participants are also similar to those of Dewitte (2015), who investigated a substantially younger sample. In both the present study and the Dewitte (2015) study, higher implicit wanting was related to higher levels of sexual functioning and frequency of sexual behavior in female participants. Although these studies also both found a significant relationship between implicit sex liking and sexual functioning/behavior in male participants, the directions of these relationships were opposite. In Dewitte’s (2015) study, a relationship between high implicit sex liking and high sexual behavior frequency was found; in the present study, there was an association between high implicit sex liking and low levels of sexual functioning.
With regard to explicit sexual attitudes, erotophilic scores were associated with better functioning on various aspects of sexual functioning in both women and men in the present study: in women on subscale scores of sexual desire, sexual arousal, vaginal lubrication, and orgasm; and in men on sexual desire scores. The associations in women of higher erotophilia scores and stronger implicit sex wanting with better sexual functioning were in line with the literature and with previous findings in a nonclinical sample (Dewitte, 2015). More positive automatic and controlled evaluations of erotic stimuli aligned and related positively to sexual functioning. However, they appeared to independently contribute to the variance in sexual functioning, because no significant correlations were observed in female participants between explicit and implicit measures of sex liking and wanting.
Whereas no association was found between implicit liking of erotic stimuli and sexual functioning in female participants in the present study, such an association was shown in a study of women with HSDD (Brauer et al., 2012). The methodology used in Brauer et al.’s study and the current study was very similar, although the selection of erotic pictures only partly overlapped. The observed significant effect in women diagnosed with HSDD may reflect a stronger implicit association in this clinical group compared to the present community sample and is consistent with a dimensional view on sexual psychopathology.
The initially counterintuitive link in men between low implicit sex liking and higher level of sexual functioning, which was found both in the present study and the two previous ST-IAT investigations in clinical samples (van Lankveld, de Jong, et al., 2018; van Lankveld et al., 2015), provokes speculation. A possible explanation might be that men with a history of unsuccessful and disappointing sexual encounters do not experience their own partner as a positive sexual stimulus even though they have a strong positive appreciation of sexual stimuli in general. The erotic stimuli in the ST-IAT depicted anonymous porn actors. A strong, positive implicit association with this type of stimuli in men with lower levels of sexual functioning might be the end stage of a learning process (Georgiadis et al., 2012). Such an end stage might result from frequent exposure to explicit pornography and the linkage of these stimuli with the rewards procured by orgasm through masturbation, as opposed to unrewarding sexual experiences with their partners. In several studies, such links were found, including in men with low sexual desire (Carvalheira, Træen, & Štulhofer, 2015) and in women and men in a community sample (Vaillancourt-Morel et al., 2017), although another study among community young men failed to find a strong link (Landripet & Štulhofer, 2015). To test this speculative explanation, van Lankveld, de Jong, et al. (2018) suggested embedding pictures portraying each participant’s own partner in the erotic stimuli in a ST-IAT. Alternatively, the associations of sexual stimuli with positive valence, such as in men with low levels of sexual functioning, might represent a strong desire for the sexual interactions as were displayed in the erotic pictures. The discrepancy between this desire and their actual sexual interactions might, in fact, be one of the driving forces of their dysfunctional sexual experiences. A final possibility is that men who have higher implicit sex-liking associations also harbor highly demanding, performance-related sexual beliefs (“macho beliefs”) that act as vulnerability factors for the development of sexual dysfunction (Peixoto & Nobre, 2017). Testing the hypothesis that strong implicit sex-liking associations are explained by stronger macho beliefs warrants the inclusion of sexual beliefs in future studies.
In contrast with the seemingly contradictory findings in men regarding the association between automatic sex liking and sexual functioning, the observed significant link in men between higher erotophilia scores and higher sexual desire scores is straightforward. Although higher erotophilia scores were associated with higher implicit sex wanting in male participants, to reiterate, implicit sex wanting did not show an association with sexual functioning in men.
Multiple regression analyses failed to confirm the hypothesized moderation effects of WMC and anxiety and depression symptoms on the associations between implicit and explicit measures and sexual functioning. Thus, our findings do not shed any further light on the theoretical presumptions a dual-process framework has to offer for the explanation of the variability in male and female sexual functioning. Anxiety and depression symptoms did not add to the prediction of any aspect of sexual functioning, probably due to the low symptom levels, combined with adequate levels of sexual functioning in the study sample.
Several tentative explanations for not finding a moderation effect of WMC can be put forward. The first is that such an effect of WMC is truly nonexistent. Some previous empirical studies, however, provide indications that working memory, and possibly also other aspects of executive functioning, are involved in sexual functioning, specifically sexual arousal in young men (Amezcua-Gutierrez et al., 2017; Ruiz-Diaz, Hernandez-Gonzalez, Guevara, Amezcua, & Agmo, 2012). Another tentative explanation is that moderation by WMC was obscured by instrumentation problems. Although the ToH-R was been used to index working memory characteristics (Goel & Grafman, 1995; Goldman-Rakic, 1987; Zook et al., 2004), the visuospatial element in it may dominate (Handley et al., 2002) and make it less suitable to represent the verbal/linguistic aspects of working memory that are invoked for the execution of this particular task. Other instruments, including word and digit span tests, might be more appropriate to capture the relevant aspect of working memory. A final speculative explanation may be that the effect size of the constraints of limited WMC in a nonclinical sample is smaller than expected, resulting in insufficient statistical power of the (small) current sample size, which became even smaller because several participants encountered technical problems and were not able to perform the ToH-R. Another substantial proportion of the participants failed to pass the performance threshold of the minimum three failed trials because they stopped their test participation prematurely. Future research is warranted to test these speculative explanations.
The scores of female participants in our sample were quite low, suggesting lower levels of sexual functioning (Ter Kuile et al., 2006), and might cast doubt on whether they truly represented a nonclinical population. However, the FSFI scores of the two female respondents who self-reported experiencing sexual problems were in the intermediate and in the above-average range of FSFI scores. Similar findings of low FSFI scores were also reported in a Dutch general population sample (Lammerink et al., 2017).
In conclusion, we found evidence in this community sample that several aspects of sexual functioning are associated with implicit associations of erotic stimuli with liking and wanting, in addition to explicit aspects of sexual cognition. Our findings replicated findings in previous studies. We did not find evidence for the moderation of these associations by WMC, as suggested by a dual-process model of sexuality.
Acknowledgments
We thank Anne Camper, Chantal Bos, Jill Philipsen, Marcella Hagenaar, Marije Koppenens, Marissa van der Velde, Myrinne M. Tinselboer, and Esther Stehouwer for their participation in data collection.
Online Supplemental Table 2
Online Supplemental Table 1
Notes
1 Erotic pictures for the liking ST-IAT were IAPS numbers 4658, 4659, 4664, and 4680. These pictures were previously used in the study of van Lankveld et al. (2015). Selected erotic pictures for the wanting ST-IAT stimuli were IAPS numbers 4611, 4652, 4690, and 4800.
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