Week 4 Assignment

Please no plagiarism and make sure you are able to access all resources on your own before you bid. Main references come from Murray, C., Pope, A., & Willis, B. (2017) and/or American Psychological Association (2014).  Assignments should adhere to graduate-level writing and be free from writing errors. Please follow the instructions to get full credit. I need this completed by 03/22/2020 at 5pm. 

Assignment – Week 4

Don't use plagiarized sources. Get Your Custom Essay on
Week 4 Assignment
Just from $13/Page
Order Essay

Family Life-Cycle Stages

Although every individual experiences family life cycle transitions in unique ways, common challenges and experiences often arise at these transition periods. For example, many couples experience changes in their sexual relationship after they become parents. Likewise, adults’ understanding of what it means to have “positive” sexual functioning may differ at different stages in the family life cycle. It is important for counselors to pay attention to the unique needs of the individual clients they serve, while also keeping in mind these common challenges and experiences that may arise.

For this week’s Assignment, use the

Sexuality in Adulthood Across the Family Life Cycle

chart provided in this week’s Learning Resources to describe both:

· At least two common sexuality-related transitions or concerns at each stage.

· At least two examples of how research and theory characterize positive sexual functioning during each stage.

The family life-cycle stages you will consider for this assignment are:

· Single adulthood

· Committed, long-term relationships

· Becoming parents

· Divorce/relationship termination and remarriage/re-partnering

· Older adulthood

The Assignment (2- to 3-page paper):

For the five family life-cycle stages:

· Describe two common sexuality-related transitions or concerns at each stage.

· Provide two examples of how research and theory characterize positive sexual functioning during each stage.

· Briefly describe how you might intervene or use this information to assist clients.

Support your Assignment with specific references to all resources used in its preparation. You are to provide a reference list for all resources, including those in the Learning Resources for this course.

Required Resources

· Course Text: Murray, C., Pope, A., & Willis, B. (2017). Sexuality counseling: Theory, research, and practice. Thousand Oaks, CA: Sage

· Chapter 5, “Lifespan Development and Sexuality”

· Chapter 8, “Sexuality and Intimate Relationships”

· Article: Aalgaard, R. A., Bolen, R. M., & Nugent, W. R. (2016). A literature review of forgiveness as a beneficial intervention to increase relationship satisfaction in couples therapy. Journal of Human Behavior in the Social Environment, 26(1), 46–55. Retrieved from the Walden Library databases.

· Article: Brotto, L. A., Chivers, M. L., Millman, R. D., & Albert, A. (2016). Mindfulness-Based sex therapy improves genital-subjective arousal concordance in women with sexual desire/arousal difficulties. Archives Of Sexual Behavior, 45(8), 1907–1921. Retrieved from the Walden Library databases.

· Article: Faircloth, C. (2015). Negotiating intimacy, equality, and sexuality in the transition to parenthood. SOCIOLOGICAL RESEARCH ONLINE, 20(4). Retrieved from the Walden Library databases.

· Handout: Sexuality in Adulthood Across the Family Life Cycle

©2019 Laureate Education, Inc.

Sexuality in Adulthood Across the Family Life Cycle
COUN 6361/COUN 6361S: Human Sexuality

Family Life-Cycle

Stage

At Least Two Common

Sexuality Related
Transitions or Concerns

at This Stage

At Least Two Examples of
How Research and Theory

Characterize Positive Sexual
Functioning During This

Stage

How You Would

Intervene/Use This
Information to Assist the

Family

Single Adulthood

Committed Long-
Term Relationships

Becoming Parents

©2019 Laureate Education, Inc.

Divorce/Relationship
Termination and
Remarriage/Re-
Partnering

Older Adulthood

1.

1

1.

2

2.1

Negotiating Intimacy, Equality and Sexuality in
the Transition to Parenthood

by Charlotte Faircloth

University of Roehampton

Sociological Research Online, 20 (4),

3


DOI: 10.5153/sro.3705

Received: 9 Dec 2014 | Accepted: 12 Jun 2015 | Published: 30 Nov 2015

Abstract
Whilst both ‘parenting’ and ‘intimacy’ have been explored extensively in recent social scientific research (for example, Lee et al
2014,Gabb and Silva 2011), their intersections in the context of family life remain curiously absent. This paper presents findings from
on-going longitudinal research with parents in London, which investigates how the care of children, and particularly the feeding of
infants, affects the parental couple’s ‘intimate’ relationship. In particular, as part of this special section, it looks at couples’ accounts of
sex as they make the transition to parenthood, as a lens on the themes of gender, intimacy and equality. Far from being an easy
relationship between them, as predicted by some scholars, this research shows that they are in fact, ‘uncomfortable bedfellows’.

Keywords: Parenting, Gender, Intimacy, Equality, Sex, Couples

Negotiating intimacy, equality and sexuality in the transition to parenthood
Based on longitudinal work with new parents in London, this paper draws on research which
investigates how the care of children, and particularly the feeding of infants, affects the parental couple’s intimate
relationship. To that end, it brings together two (traditionally distinct) bodies of literature – one calling attention to
a shift in British parenting culture towards a more ‘intensive’ and ‘child-centred’ form of care, the other, looking at
changes to intimate relationships in an age of ‘reflexive modernisation’ and greater gender equality. Specifically,
this paper focuses in on couples’ accounts of sex as they make the transition to parenthood, as a lens on the
themes of gender, intimacy and equality.

Whilst intimacy itself can incorporate a range of different practices, as a vehicle for intimacy, sexual
intercourse often serves as a barometer for couples in how they assess the quality of their relationship (Weeks
1995). In line with other papers in this special section, then, the research shows that far from being a
straightforward correlation between gender equality and greater intimacy, (as predicted by Giddens et al 1992),
the two are, in fact, ‘uncomfortable bedfellows’, particularly once couples become parents. The article briefly
reviews the two bodies of literature, explains the policy context around parental leave and childcare in the UK,
discusses the study methodology, and then presents findings, analysis and discussion by way of conclusion.

Theoretical background: Intimacy and parenting
As Gabb and Silva (2011) note, the ‘conceptual challenge to researchers working in the field of family
and relationship studies…is how to carry on building concepts and finding new methods to capture the vitality of
personal relationships while keeping sight of the social contexts, patterns and practices of contemporary intimate
life’ (1.1, 2011). Famously, work by Giddens (1992), Bauman (2005) Beck (1992) Beck and Beck-Gernsheim
(1995) and others has explored shifting patterns of intimacy in the contemporary age of ‘individualisation’.
Broadly speaking, this body of work argued that, in the age of ‘reflexive modernisation’, there had been a shift
away from traditional, patriarchal couple relationships, based on an inherent inequality between men and
women, toward a more equitable, mutually fulfilling model, accompanied by the rise of a more ‘plastic’ sexuality in

http://www.socresonline.org.uk/20/4/3.html 1 30/11/2015

http://www.socresonline.org.uk/20/4/3/faircloth.html

http://crossmark.crossref.org/dialog/?doi=10.5153%2Fsro.3705&domain=pdf&date_stamp=2015-11-30

2.2

2.3

2.

4

2.5

2.6

particular (Giddens 1992; this special section). Giddens argued that in the late twentieth century, in the place of
traditional patterns of marriage, for example, individuals became more aware of the need for a fulfilling
relationship, based on ‘confluent love’; one that is active and contingent. The ‘pure relationship’, which is not
bound by traditional notions of duty and obligation, has come to depend, instead, on communication and
negotiation. The implication of this work is both that greater equality leads to greater intimacy, and that this is a
desirable aspiration for contemporary relationships.

Since this work was published, however, scholars working in the field of family and relationship studies
have critiqued the model, arguing for a more nuanced perspective, grounded in the realities of everyday
experience. Specifically, Gabb and Silva identify three main strands of thinking which have been particularly
influential in shaping and reorienting contemporary UK family and relationship studies over the past 15 years,
since the publication of Beck and Giddens’ work, including Morgan’s notion of ‘doing family’ as sets of
expectations and obligations connected to kin relations (1996); Smart’s conception of ‘personal life’ beyond that
of the family (2007); and Jamieson’s notion of intimacy defined as ‘any form of close association in which people
acquire familiarity, that is shared detailed knowledge about each other’ (Jamieson 1998: 8).

The last of these is particularly relevant here, specifically as it relates to changes in the division of labour
between couples once children arrive. For Jamieson, ‘[t]he majority of people in Euro-North American societies
have lives which are sufficiently privileged to seek ‘good relationships’ which are not dominated by necessity.
However [even then] most personal relationships include a mix of love, care, sharing, understanding and
knowing, which involve a degree of relying on, needing or depending on the other, if not desperate necessity’
(1998: 174).

The intention here is to bring this perspective on intimacy to bear on the subject of parenting, my own
area of research to date (Faircloth 2013). The underlying argument of that work was that there has been a
significant shift in ‘parenting culture’ in the UK over the last twenty years. The word ‘parent’, for example, has
shifted from a noun denoting a relationship with a child (something you are), to a verb (something you do).
Parenting is now an occupation in which adults (particularly mothers) are expected to be emotionally absorbed
and become personally fulfilled; it is also a growing site of interest to policy makers, thought to be both the cause
of, and solution to, a whole host of social problems (Lee et al 2014). ‘Ideal’ parenting is financially, physically and
emotionally intensive, and parents are encouraged to spend a large amount of time, energy and money in raising
their children, often with the aid of ‘experts’ (Hays 1996). Whilst this ideology of parenting is not carried out by all
parents, or affects all parents in the same way, it nevertheless serves as an ideal standard to which all become
accountable (Arendell 2000). This ‘intensive parenting’ climate, as several scholars have now argued, has
changed how parents experience their social role, to the point that one’s style of parenting has become more and
more central to adult ‘identity-work’ (for example, whether one is a ‘Tiger Mother’, an ‘Attachment Parent’ or a
‘Gina Fordist ‘). Drawing on Goffman (1959) this term is used in place of a more static ‘identity’ to highlight the
active processes by which identity is constructed, and the inherently social nature of this enterprise, as opposed
to being simply a means of self-expression (Faircloth 2013).

Accounts of the development of this ‘intensive parenting’ culture, including my own, have emphasized
how it influences mothers in particular, noting how the demands placed on women in their role as mothers have
intensified as women have continued to enter the labour market (rather than decrease, as one might expect).
Partly as a means to counter this imbalance, which sees women working the ‘double shift’ Hochschild (2003),
British society has witnessed the construction of the ‘involved father’ – mirroring, to some extent the more familiar
‘intensification’ of motherhood (Dermott 2008, Miller 2011). Men are increasingly encouraged to be ‘engaged’ in
childcare, with a particular emphasis on the importance of creating a close emotional connection with children, in
place of the more traditional model of the patriarchal breadwinner (Dermott 2008, Lee et. al 2014). Involved
fatherhood is also promoted as a means of building stronger communities, with a particular concern about rates
of single motherhood in poorer communities (BBC 2007). Not surprisingly, then, accounts from sociologists
reveal that fatherhood is becoming more and more central to men’s ‘identity work’ in their accounts of personal
life.

Yet whilst discursively fathers may be encouraged to be ‘involved’ in parenting and take more of an
equal load of childcare, in reality, it is women who continue to shoulder most of the responsibility for this (Dermott
2008, Lee et. al 2014). It is women who typically take extended periods of time away from paid work, and move
to part-time hours when they do return to the work place, if they return at all. What is more, despite this emphasis
on the importance of splitting responsibilities, optimal infant care as promoted by the state is an inherently
gendered, embodied one: women are strongly encouraged to breastfeed their babies by health professionals and

[1]

http://www.socresonline.org.uk/20/4/3.html 2 30/11/2015

2.7

3.1

3.2

3.3

3.4

4.1

policy makers, particularly in the early months, a practice which has a cascading impact on many other aspects
of infant care (such as soothing and sleeping).

To heed Jamieson’s caution again, then, we need to consider how relationships alter when children
arrive, and the increased ‘necessity’ and ‘dependence’ they create between partners. How, for example, does
‘plastic sexuality’ work in the context of parenthood, for both men and women? Does the equitable model of the
‘new fatherhood’ fit into this picture, or does the reality of life as parents inevitably engender a more traditional
family set up? And finally, how does the state provision of care affect couples’ ‘choices’ in this matter? The
analysis therefore moves to consider the role of the state in creating and sustaining gender roles in parenting
culture.

The policy context: Parental leave and childcare provision
Since April 2011 (replacing the previous arrangement of twelve months leave for mothers, two weeks for
partners) employed mothers who return to work before their child is twelve months old have been able, in effect,
to transfer any outstanding leave (of up to six months) to the father or partner. Her leave is calculated at 90% of
her previous earnings for the first six weeks, the middle 33 weeks at a statutory rate of around £130/week, and
then unpaid leave for the final 13 weeks (although some women may have this ‘topped up’ by their employers).
Additional paternity leave is calculated as the last six months of a mother’s leave – i.e, three months of statutory
leave, then three months of unpaid leave. Currently, the couple can only take this sequentially. In the last few
months, however, new proposals have been legislated which will alter this provision again, as of April 2015, so
that the couple will have more flexibility in how to divide their leave, with the entire year being taken by the
partner, after a period of medical leave by the mother, and/or leave taken concurrently (Guardian 2015).

Critics have some reservations about this new leave structure, because whilst the discourse is there
around equality, the financial support (or supportive bosses) may not be. As Asher says ‘Parents may worry
about fathers taking the earnings hit involved… Fathers may fear alienating bosses by going on extended
paternity leave. Families in which mothers can afford not to return to work earlier than twelve months may be
minded to stick with the status quo: habits within the household have already been formed at this stage in the
leave period; and women may be reluctant to give up what has been established as ‘their’ leave.’ (2011:52-3).
Indeed estimates put the percentage of eligible men who actually take up any or all of this leave at only 1.437.

Furthermore, after the initial 12-month leave period, parents often find themselves in a more financially
taxing situation than before. The average cost for a full-time nursery place/after school club for one child in
London in 2014 was £189.16/week, or nearly £10,000/annum, with only a limited amount of this paid for out of
pre-tax earnings (Daycare Trust 2014). For many couples, childcare becomes an expense narrowly second to a
mortgage repayment. In a city like London, which typically requires a considerable commute to work places,
many parents also require ‘wrap-around care’ in the form of a nanny or breakfast club to cover the period before
a nursery opens or when it closes and they are able to reach home. At three years old, all children currently
qualify for 15 hours of free nursery care per week (and some 2 year olds do in deprived areas), although this
frequently has to be taken in regular shifts (for example, five mornings between 9am-12pm), which clearly
requires considerable top-up if both parents are working.

Where childcare is largely seen as the responsibility of the family (as opposed to a state provision, as it
might be in other European countries, for example), it will clearly sit uncomfortably with a dual-earner family set-
up. The cost of care in the UK means that for many couples, what makes ‘most sense’ is for the lower-earner to
be the one who cuts back their hours, or stops work entirely, whilst the other acts as a breadwinner, particularly if
they have more than one child. (It is worth reiterating here then that whilst it is more noticeable after the birth of
children, a gender pay gap continues to exist before this point too). Indeed, even for those in professional
occupations, and earning over the average wage (£476/week or £24,750/annum) , the reality is effectively to
start living on the equivalent of one salary anyway – either because one person stops work entirely, or because
one salary’s worth of post-tax pay is spent on childcare.

Methods
This paper presents preliminary findings from an on-going study which includes repeat in-depth
interviews with 30 participants (15 first-time parent, heterosexual couples), one-off interviews with a further 10
participants (5 couples who were lesbian, gay, and/or second time parents), and a survey with a sample of 125
parents (distributed via Qualtrics to a demographically diverse panel of parents in the UK with children under a
year old). The intention of the study as a whole was to explore the relationship between gender, equality and

[2]

[3]

http://www.socresonline.org.uk/20/4/3.html 3 30/11/2015

4.2

4.3

4.4

4.5

4.6

4.7

intimacy as couples make the transition to parenthood.

Where other publications from the project look more specifically at the corrosive effect of this child-
centred parenting on the couple relationship, or at the theoretical contradictions of policy measures designed to
promote ‘equality’ in parenting, this paper looks more specifically at sexuality – an emergent theme from the
interviews with (some) couples when asked about ‘intimacy’. The focus is on the accounts of the dual earner
heterosexual professional couples who are first time parents, and on a selection of those couples in particular to
explore the issues at hand in depth, and map directions for future research. In addition to being those who spoke
most openly about sex, these were couples who most readily seemed to embody the conflicts between intimacy
and equality, magnifying many of the tensions common to the sample as a whole, as I explain below. The
analysis here therefore focuses on a sub-section of the main sample, in part as a result of this grounded and
iterative approach to data collection and analysis.

Drawing on past work, I was particularly interested in finding parents who internalise the injunction to ‘do
parenting’ in line with expert advice, and who consciously reflect on and articulate their decisions as an element
of their ‘identity work’. Furthermore, I wanted to work with couples who would technically be able to afford an
‘equitable’ division of parental leave, even if they chose not to. Bringing together these aims, I contacted parents
through a range of antenatal education classes and courses in London – such as the National Childbirth Trust,
recognised by a number of scholars (for example Kitzinger 1990; Thomson et al 2011) as being primarily made
up of this demographic.

I interviewed these couples in various areas of London . After meeting one or both of them at an
antenatal group or similar, and a discussion with the aid of a study information sheet, couples were asked to fill
out a brief online survey (designed and administered via Qualtrics) to collect demographic data, using sections
from the 2011 census as a template (e.g., age/marital status etc). These couples were then interviewed, usually
in their homes, at times convenient to them. The first interview (both together and separate) was before their
child was born, and then jointly when their child was 1-2 months old, at 6 months old, and then finally at 11-12
months old, when we also repeated the individual interviews. Recordings were transcribed and coded, with the
aid of relevant software. More recently, I have contacted the couples again to ask for their experiences of
childcare, now that their children are 2-and-a-half years old, and on the cusp of the 15 hours free provision, to
ask whether this would make any difference to their current domestic/working arrangements. Around a third of
these couples are now expecting their second child, which will feed in to the results of the study moving forward.

I also refer to the interview material from the heterosexual dual-earner professional couple expecting
their second baby. Much research with second-time parents has noted that that the ‘ideal’ picture of parenting
and gender norms, so strong for first time parents, tends to be a more pragmatic one for these more experienced
couples. Seeing how parents have negotiated parental leave and childcare arrangements over the course of
several years also gives an interesting contextualisation on the parental leave measures available to new
parents.

Of course, one of the key problems with writing about parenting, intimacy, or indeed any aspect of family
life, is how to go about accessing it at all. Analytically and methodologically, I drew on inspiration from Gabb’s
discussion of ‘interactive’ interviews (2010) and have taken a largely narrative approach to research here. Many
scholars have emphasized the role of language in the constitution of personhood, and have argued ‘that human
beings actually live out their lives as ‘narratives’, [and] that we make use of the stories of the self that our culture
makes available to us to plan out our lives… to account for events and give them significance, to accord
ourselves an identity’ (Rose 1999: xviii). Looking at how couples ‘accounted’ for the division of labour within their
respective partnerships was the intention of the study, analysing both anticipation and outcomes before and after
children were born.

Nevertheless, there are clearly limitations to the interview method, particularly when talking about
sensitive issues. The intention was to study intimate practices generally but not necessarily sexual practices. As
a rule, I did not ask couples directly about their sex lives, but rather, would open the space for them to address it,
either together or separately (on the whole, this topic was easier to broach with mothers in one-on-one
interviews, rather than with couples or with fathers). Typically, this would involve asking a question such as
‘Given this study is titled ‘Gender, intimacy and equality’ could you tell me what those terms mean to you?’ It was
interesting, however, that for most couples that the word ‘intimacy’ was taken as an invitation to discuss sex,
even though this was not directly intended. Indeed, the assumption that intimacy meant sexual intercourse gave
rise to this paper, with the couples featured here being most open about their expectations and experiences of

[4]

http://www.socresonline.org.uk/20/4/3.html 4 30/11/2015

4.8

4.9

5.1

5.2

5.3

5.4

this topic. Again, this points to some interesting assumptions around what sex is taken to stand for in
relationships, as is discussed further below.

Demographic profile
The majority of the couples interviewed – and on whom the analysis here is based – were largely middle
class (in that they overwhelmingly had higher educational qualifications and professions) middle aged (between
45 and 29 though typically 34 or 35), white, heterosexual and married (all were living in long-term relationships,
though if they were not married ‘partner’ was used, rather than ‘husband’ or ‘wife’). The average household
income for the group ranged between £30,000 (in the case of a couple where the wife was undertaking a PhD)
and over £200,000, with the majority between £50,000 and £150,000. All interviews were conducted in English,
though some participants were born outside the United Kingdom.

As might be imagined, these couples demonstrated the sort of attitudes that the current policy around
parenting tries to foster: that it is an intensive, fulfilling and rewarding activity that both parents (notably fathers)
should want to be ‘involved’ in (a word that cropped up a lot). That said, however, these ‘attitudes’ around
equality appeared to be aspirational, rather than enacted in a practical sense (clearly chiming with the kind of
‘identity-work’ fostered in the more reflexive age, mentioned above). The majority of couples stuck to the
traditional division of parental leave – with mothers taking longer periods than fathers in all cases, and only one
couple seeming to know about the possibility of splitting leave more equitably. This is discussed further
elsewhere, but clearly this raises some interesting questions around choice, accountability and preference (that
is, how far these decisions are pragmatic, and how far they are what each partner ‘wants’).

Accounts: Intimacy and sex
In reading literature from the area of sexuality studies in preparation for writing about this aspect of the
study, it quickly became apparent that much of this concerns desire or sexual identity. There was less on
changing patterns of sexual activity over the lifecourse. To this extent, this paper – like Van Hoof’s in this special
section – contributes to what Jackson calls the ‘everyday’ aspect of studying sex and relationships (2008). In
particular, these findings reveal the importance of sexual intercourse for couples as a means of assessing the
strength of their relationships (Weeks 1995). It therefore maps the ways anticipations around sexual intercourse
matched up (or not) with realities once children were born, as a lens on changing understandings of intimacy and
equality. These accounts are foregrounded as evidence of a cultural contradiction between the competing
ideologies of intensive parenting, gender equality and fulfilling intimate relationships.

Providing a useful introduction to this subject is Clare, the only mother cited in this paper to have had a
child already. She works full-time as a secondary school teacher, having taken 6-9 months of leave with each
child, and talks about how important sex is for her and her husband – not only in the sense of being a physically
pleasurable sensation, but more for what it represents for them:

Clare: No, but do you know what? It’s so important to have sex in a relationship. You just always come back to it
because if you don’t you are very, very good friends and there’s that intimacy lacking. [My husband] and I get
scratchy with each other and we lose our connection when we don’t have sex frequently and regularly for me. If we
manage once a week I’m really proud of that and that’s pretty good, that’s what we do. I’m really quite…I feel quite
proud of that. Sometimes it goes down to every couple of weeks but if it’s not every couple of weeks then we both get
really sad.

In what might be referred to as a hierarchy of intimacy, (penetrative) sex with a partner has come to
symbolise the pinnacle of intimate relations (as opposed to, say, cooking for each other, sleeping in the same
bed or massage, which might be others sorts of ‘intimate’ behaviours) (Weeks 1995). She continues – with the
benefit of hindsight as a second time mother – to talk about how this changes over a couple’s relationship, in
terms of what it symbolises:

Clare: It comes to symbolise such different things, like when you first meet somebody you’re at it all the time and it’s
a kind of bonding, it’s a really fun thing as well. Then when you move in together you’re very cosy and settled. Then
maybe when you get married it will happen more. Then when you want to have a baby you will have sex all the time
and it will become a military procedure but [then] you will probably start enjoying it again.

Anticipation and reality: Accounting for dissonance
Like the other stages Clare mentions, it was certainly true that having children meant a major shift in
sexual practices for most couples. This was something that was anticipated (albeit without much clarity as to

http://www.socresonline.org.uk/20/4/3.html 5 30/11/2015

http://www.socresonline.org.uk/20/4/4.html

5.5

5.6

5.7

what these changes would actually be) during pregnancy by many first-time parents. Interestingly, many couples
were confused as to how to negotiate actually having sex with the physical presence of a new baby in their
bedroom (the ideal sleeping arrangement parents are advised to adopt for the first six months). Like Lucy, below,
couples often spoke about the importance of maintaining their regular patterns of sex, which they hoped would
get back to normal after the disruption of pregnancy, birth and/or breastfeeding. Already on her anticipated year-
long maternity leave from work at one of the large trade unions, she is speaking a few days before she gave birth
to her first baby here:

Lucy: …you were asking about how you think it’s going to affect your relationship, one of the reasons I was saying
about the bed and sharing thing is the sexual aspect of it and I don’t want that to get lost although it has recently, he’s
been really worried about hurting me or the bump, he’s been a bit put off things, and I guess that’s one of the things
that worries me most about breastfeeding is your breasts going from being this sexual thing to a feeding practical
thing for the baby, so I think that’s one of my worries about our relationship and about breastfeeding…So we want to
try and make an effort … That’s the other thing … you shouldn’t even like leave the baby on its own in the room, not
even to have a shower, I mean I don’t know what you’re supposed to do, but if you want to have sex or whatever, are
you supposed to have the baby in the room? I haven’t thought very hard about it but … I’m sure you can leave the
baby to have a shower for 10 minutes.

Despite some awareness about embodied changes, unfortunately the experiences of post-baby sex
were worse than expected in some cases, and many women I spoke with were totally shocked by how their
bodies had undergone what one mother described as a ‘total physical onslaught’, which they felt totally
unprepared for. Speaking when their baby was around 6 weeks old, this couple, who work in HR and fashion
design respectively, point out not only the physical barrier to having sex, but emotional and practical ones too:

Katie: Ah yeah. I feel I’m neglecting [him].
Paddy: No you’re not.
Katie: And because of that I have the episiotomy, I’m really scared about having sex…So that’s really sort of…But I
mean it hasn’t even been for six weeks yet…I am scared. It feels like it’s going to be months, if not years. So, …so
yeah. But even the thought of having sex because she’s in the bedroom, I don’t even know how it would work really.
Seems a bit weird. So, yeah that’s a bit strange. And yeah it does just feel like you don’t get any time together. You’re
just talking about what you going to have to do now. ‘Do you want to cook dinner?’ ‘I’ll wash up’. That’s it really. ‘Do
you want to change the baby’s nappy?’ ‘Do you want to hold the baby?’

The same mother said at 6 months (as the main earner, she returned to work full-time when her baby
was around 10 months, whilst her partner worked part-time, and their daughter attended a nursery part-time):

Katie: We’ve only had sex three or four times since she’s been born and I didn’t think that would fall apart the way it
has. But it is just timing and opportunity and not feeling tired and being in the same room. If we had our own room, it
might be different…And the episiotomy is quite painful.
Author: Is it still quite sore?
Katie: Well, it was last time! I think all those things have contributed to … and that really worries me because you
need that for a healthy relationship…I think I knew that it would put a strain on the relationship but you can’t really
imagine it happening until it has happened. And my sister just kept saying everything that’s wrong with the
relationship is magnified when you have children and she’s going through a really bad patch with her husband. So I
did know to expect it and I don’t know, it is good and it isn’t good. But I think it’s not helped by [his] working pattern
and that situation, by him being around but not really being there to help, it’s made me a bit resentful.

Intimacy and inequality: Embodying difference
Like Clare, we can see here that Katie uses how often she has sex with her partner as a barometer for
the relationship as a whole. This points to the way in which a ‘good sex life’ is linked to notions of a ‘healthy
relationship’ – and something to be ‘performed’ (in the sociological sense) both to each other as partners, and to
friends, family (and researchers) as peers. Like Woodiwiss’s research, then (also in this special issue), we see
how powerful the discourse of ‘compulsory sexuality’ can be for individuals, at all stages of the life course. This
comes from Cathy, a 32-year-old academic at a London university, who planned to take 6 months off work, and
then return 4 days a week. Her husband, a 31 year old IT manager in a bank, was planning on taking 2 weeks of
statutory leave, and then also moving to a 4 day week when their baby was 6 months, so that they each do a day
of childcare, with a nanny or relatives covering the other three days. At this point she earned around £45,000 he
earned around £95,000.

Cathy: It’s just so hard to explain that I’ve felt like a physical continuous onslaught… this massive physical thing that

http://www.socresonline.org.uk/20/4/3.html 6 30/11/2015

http://www.socresonline.org.uk/20/4/1.html

5.8

5.9

5.10

5.11

5.12

6.1

happens to your body. Whereas other people, like Libby, had a reasonably quick and easy birth. Was back having
sex all the time within about a week or something. And they were just like, back on the…and their…they put Alice
out in the other room, after five weeks or something, because it was ruining their sex life. I was just like, I’m not…but
she was sleeping through the night from, like, three weeks old. They just had a whole completely different
experience. So I know that it can be the ideal thing. That does happen. […]
Colin: It could be that she’s lying to you.
Cathy: No. She told [Emma].

Cathy also talked about the physicality of motherhood (and breastfeeding, in particular) coming as a
shock, and a limit on her ‘intimacy time’ with her husband, which made her feel less desirable, something many
women reported as a problem of the ‘mother/lover’ division. She describes the shift from bodies being conduits of
pleasure to being sources of nutrition particularly graphically here:

Cathy: Yeah. My body was alien to me for a period of time. I embraced it more when I was pregnant, I was annoyed
by it but after, particularly with the breastfeeding, you can’t take your bra off ever. With mine, because I had such a
milk supply and I’d have to wear those breast pads all the time and how many would I get through in a day, six or
seven?… So we were buying stacks and stacks of them and as soon as I’d take my bra off, I’d go into the shower, I’d
just be squirting everywhere so it makes physical intimacy very difficult.

Whilst I do not expand on it here this couple had quite an interesting experience of the division of
childcare. They trialled their ‘4-day week each’ arrangement by using some of their holiday allowances, though
sadly – and perhaps tellingly – when her husband requested the arrangement on a more permanent basis, he
was made redundant. This meant that he had a period of several months at home, without work (but with a
generous payment package; and interestingly, rather than a period of full-time childcare; a nanny 3 days a
week). He subsequently found another job, working 5 days a week.

Given that they were so busy, they talked at length about how important it was for them to schedule other
sorts of ‘intimacy time’, including, but not limited to sex, particularly because they could no longer be
spontaneous in spending time with each other, and that their son would ‘take all of their attention’ otherwise:

Cathy: [Speaking to her husband] But even with [our son], if you were with him, I could quite easily come into the
room at the end of the day and just give [our son] all of my attention and not even kiss you hello. And it would happen
the other way round too. He takes all of our attention, you have to remind yourself that the other person is right there
and needs to be greeted and made into a person by actually being recognised!

Negotiating cultural contradiction
It is also interesting to note here the inherent contradiction between government advice to mothers
around breastfeeding and the ideological commitment to ‘shared’ parental leave. (Exclusive breastfeeding for six
months and anything up to two years or beyond clearly not being the easiest of activities to split according to a
50/50 model or similar). As we can see from these accounts, new parents often find themselves at the juncture of
several competing cultural discourses: one around the importance of intensive, embodied care carried out by
biological mothers, particularly as it relates to feeding; another about the importance of gender equality at home
and work, particularly as it relates to providing ‘child-centred’ care; and another around the importance of
maintaining a healthy couple relationship, particularly as it relates to having regular sex. No wonder many of
them reported feeling tired and ‘torn’.

If there was a ‘typical response’ amongst this group of new parents, then, this couple probably best
capture it. Reflecting on working full-time in the charity sector and taking on full-time childcare (whilst training to
be a certified child minder in place of returning to administrative work) respectively, Mark writes:

Mark: Well, we don’t have as much sex as we would like. [My wife] in particular is always tired, and I am pretty tired
too so am often easy to put off! However we try to schedule sexytime so that it doesn’t fall off the radar, as it easily
could. We both realize the importance of this, as when we didn’t have sex for some time after the birth of [our
daughter], we felt that our relationship changed. I wouldn’t call it deteriorating, but we just didn’t feel as close to each
other in a way, which we missed. Maybe we felt too much like a ‘team’ and a little less like lovers! So we are less
impulsive, but if it was left to chance it wouldn’t happen! We are getting more time on our own recently, due to family
members taking her away for weekends and longer, so that too is changing.

Discussion
In her study, When Couples Become Parents based on interviews with couples in Canada, Bonnie Fox

http://www.socresonline.org.uk/20/4/3.html 7 30/11/2015

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

also observed that there was a ‘dramatic change in sexuality’ during the first year of parenthood for most of her
participants (2009:249), a loss that was more keenly felt by men. Women’s need to recuperate, their tiredness,
and the fact that they were breastfeeding reduced their desire for sex. And even when they did have sex, it was
different to before, clearly chiming with the set of accounts here around expectation not matching up to reality.

Developing a useful typology, Fox notes that these changes in sexual activity were indicative of other
kinds of changes that occurred in couples’ relationships as they negotiated the first year of parenthood. In the
first pattern (around 30 percent of couples) the relationships deteriorated, and were ‘riddled with tension and
worn down by the upset and anger of one or both partners’ (2009:252) In these cases, she describes
relationships on the brink of divorce, or ‘nonexistent’.

In the second pattern, made up of around 25 percent of couples, the relationship was marked by tension
between the partners, but ‘there was no noticeable weakening of the relationship over the year. Often the anger
was about the men’s avoidance of the newly expanded housework, for example, and it created tensions that were
new to these relationships. Nevertheless, these couples’ happiness about being parents sometimes meant that
they – especially the men- felt closer to their partners’ (2009:252).

In the third pattern, which comprised another 25 percent, the relationships neither seemed to weaken or
strengthen, but ‘clearly suffered from the absence of time for intimacy’ (2009:252). ‘In these relationships, there
was only minimal tension between partners – usually blamed on tiredness – but both people found the year to be
difficult emotionally, given how little time they spent together.’

Lastly, in the final 20 percent were couples whose relationships were improved by parenthood. These
were couples who experienced parenthood ‘largely as an addition to their relationship’ (2009:252)

What Fox notices is that in those couples that displayed the first pattern, there was a lot of anger and
resentment. This was ‘fostered by the gender-based divisions organising their daily lives and sometimes
enhanced by the insularity of their families… men’s detachment from the care of their babies and the dramatic
differences in the men’s and women’s daily experiences – especially when the women were home full-time –
were usually what undermined mutual understanding and often support. When both parties were stressed by the
high demands of their daily work, that stress could further erode empathy, negate any hope of mutual gratitude,
and produce considerable anger’ (2009:265).

Less equality, less intimacy? Accounting for cultural contradiction
Fox’s typology is useful in understanding the accounts presented here. The issue of ‘resentment’ and
feelings of inequality and unfairness were demonstrated by participants such as Katie, above. Writing about the
emergence of the ‘companionate marriage’ (as opposed to the more traditional patriarchal one), Collins (2003)
notes that ‘The keywords of companionship were intimacy and equality. Intimacy was at once achieved and
expressed through privacy, closeness, communication, sharing, understanding and friendship’ (Collins 2003:24).
However, he identifies a problem with this once children come along: parenthood accentuated the sexual division
of labour and had the potential to divide companionate couples every bit as profoundly as their patriarchal
counterparts. Whereas spouses were able to live ‘almost identical lives’ before they had children, any resulting
intimacy came under pressure from the inescapable differentiation between the two sexes once there is a child.

Particularly if women were earning less than their partners before (which in all but one case they were)
what usually emerged from the interviews is that it made ‘most sense’ that they were the ones to take time off
work, or stop work entirely. Many women ‘accounted’ for this in an understandably contradictory way as they
went about trying to narrativise it; it was both what they ‘wanted’ to do, and what they ‘had’ to do: They had an
ideological commitment to equality in career opportunities, yet a gendered ‘pull’ towards a model of intensive
parenting (or, motherhood).

It is important to contextualize these accounts in our particular historical moment, then. In line with much
sociological and popular literature, the accounts here show that the transition to motherhood is felt particularly
acutely by many women today (for example, Cusk 2001, Miller 2005). This is, no doubt, in part as a reflection of
the shift Giddens et al identify – the period before children is (discursively at least) one of equality for
contemporary men and women, particularly in the middle classes: women match their male counterparts through
the education system and (largely) have professional opportunities unfettered by gender, being able to gain
financial independence. Furthermore, they have freedom in romantic and sexual unions and are able to express

http://www.socresonline.org.uk/20/4/3.html 8 30/11/2015

6.10

6.11

6.12

6.13

6.14

7.1

disdain for housework and homemaking in ways unthinkable in the past (Bristow 2008, Giddens 1992).

As the narratives point to, however, something happens around the time of motherhood that means that
many women suddenly ‘get’ feminism, and indeed their biological difference to men in a more explicit way than in
the past (Bristow 2008). Bodies, which had so far been a marker of the self (and self-control) started to ‘betray’
them, as Cathy puts it. This realisation of biological difference – that Cathy points to in her account – is often
accompanied by a shift from being financially independent towards dependence whilst on maternity leave.
Similarly, when she does go back to work, like many other women in the sample, Cathy sees her career fall
more readily into the ‘mummy track’ of a 4-day week, where her husband continues with the same 5-day pattern,
despite an ideological commitment (and practical agreement) around the importance of career parity for both
parents.

Furthermore, housework is no longer a case of taking ‘turns’ to carry out chores, but a hugely expanded
task which has to be carefully orchestrated to keep all household members fed and clean. The invisibility – and
cultural de-valuation of – this labour after motherhood is something many other women in the sample also
expressed resentment about, feeling that their partners simply ‘didn’t see’ the extra work they were doing, often
by virtue of being the ones at home more often. These material and practical changes to women’s financial
situation (despite being coupled with a policy emphasis on ‘equal parenting’) often serve to magnify this sense of
injustice. And clearly, for many women, losing their previous identities as workers could create its own kind of
challenges here.

This has an impact on intimacy, as expressed through sex. So, where before, sex is something that is
‘kind of fun’ and ‘bonding’ for couples, as Clare puts it, afterwards, Katie talks about it like more of a gendered
currency, or something she feels she ‘owes’ her partner, despite feeling physically uncomfortable. (It is notable
too that at the point she makes that remark, she is being supported by him financially; in this instance, policy has
clearly entered the bedroom). Furthermore, many couples are simply too tired, or physically uncomfortable to
resume a ‘normal’ pattern of intercourse.

In terms of the theoretical contribution of this paper, in part, then, these observations back up the shift
Giddens et al describe – clearly, any cultural focus on female sexual pleasure and the fact that many women
were able to talk about their sexual needs and desires so openly is proof of a move towards a more equitable
focus on mutual pleasure in relationships today than in the past (1992). However, rather than moving in a
progressive fashion from patriarchal to companionate to more ‘plastic’ intimacies, for example, there appears to
be some movement back and forwards between these various arrangements, with parenthood often pushing
couples back into an unfamiliar patriarchal set up (at least financially, if not ideologically). Clearly, this shift back
into a more traditional pattern is exacerbated by a lack of resources – for many couples, there is no choice but to
opt for more gender segregated roles. As this paper has shown, however, even in the case where a couple has a
joint income of nearly £150,000 (such as Cathy and Colin) there still seems to be a ‘pull’ towards these more
traditional patterns. It is worth reiterating the impressive power of the intensive mothering ideology in shaping
women’s perceptions of themselves as good mothers, and working out how they ‘want’ to arrange their working
and home lives. Yet again we see how an equal parenting ideology meshes uncomfortably with a culturally
elaborated intensive, embodied commitment to motherhood.

Similarly, there is clearly a tension between a more ‘plastic sexuality’ and the transition to parenthood.
Whilst Giddens’ theory of a more ‘pure’ relationship might have some purchase on how sex is at least imagined
prior to the arrival of children, the idea that the couples here are only in relationships for as long as they are
individually satisfying is not substantiated by the account here: clearly parenthood creates demands and
necessities that they view as valuable, beyond their own individual sexual pleasure. Most couples acknowledged
that the first year of parenthood was a particularly tough time for their relationship, but it was, essentially, a
temporary state of affairs that would eventually pass. (Although it is true that if they did not take steps to
reintroduce ‘sexytime’, as Mark puts it, they recognised their relationship would deteriorate). Yet again, we see
how policy frameworks, and material resources, therefore shape even the most intimate of our interactions as we
go about negotiating these competing ideologies.

Conclusions and future directions
These accounts show how couples’ experience of changing sexual practices can offer us a lens on the
relationship between gender equality and intimacy. Far from being a straightforward correlation between them,
they are, in fact ‘uncomfortable bedfellows’, fraught with frustrations from all sides. In contributing both to the
literature around changes to intimate relations and parenting culture, this paper provides evidence that whilst our

http://www.socresonline.org.uk/20/4/3.html 9 30/11/2015

7.2

7.3

gender roles are less and less scripted before children arrive, they are very often thrown back into traditional
models once they do.

Whilst efforts to make parenting more equitable are clearly laudable, the evidence here seems to imply
that current policy is missing the point: even for couples who are ideologically committed to, and can afford, a
more equal split there seems not to be an practical commitment to sharing care. This certainly suggests that for
those social groups who cannot afford this division that such policy drives will be even more irrelevant (Gillies
2009). What is more, there is a danger that though these moves would be beneficial in giving parents more
freedom in how to divide up their time, many of the efforts to involve fathers in childcare appear only to extend a
cultural logic around parenting to men – an intensive one, which puts children at the centre of all considerations.
This has the potential to leave two parents feeling ‘torn’, rather than, for example, challenging our view of children
as requiring one-on one care by a biological relative, or alleviating a cultural guilt around the place of childcare.
This has its own knock-on effect on couple intimacy. Mark and his wife talk about feeling more like a ‘team’ of
partners, rather than ‘lovers’, as they have little space to think about themselves as a couple beyond being
parents to their daughter (although this raises its own interesting considerations around how sexual desire
intersects with ‘gender equality’).

How ‘equality’ and ‘intimacy’ work themselves out in a couple’s practices is demonstrably deeply
uncomfortable for their ‘identity work’ as gendered beings, in negotiating dissonance between expectation and
outcome. For many parents in this study, struggles around how to negotiate competing cultural discourses –
about good parenting, about good relationships and about gender equality – are indicative of an interesting
historical moment in social life. Rather than showing a straightforward correlation between (or continual
progression towards) greater intimacy and equality, these accounts show the two are in a state of flux. As this,
and other papers in this section demonstrate, then, attention to these ‘everyday’ experiences, provide interesting
intellectual reflections, far beyond the bedroom.

Notes
Gina Ford is one of the best selling parenting experts in the UK, advocating a structured approach to
infant care, with practices such as scheduled feeding and sleeping routines.

http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm140403/text/140403w0001.htm
Accessed 25.11.2014

http://www.ons.gov.uk/ons/rel/lms/labour-market-statistics/may-2014/info-awe-may-2014.html Accessed
25.11.2014

Ethical approval for the study was granted by the University of Kent’s Review Board, in accordance with
BSA guidance http://www.britsoc.co.uk/media/27107/StatementofEthicalPractice

References
ARENDELL, T. (2000) ‘Conceiving and Investigating Motherhood: The Decade’s Scholarship’, Journal of

Marriage and the Family 62(November): p. 1192-1207. [doi:10.1111/j.1741-3737.2000.01192.x]

ASHER, R. (2011) Shattered. Modern Motherhood and the Illusion of Equality. London, Harvill Secker

BAUMAN, Z (2005) Liquid Life Cambridge: Polity Press.

BBC NEWS. (2007) ‘Gang Crime ‘Due To Absent Dads’,’ Retrieved 1 April 2011 from
http://news.bbc.co.uk/1/hi/uk_politics/6956303.stm

BECK, U. (1992) Risk Society: Towards a new modernity London: Sage.

BECK, Ulrich and Beck-Gernsheim, Elisabeth. (1995) The Normal Chaos of Love. Cambridge: Polity Press.

1
2
3
4

http://www.socresonline.org.uk/20/4/3.html 10 30/11/2015

http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm140403/text/140403w0001.htm

http://www.ons.gov.uk/ons/rel/lms/labour-market-statistics/may-2014/info-awe-may-2014.html

http://www.britsoc.co.uk/media/27107/StatementofEthicalPractice

http://dx.doi.org/10.1111/j.1741-3737.2000.01192.x

http://news.bbc.co.uk/1/hi/uk_politics/6956303.stm

BRISTOW, J. (2008) ‘Why we need a parents’ liberation movement’. Spiked Review of Books. http://www.spiked-
online.com/review_of_books/article/5386.

COLLINS, M. (2003) Modern Love: An Intimate History of Men and Women in Twentieth-Century Britain London:
Atlantic Books

CUSK, Rachel. (2001) A Life’s Work: On Becoming a Mother. London: Fourth Estate.

DAYCARE TRUST. (2014) ‘Childcare Costs Survey 2014’. London: Daycare Trust
http://www.familyandchildcaretrust.org/childcare-costs-surveys.

DERMOTT, E. (2008) Intimate Fatherhood: A Sociological Analysis London: Routledge.

FAIRCLOTH, C. (2013) Militant Lactivism? Attachment Parenting and Intensive Motherhood in the UK and
France Oxford and New York: Berghahn Books.

FOX, B. (2009) When couples become parent:s The creation of gender in the transition to parenthood Toronto:
University of Toronto Press.

GABB, J. (2010) Researching Intimacy in Families. London, Palgrave Macmillan.

GABB, J. and Silva. E. (2011) Introduction to Critical Concepts: Families, Intimacies and Personal Relationships.
Special Issue, Sociological Research Online http://www.socresonline.org.uk/16/4/23.html.

GILLIES, V. (2009) ‘Understandings and experiences of involved fathering in the United Kingdom: exploring
classed dimensions’, The Annals of the American Academy of Political and Social Science, 624, p. 49-
60. [doi:10.1177/0002716209334295]

GOFFMAN, E. (1959) The Presentation of Self in Everyday Life London: Penguin.

GUARDIAN. (2015) ‘Shared parental leave: ‘nightmare’ new rules, or the first baby steps to equality?’
http://www.theguardian.com/money/2015/apr/11/shared-parental-leave-rules-equality Accessed 20 April
2015.

GIDDENS, A. (1992) Transformation of Intimacy: Sexuality, love and eroticism in modern societies Cambridge:
Polity.

HAYS, S. (1996) The Cultural Contradictions of Motherhood. New Haven and London: Yale University Press.

HOCHSCHILD, A. (2003) The Second Shift (London and New York: Penguin Books).

JACKSON, S. 2008. Ordinary Sex. Sexualities, 11(1/2), 33-37. [doi:10.1177/13634607080110010204]

KITZINGER, J. (1990) ‘Strategies of the Early Childbirth Movement: A Case-Study of the National Childbirth
Trust’, in Garcia, J., Kilpatrick, R. and Richards, M. (eds), The Politics of Maternity Care: Services for
Childbearing Women in Twentieth-Century Britain. Oxford: Clarendon Press, p. 92-115.

LEE, E. Bristow, J. Faircloth, C. and Macvarish, J. (2014) Parenting Culture Studies Basingstoke and New York:
Palgrave Macmillan.

JAMIESON, L. (1998) Intimacy: Personal relationships in modern societies Cambridge: Polity Press.

MILLER, T. (2011a) Making Sense of Fatherhood Cambridge: Cambridge University Press.

MILLER, T. (2005) Making Sense of Motherhood: A Narrative Approach. Cambridge: Cambridge University
Press. [doi:10.1017/CBO9780511489501]

SMART, C. (2007) Personal Life: New Directions in Sociological Thinking. Cambridge, Polity.

ROSE, N. (1999 [1989]). Governing the Soul: The Shaping of the Private Self. London: Routledge.

THOMSON, R, Kehily, M.J, Hadfield, L and Sharpe, S. (2011) Making Modern Mothers Bristol: Policy Press.

WEEKS, J. (1995) Invented Moralities, Sexual Values in an Age of Uncertainty. Cambridge: Polity Press.

http://www.socresonline.org.uk/20/4/3.html 11 30/11/2015

http://www.spiked-online.com/review_of_books/article/5386

http://www.familyandchildcaretrust.org/childcare-costs-surveys

http://www.socresonline.org.uk/16/4/23.html

http://dx.doi.org/10.1177/0002716209334295

http://www.theguardian.com/money/2015/apr/11/shared-parental-leave-rules-equality

http://dx.doi.org/10.1177/13634607080110010204

http://dx.doi.org/10.1017/CBO9780511489501

http://www.socresonline.org.uk/20/4/3.html 12 30/11/2015

  • Negotiating Intimacy, Equality and Sexuality in the Transition to Parenthood
  • Abstract
    Keywords: Parenting, Gender, Intimacy, Equality, Sex, Couples
    Negotiating intimacy, equality and sexuality in the transition to parenthood
    Theoretical background: Intimacy and parenting
    The policy context: Parental leave and childcare provision
    Methods
    Demographic profile
    Accounts: Intimacy and sex
    Anticipation and reality: Accounting for dissonance
    Intimacy and inequality: Embodying difference
    Negotiating cultural contradiction
    Discussion
    Less equality, less intimacy? Accounting for cultural contradiction
    Conclusions and future directions
    Notes
    References

ORIGINAL PAPER

Mindfulness-Based Sex Therapy Improves Genital-Subjective
Arousal Concordance inWomenWith Sexual Desire/Arousal
Difficulties

Lori A. Brotto1 • Meredith L. Chivers2 • Roanne D.Millman3 • Arianne Albert4

Received: 3 February 2015 / Revised: 3 November 2015 /Accepted: 30 December 2015 / Published online: 26 February 2016

� Springer Science+Business Media NewYork 2016

Abstract There isemergingevidencefor theefficacyofmind-

fulness-based interventions for improvingwomen’ssexual func-

tioning. To date, this literature has been limited to self-reports of

sexual responseanddistress.Sexualarousalconcordance—the

degree of agreement between self-reported sexual arousal and

psychophysiological sexual response—hasbeenof interest due

to thespeculationthat itmaybeakeycomponent tohealthysex-

ual functioninginwomen.Weexaminedtheeffectsofmindful-

ness-basedsextherapyonsexualarousalconcordanceinasample

ofwomenwith sexual desire/arousal difficulties (n=79,M age

40.8 years) who participated in an in-laboratory assessment of

sexualarousalusingavaginalphotoplethysmographbeforeand

after foursessionsofgroupmindfulness-basedsextherapy.Genital-

subjective sexual arousal concordance significantly increased from

pre-treatment levels, with changes in subjective sexual arousal

predicting contemporaneous genital sexual arousal (but not the

reverse). These findings have implications for our understand-

ingof themechanismsbywhichmindfulness-basedsex therapy

improvessexualfunctioninginwomen,andsuggest thatsuchtreat-

mentmay lead to an integration of physical and subjective arousal

processes.Moreover, ourfindings suggest that future research

might consider the adoption of sexual arousal concordance as a

relevant endpoint in treatment outcome research ofwomenwith

sexual desire/arousal concerns.

Keywords Sexual desire � Sexual arousal �
Vaginal photoplethysmography �Mindfulness �DSM-5 �
Sexual dysfunction

Introduction

Lack of motivation for sex affects up to 40% of women aged

16–44 (Mercer et al., 2003;Mitchell et al., 2013) and is the

most common reason prompting women to seek sex therapy.

Whenclinicallysignificantdistressaccompanies the lossofsex-

ualdesire, estimates reveal thatup to12%ofwomenareaffected

(Shifren,Monz,Russo, Segreti,& Johannes, 2008). The 5th edi-

tion of the Diagnostic and Statistical Manual of Mental Disor-

ders (DSM-5)defines this syndromeas‘‘FemaleSexual Interest/

ArousalDisorder’’(SIAD;AmericanPsychiatricAssociation,

2013) and a diagnosis ismadewhen any three of six criteria are

met for a minimum duration of 6 months and accompany clin-

ically significantdistress.Thecriteria include: (1) lackofdesire

for sex, (2) lack of sexual thoughts/fantasies, (3) lack of initia-

tionand receptivityof sexual activity, (4) lackof sexualpleasure,

(5) inability for sexualstimuli to triggerdesire,and(6)an impaired

physical sexual arousal response.

Todate,themostwidelystudiedtreatmentforlowsexualdesire

inwomenhasbeentestosterone.A largenumberof randomized

controlledstudieshavedemonstratedtheefficacyof topical testos-

terone in surgically menopausal women (reviewed by Davis,

2013).Moreover, estimates suggest that 4.1million prescrip-

tions for off-label testosterone are made annually in the U.S.

alone(Davis&Braunstein,2012).Nonetheless, testosteroneremains

unregulated,andalthough itwasapproved foruse inpatch form

in Europe (for surgically menopausal women with low sexual

desire), it is currently unavailable in North America. Various

other pharmaceutical agents have been the subject of clinical

& Lori A. Brotto
Lori.Brotto@vch.ca

1 Department of Gynaecology, University of British Columbia,

2775LaurelStreet, 6thFloor,Vancouver,BCV5Z1M9,

Canada

2 Department of Psychology, Queen’s University, Kingston, ON,

Canada

3 Department of Psychology, Simon Fraser University, Burnaby,

BC, Canada

4 Women’s Health Research Institute, Vancouver, BC, Canada

123

Arch Sex Behav (2016) 45:1907–1921

DOI 10.1007/s10508-015-0689-8

http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-0689-8&domain=pdf

http://crossmark.crossref.org/dialog/?doi=10.1007/s10508-015-0689-8&domain=pdf

trials for treatmentof lowsexualdesire,but asofOctober2015,

flibanserin is the onlymedication approved in the U.S. for this

condition.

Despite considerable interest in testingpharmacological options

forwomen’s lowsexualdesire,psychological treatmenthasbeen

themainstayof therapyforwomenwithsexualdesiredifficulties.

Because cognitive distraction during sexual activity is prevalent

amongwomenwith sexual dysfunction, and negatively impacts

their sexual satisfactionanddesire (Nobre&Pinto-Gouveia, 2006),

this provides justification for the application of cognitive chal-

lenging strategies (i.e., identifying, challenging, and replacing

irrationalthoughts)inherenttocognitivebehavioraltherapy(CBT).

Trudeletal. (2001)comparedtheeffectsofCBT(whichincluded

both cognitive challenging aswell as behavioral strategies) to a

wait-list control in 74 couples in which womenmet criteria for

HypoactiveSexualDesireDisorder(HSDD).After12weeks,74%

ofwomenno longermet diagnostic criteria forHSDD, and this

stabilized to 64% after 1-year follow-up. In addition to signifi-

cantly improvedsexualdesire,womenalso reported improved

quality ofmarital life andperception of sexual arousal, but the

groupcouple therapyformatmaynotbefeasible in typicalclini-

cal settings.Another treatment outcome study of 10 sessions of

CBT,2–3ofwhichincludedthepartner,foundonlya26%reduc-

tion in the proportion of women who had significant concerns

with lowsexualdesire (McCabe,2001).Taken together, these stud-

ies suggest thatCBTiseffective foraproportionofwomenwith

lowsexualdesire,but suchanapproachmayalsohave limitations.

Specifically, because of the often-noteddistractibility, anxiety-

proneness, judgmental intrusions, and inattentiondescribedby

womenwith lowsexualdesire (Meston,2006), andalsobecause

of thevariedways inwhichdesire is experienced (Meana,2010;

Sand&Fisher, 2007), other skill-based approachesmaybenec-

essaryforwomenwhodonotbenefitfromcognitivechallenging.

Toaddress thesegaps, third-generationCBTapproaches,suchas

mindfulness-basedcognitivetherapy,havebeengainingtraction

in many domains of physical and psychological health.

Mindfulnessmeditationhasa3500yearhistoryandfornearly

thepast fourdecadeshasmade itsway intoWesternmedicine.

Defined as present-moment, non-judgmental awareness with

curiosity,openness,andacceptance(Bishopetal., 2004),mind-

fulness meditation has been amajor addition to the psycholog-

ical treatmentarsenalfor thetreatmentofanxiety,depression,sub-

stance use, childhoodbehavior problems, anda host ofmedical

concerns, includingpain, irritable bowel syndrome, fibromyal-

gia, and highbloodpressure (Grossman,Niemann, Schmidt,&

Walach,2004;Merkes,2010).Althoughtheprecisemechanisms

by which mindfulness is associated with symptom relief is not

fullyunderstood, itsbenefitsmaybeassociatedwithan increase

inmetacognitiveawareness, or theability toexperience thoughts

merely asmental events (Teasdale et al., 2002). Over the past

10 years,mindfulness has been applied to and found effective

for the treatment of sexual dysfunction in women (Brotto,

Basson,&Luria,2008a;Brottoetal.,2008c,2012a;Brotto,Seal,

& Rellini, 2012b).

Themechanismsbywhichmindfulness led to these improve-

ments in women with sexual dysfunction are not entirely clear

andmayrelate toadecrease inspectatoring—definedbyMasters

andJohnson(1970)as theprocessofwatchingoneselfduringsex-

ual activity from a third person perspective—a decrease in anx-

iety, encouraging an attitude of acceptance and non-judgment,

and/or an increase in perception of physical sexual response. In

support of the latter, one laboratory-based study inwhich female

studentswithout sexual difficultieswere randomized to either an

8-weekmindfulnessmeditationgroupor to anactivecontrol rated

the intensityof theirphysiological responsesafterviewingemo-

tionalphotos (Silverstein,Brown,Roth,&Britton,2011).Thepri-

maryanalysis focusedon interoceptive awareness, the capacity to

accuratelydetectphysicalsensations,after themindfulness inter-

vention. Interoception has long been of interest to emotion research-

ers,and isknown tocorrespond toanafferentpathway fromparts

of thebody to the spinal cord, brain stem, andultimately to the

rightanteriorinsularcortex(Craig,2002).Studyparticipantswere

shown a series of 31 pictures containing sexual and non-sexual

imagesandwereaskedtoindicatetheirlevelofphysiologicalarousal

(calm, excited, andaroused).Reaction time, or howquickly an indi-

vidualratedtheintensityofarousalintheirbody,wasusedasanindex

ofgreaterinteroceptiveawareness.Womeninthemeditationgroup

hadsignificantlyfaster reactiontimesthanwomeninthecontrol

group,andthequickerreactiontimesignificantlycorrelatedwith

increasesinmindfulness,attention,non-judgment,self-acceptance,

andwell-being,andwithdecreasesinself-judgmentandanxiety.Sil-

versteinetal. inferredthistomeanincreasedinteroceptiveawareness

followingmindfulness training thatmay correspondwith activity in

the insula cortex.

Thereismarkedindividualvariabilityintheabilitytodetect inter-

nal physical sensations,with some individuals beinghighly intero-

ceptively aware, and others being relatively naı̈ve to changes in

bodily reactions. Furthermore, there ismarkedvariation in sex-

ual concordance amongwomen. In theirmeta-analysis of the sex-

ualpsychophysiology literature,Chiversetal. (2010) found,using

apooled sampleofn= 2345women, that variation inwomen’s

sexualconcordancewasnotaccountedforbyavarietyofmethod-

ological factors such as the number of stimulus trials in a given

experiment, theuseof female-centeredversusmale-centerederotic

stimuli, or stimulus length;however, higher sexual concordance

was associatedwith using stimuli that varied in content, inten-

sity, ormodality (r= .49) andmethodof calculating

correlations

(between-subjects [r= .29]versuswithin-subjects [r= .43]).

Chivers et al. also found that concordance among womenwas

related tomethodofassessinggenital response,withgenital tem-

perature (e.g., labial thermistors and thermographic imaging)

yieldinghigherestimatesofsexualconcordancethanvaginalpho-

toplethysmography (.55 vs. .26, respectively), although thermo-

graphicmethods of assessing genital response also producewide

1908 Arch Sex Behav (2016) 45:1907–1921

123

inter-individual variation in sexual concordance, similar to vagi-

nalphotoplethysmography(Kukkonen,Binik,Amsel,&Carrier,

2010). Regardless of measurement method, broad variation in

sexualconcordancesuggests thepresenceofmoderators,ofwhich

sexual functioningmaybeone (Boyer,Pukall,&Chamberlain,

2013).

Low sexual concordance can manifest in one of two ways:

increases ingenital sexual response in theabsenceofgenital aware-

nessorsexualaffect,ortheconverse.Consistently, it is theformer

that is thecaseforsexuallyfunctionalwomen;genital responseto

sexual stimuli is rapidly andautomatically evokedbyprocessing

ofsexualstimuli (Chivers&Bailey,2005),butgenitalawareness

or sexual affect may not be simultaneously reported (Chivers

et al., 2010). This pattern is also common amongwomenwith

FemaleSexualArousalDisorder (FSAD)—which the former

DSM-IV-TR characterized as self-reported impairments in

genital vasocongestion (American Psychiatric Association,

2000)—suchthat theyself-reportedlowersexualaffect tosexual

stimuli in the laboratory but showed a robust genital response,

similar to womenwithout sexual arousal problems (Laan, van

Driel,& vanLunsen, 2008;Meston, Rellini,&McCall, 2010).

In their meta-analysis, Chivers et al. reported the average cor-

relation forwomenwithvarious sexualdifficulties (n=235)as

.04 (-.10 to .17),whereas forwomenwithout sexual difficulties

(n=1144), the correlation was .26 (.21 to .37).

Sexualconcordancemayberelatedtosexualfunctioningamong

healthywomen, such that greater concordance is associatedwith

morefrequentexperienceoforgasm(Adams,Haynes,&Brayer,

1985;Brody,2007;Brody,Laan,&vanLunsen,2003).Coupled

withdatashowinghighersexualconcordanceamongwomenwith-

outasopposedtowithasexualdysfunction,thesedatasuggestthat

sexualconcordancemaybeakeycomponent tohealthysexual

functioninginwomen.Current treatmentsforsexualdysfunction,

however,donot focusonskills thatmayenhancewomen’ssexual

concordancenorhave treatmentefficacystudiesusedsexualcon-

cordance as a primary outcome.

In light of mounting evidence that mindfulness improves

women’s self-reportofsexual functionandawarenessofbodily

sensations, and that concordance between genital and self-re-

portedarousalmayberelevant towomen’ssexual interoceptive

awareness, the current studywas designedwith these themes in

mind.Specifically, thegoalswereto: (1)examinetheeffectsofa

groupmindfulness-based sex therapy (MBST) on concordance

between genital and subjective sexual arousal; (2) examine the

effects of treatment on self-reported sexual arousal and, sepa-

rately, on genital arousal; and (3) test the relationship between

changesinconcordanceandimprovements inclinicalsymptoms

(i.e., sexual desire and sex-related distress) with treatment. A

separate publicationdocuments the significant beneficial effect

of this MBST compared to a delayed treatment control group

on theprimaryendpoint of self-reported sexualdesire (Cohen’s

dtreatment=0.97; dcontrol=0.12) (Brotto&Basson, 2014). Sex-

related distress also significantly improvedwith treatment, and

did not significantly differ from the control group (Cohen’s d

full sample=-0.56).

In thisarticle,wefocusedonchanges inconcordancebetween

genitalsexual response(vaginalpulseamplitude;asmeasuredby

vaginalphotoplethysmography)(Sintchak&Geer,1975)andcon-

tinuously reportedsubjectivesexual arousal (Rellini,McCall,

Randall,&Meston,2005) following treatment.Given that the

MBSTencouraged thedailypracticeof focusingonandexperi-

encing general and genital arousal responses non-judgmentally,

weexpectedtreatmenttobeassociatedwithsignificant increases

ingenital-subjectiveconcordance.Sinceparticipantswereencour-

agedtopracticemindfulnessexercisesdailybetweengroupses-

sions,wepredicteddegreeofhomeworkcompliancewouldmod-

eratetheincreasedconcordanceaftertreatment.Asanexploratory

analysis, we also included age, diagnosis of FSAD, and arousal

scoresfromavalidatedmeasure(bothsubjectivearousalaswell

as lubrication) tomoderate improvements in concordance.Fur-

thermore,wehypothesizedan increase in self-reported sexual

arousalwithtreatment,consistentwithpreviousfindings.Wedid

not expect tofindaneffect of treatment ongenital sexual response

per se, givenevidence thatvaginalpulse amplitudemaynotdif-

ferbetweenwomenwithandwithoutsexualdysfunction(Laan

etal.,2008).Finally,wepredictedchanges inconcordance tobe

associatedwith improvements in sexualdesire andwithdecreases

in sex-related distress.

Method

Participants

Participantswere part of a larger study evaluating outcomes of

groupmindfulness-basedsex therapyonvarious indicesof sex-

ualdesire, sexual response, andaffect (Brotto&Basson,2014).

Womenseeking treatment for sexual desire and/or arousal con-

cerns from the British Columbia Centre for Sexual Medicine,

whether thedifficultieswere lifelongoracquired,wereeligible

to participate. Inclusion criteria included: age between 19 and

65years,fluent inEnglish, andwilling tocomplete all fourgroup

sessions, regularhomework,aswellasassessmentmeasures (con-

sistingofbothself-reportquestionnairesandalaboratory-based

psychophysiological sexual arousal assessment) at three time

points.Womenwith difficulties in achieving orgasmwere also

includedaslongasthosewerenotexperiencedasmoredistressing

than thedesire and/orarousal concerns.Weexcludedanywoman

with dyspareunia (chronic genital pain not resolvedwith a per-

sonal lubricant).

Theoriginalstudydescribingtreatmentefficacyincluded117

womenwho provided pre-treatment assessment data. The data

here focuson79womenwhohadcomplete data from their psy-

chophysiologicalassessments (bothgenitalandsubjectivearousal)

atall threetimepoints—immediatepre-treatment,post-treatment,

and6-month follow-up.Thesample included41(51.9%)women

Arch Sex Behav (2016) 45:1907–1921 1909

123

who were assigned to the immediate treatment group and 38

(48.1%)womenwhoreceived treatmentafteran initial3-month

wait-list period. Only pre- to post-treatment data for women in

thecontrolgroupwereincluded(i.e., theirwait-listdatawerenot).

Also, in thisarticle,wedidnot includedatafromthecontrolgroup

for their two pre-treatment assessments, so the present analyses

did not compare the effects of treatment versus wait-list control

on concordance.Themean age of the samplewas 40.8years (SD

11.5, range 20–65). A total of 84.6% were in a committed rela-

tionship, 6.4%were casually dating, and 9.0%were single. The

mean relationship length was 13.2years (SD 10.7). Most partic-

ipantswere ofEuro-Canadiandescent (81.0%) followedbyEast

Asian (7.6%) and South Asian (2.5%). This was a highly edu-

cated group in that 67.1%had some post-secondary education,

and 22.8% had an advanced graduate degree.

Althoughallparticipants self-reporteddifficultieswith sexual

desire and/or arousal andmet criteria for theDSM-5diagnosis of

SIAD,33 (41.8%)womenmetDSM-IV-TR(AmericanPsychi-

atric Association, 2000) diagnostic criteria for HSDD and 24

(30.4%) women met criteria for FSAD. The remaining 22

(27.8%) women met criteria for both HSDD and FSAD.

Measures

Assessment of Psychophysiological Sexual Arousal

Genital response was measured with a vaginal photoplethys-

mograph(Sintchak&Geer,1975)consistingofatampon-shaped

acrylic vaginal probe, inserted in private by the participant. The

probe (Behavioral Technology Inc., Salt LakeCity, UT) contin-

uouslymeasuredvaginalpulseamplitude(VPA)duringtheneu-

tralanderoticfilmsegments.VPAwasrecordedusingapersonal

computer(HPPentiumMLaptop)thatcollected,converted(from

analog to digital, using aModelMP150WSWdata acquisition

unit [BIOPAC Systems, Inc.]), and transformed psychophysi-

ological data, using the software programAcqKnowledge III, Ver-

sion3.8.1(BIOPACSystems,Inc.,SantaBarbara,CA).Thesignal

wassampledat200Hzandbandpassfiltered(0.5–30Hz).Atrained

research assistant performed artifact smoothing of the signal fol-

lowingvisual inspectionofthedataandbeforedatawereanalyzed.

VPAdatawere subsequentlydivided into30-sepochs,producing

sixdatapoints for theneutralfilmand13datapoints for theerotic

film for each sexual arousal assessment.

Contemporaneous Assessment of Subjective Sexual Arousal

Subjective sexual responsewasmeasuredcontinuouslyduring

the neutral and erotic films with an arousometer that was con-

structedbya local engineermodeledafter the onedescribedby

Rellini et al. (2005). This device consisted of a computer optic

mouse mounted on a plastic track with 10 intervals, and was

affixed to the arm rest of the recliner so that theparticipant could

easily move the mouse, while simultaneously reclining and

viewing stimuli. Women were instructed to move the mouse

up and down the track over the course of the film to indicate

their level of subjective sexual arousal, from7 to-2,with7=

Highest Level of Sexual Arousal, 0=No Sexual Arousal, and

-2=Sexually Turned Off.Wehavepreviouslyused this device

in treatmentoutcomestudiesonwomenwithsexualdysfunction

(Brottoetal.,2012b).LikeVPAdata, themeancontemporaneous

sexual arousal responsewas obtained every 30-s, producing six

datapointsduring theneutral filmand13datapointsduring the

erotic film, corresponding with the 30-s epochs of VPA data.

Discrete Measure of Sexual Response and Affect

The Film Scale, a 33-item self-report questionnaire, was used

toassess subjectivearousal and affective reactions to the erotic

films.This scalewasadapted fromHeimanandRowland(1983)

andassessed sixdomains: subjective sexual arousal (1 item),

perceptionofgenital sexual arousal (4 items), autonomicarousal

(5items),anxiety(1item),andpositiveandnegativeaffect(11items

each). The scale has been found to be a valid and sensitive mea-

sureofemotional reactions toeroticstimuli. Itemswereratedon

a 7-point Likert scale from Not at All (1) to Intensely (7). Pre-

treatment reliability for the FilmScale during the neutral phase

wasverygood(Cronbach’salpha=0.82)andexcellent following

the erotic phase (Cronbach’s alpha= 0.94).

Homework Compliance

Homeworkcompliancewas ratedby thegroup facilitators ona

Likert scale from0 (did not complete homework/did not attend

sessions) to 2 (notable efforts at completing homework/attend-

ing sessions).A ratingwas given for eachparticipant at eachof

the fourgroupsessions, and thenameanscoreacross thesessions

was derived.

Female Sexual Arousal Disorder symptoms

Subscales of‘‘Arousal’’and‘‘Lubrication’’on the Female Sex-

ualFunction Index (FSFI) (Rosenet al., 2000)wereused inmod-

eration analyses. The FSFI is a 19-item self-report questionnaire

considered to be the gold standardmeasure of sexual function in

women.Therewere4 items in theArousaldomainand4 items in

theLubricationdomain; responseswere codedona5-pointLikert

scale.A respondentwhohadnot engaged in sexual activity for the

past4weekswasexcludedfromthose items.Cronbach’salphafor

these two domains was excellent (a=0.89 and a=0.93, respec-
tively) for the current sample.

Sexual Desire was measured with the 14-item Sexual Inter-

est/DesireInventory(SIDI)(Claytonetal.,2006).Possible total

scores range from 0 to 51, with higher scores indicating higher

levelsof sexual interestanddesire.TheSIDIhasexcellent inter-

nal consistency (Cronbach’s a=0.90). Item-total correlations

1910 Arch Sex Behav (2016) 45:1907–1921

123

were high for‘‘Receptivity,’’‘‘Initiation,’’‘‘Desire-frequency,’’

‘‘Desire-satisfaction,’’‘‘Desire-distress,’’and‘‘Thoughts-positive’’

(r[.70), good for‘‘Relationship-sexual,’’‘‘Affection,’’‘‘Arousal-
ease,’’and‘‘Arousal-continuation’’(r[.50),butpoor for theorgasm
item(r= .10)(Claytonetal.2006).Cronbach’salphaforthecurrent

sample was a=0.76.
Sexual Distress wasmeasured with the 12-item Female Sex-

ual Distress Scale (FSDS) (DeRogatis, Rosen, Leiblum, Burnett,

&Heiman, 2002). Scores can range from0 to48,where higher

scores represent higher levels of distress. The FSDS has been

shown to have good discriminant validity in differentiating

between sexually dysfunctional and sexually functional women,

with 88% correct classification rate, and found to have satis-

factory internal consistency (ranging from 0.86 to 0.90) (DeRo-

gatis et al., 2002).Reliability for the current samplewas excel-

lent at a=0.92.

Procedure

Followingacomprehensiveassessmentbyanexperiencedsexual

medicine clinician, eligiblewomenwere informedabout the

study. If interested, theywere providedwith a one-page brochure

outlining informationabout the studyandcontact information for

the study’s coordinator.Next, they tookpart in a telephonescreen

that further explained the studyprocedures, provided some infor-

mation about the treatment content, and informed women about

upcomingschedules for theMBSTgroups.Theywere thenmailed

a consent form. The return of a signed consent form indicated

informed consent, at which time women were assigned to par-

ticipate in either the immediate treatment group or the delayed

treatment group.Whenever possible, we utilized random assign-

ment to group; however, in cases where participants’ schedules

werenotflexible,weassignedwomentothegroupthataccommo-

datedtheir schedules.Participantswere thenscheduledforabase-

line sexual arousal assessment to take place in a sexual psy-

chophysiologylaboratory.Womenwerealsomailedapackageof

questionnaires and asked to return them completed at the time of

their sexual arousal assessment. These same questionnaires and

sexual arousal assessment were repeated 2–4 weeks after the

completion of their MBST group as well as 6 months later. The

duration between baseline and the two subsequent assessments

was relatively equal across all participants, with no more than

2-week variation, typically at the follow-up assessment.

The sexual arousal assessment took place in a sexual psy-

chophysiology laboratory, located in theuniversityhospital,and

housed a comfortable reclining chair, a large screen TV, and an

intercom.A thin blanket was placed over the seating area of the

chair. Following written consent, participants were tested by a

female researcher.Women were first shown the vaginal photo-

plethysmographandencouraged toaskanyquestionsabouthow

to insert it. The female researcher then left the room, while

participants inserted the probe and informed the researcher via

intercom of their readiness. In order to habituate to the testing

environment, participants were encouraged to relax on a com-

fortable reclining chair for a 10-min period after the probe was

inserted. Subjective sexual arousal and affect were assessed at

the end of the adaptation period using the Film Scale, which

servedas thediscreteassessmentof arousal andaffectbefore the

erotic film sequence.

Before the film sequence began, women were reminded to

use the arousometer to capture their subjective sexual arousal

throughout the film sequence. The researcher instructed partic-

ipants to:‘‘Monitor your subjective feelings of sexual arousal to

the film by using this device. By ‘subjective feelings of sexual

arousal,’ we mean how mentally sexually aroused you are in

yourmindwhile you’rewatching the film.’’Further instructions

were given on the numerical demarcations on the device and

whattheupper(mostsexualarousalyouhaveexperiencedorcan

imagine) and lower (sexually turned off) anchors reflect. Partic-

ipants practiced moving the arousometer in the presence of the

researcher and any questions on its operation were addressed

before the film sequence began.

The researcher then initiated the video sequence from the

adjoining room. The audio component was delivered via wire-

less headphones to the participant.Womenwatched a 3-min

neutral documentary about Hawaii followed by a 7-min erotic

film that depicted a heterosexual couple engaging in foreplay,

oral sex, and penile–vaginal intercourse. There were three dif-

ferent film sequences counterbalanced across women and ses-

sions so that participants viewed the same film only once over

the three testing sessions. Immediately after thevideo sequence,

participantscompleted theFilmScaleasecondtime,whichasked

them to evaluate their subjective sexual arousal and affect to

theeroticfilm.Theywere then instructed toremove theprobeand

meet the researcher in a separate room.After a debriefing period,

the researcher disinfected the probe in a solution of Cidex OPA

(ortho-phthalaldehyde 0.55%), a high level disinfectant (Advanced

Sterilization Products, Irvine, CA, USA), promptly following

each session.

All procedures were approved by the Clinical Research

EthicsBoard at theUniversityofBritishColumbia and theVan-

couver Coastal Health Research Institute. All procedures were

carriedout in accordancewith theprovisionsof theWorldMed-

ical Association Declaration of Helsinki.

Mindfulness-Based Sex Therapy

TheMBST (Brotto,Basson,&Luria, 2008b)was based on an

integration of psychoeducation, sex therapy, and mindfulness-

based skills, the latter of which have received extensive empir-

ical support in other populations (Grossman et al., 2004). Stem-

ming from evidence that womenwith sexual desire/arousal dif-

ficulties are often distracted during sexual activity and/or judg-

mental (of themselvesor theirpartners),mindfulness skillswere

primarily aimed at orienting the woman to the present experi-

ence,while simultaneously notingnegative thoughts as‘‘mental

Arch Sex Behav (2016) 45:1907–1921 1911

123

events’’—something to be noticed but not focused on. Consis-

tentwithmindfulness-based cognitive therapy for preventionof

depression relapse (Teasdale et al., 2000), MBST aims to help

womendevelopawareness inallareasof their life, includingreal

andanticipatedsexualsituations.Atleast4weekswerespentencour-

agingwomen to practicemindful self-awareness in non-sexual sit-

uationsasameansofdeveloping theskillofmoment-by-moment

awareness. In-session‘‘inquiries’’followingmindfulness practice

were intended to allowparticipants to view their practice as adepar-

ture from their typicalmodeof being,whichmayhave been char-

acterizedasfuture-oriented,multi-tasking,and/orruminativeabout

pastevents.Atlaterstagesofthegroup,womenwerethenencour-

aged toapply theirnewskills inprogressivelymoresexualsitua-

tions—firstontheirown(followingexposuretoaneroticstimulus

suchasavibratororeroticfilm), andnext togetherwithapartner

(if applicable,duringactualsexualactivity).Theaimof thehome

practicewas to encourage participants to develop a regularmind-

fulnesspracticeandacquireexperienceobservingthoughts,espe-

ciallynegativeones,asmentalevents,before introducingpractice

togetherwithapartner,orapplyingmindfulnessduringat-home

sexual activities.Althoughsensate focus shareswithmindfulness

thegoalofpresent-momentawareness,theformerrequiresapartner

tobepresent anddoesnothave theadvantageofportability that

mindfulnesshas (i.e., inhomeworkactivitieswomenwereenco-

uragedtouse informalmindfulnesspractice throughout theirdays

tocomplementtheformalpractices).Concurrentwiththeprinciples

ofmindfulness,womenwereencouragedat thestartofSession1to

‘‘letbe’’strongwishesforchange,andforthedurationofthesessions

to focus instead on being fully in the present. Goals for the group

were not elicited.

In the current study, treatment was delivered by two group

facilitators (selected from a trained pool of six sexual medicine

physicians, psychologists, and upper-level residents/graduate

students) togroupsconsistingof4–7women.Sessionstookplace

ina largegrouproomat theBCCentre forSexualMedicine,and

each 90min session was spaced 2 weeks apart.

Contents

Session 1 provided educational information on the prevalence

and known etiology of lowdesire and arousal.Mindfulnesswas

then introduced through in-session practice of the‘‘BodyScan,’’

which is also the foundational practice in mindfulness-based

therapies (Teasdale et al., 2000). By orienting attention to var-

ious parts of the body, women were encouraged to become

aware of sensations in that region and any subsequent‘‘mental

events’’(thoughts,beliefs, emotions,othercognitiveactivity) that

followontheawarenessof sensations.After aguided in-session

practice, participantswereencouraged topractice theBodyScan

daily at home, and were provided an audio-recorded guide.

Session 2 provided an opportunity for in-depth homework

review, followed by psychoeducation on sexual anatomy and

physiologyandthecircularsexual responsecycle(Basson,2001).

In-sessionmindfulness practice centered on‘‘Breath and body’’

as the focus of attention. Like the Body Scan, participants were

guided to notice and attend to various parts of the body, includ-

ing sensations associatedwith breathing and the breath itself. In

mindfulness-based therapy for depression (Basson, 2001), this

practice also typically follows a foundationof practice using the

BodyScan.Forhomework,participantswereencouraged todoa

‘‘seeingmeditation’’with their genitals as the focus of the prac-

tice. Theywere asked to observe their genitalswith a hand-held

mirror, and in addition to noticing moment-by-moment visual

and bodily sensations, they were also asked to take note of any

follow-on thoughts, emotions, or beliefs as a result of the seeing

practice.

Session 3 began with an in-depth review of the home body-

oriented mindfulness practice, and participants were encour-

aged to start to think about the relevance of this practice to their

sexuality more broadly. Next, there was in-session psychoedu-

cation onGottman’s principles for lasting relationships (Gott-

man&Silver, 1999). The guided in-session practice utilized

mindfulness of thoughts, and thepracticewas followedbyadis-

cussion on the high prevalence of automatic thoughts/logical

errors of thinking, and using the cognitive behavioral model to

illustrate the association between thoughts, emotions, and beh-

aviors. The discussion also highlighted how mindfulness skills

are aimed at simply bringing awareness to negative/judgmental

thoughts andwere contrastedwith CBT skills, which are aimed

at identifying and challenging problematic thoughts. For home

practice, women were encouraged to repeat the mindfulness of

genitals exercise from the previous 2 weeks in which they obs-

ervedtheirgenitalsmoment-by-momentandnon-judgmentally,

but this time were also encouraged to incorporate the sensation

of touch. This was framed as a non-masturbatory exercise

designed to enhance mindful awareness of genital sensations.

Session 4 was devoted to home practice review followed by

an introduction of sensate focus to be used with a partner (if

available). The facilitator explained the first (of three) phase of

sensate focus as originally defined by Masters and Johnson

(1970). Specifically, sensate focus was described as having the

goals of: tuning into sensations (and in this way, women were

encouraged to use the mindfulness skills they had been devel-

oping), relaxation, andproviding feedback toapartner about the

receivedtouch.In-sessiontrouble-shootingaroundcommonbar-

riers, suchasfinding the timefor thehour-longpractice, thenfol-

lowed.Sensatefocuswasdescribedspecificallyasanon-demand

exercise(Weiner&Avery-Clark,2014); ifwomen(or theirpart-

ners)experiencedsexualexcitement, theywereencouragedtonotice

theaccompanyingsensations in the sameway theyhadpracticed

noticingsensationsduringtheBodyScan.Thesecondhalfof the

finalsessionprovidedanoverviewontheuseofcognitiveandtactile

toolstoaugmentsexualresponse(e.g.,fantasy,erotica,andvibrators)

duringmindfulnesspractice.Specifically, instructionswerepro-

vided towomen to elicit a sexual arousal response using one of

these tools, and then use those sensations as the focus during a

1912 Arch Sex Behav (2016) 45:1907–1921

123

mindfulness practice, and they were encouraged to try this at

leasttwotimesathome.Byelicitingastrongerbodilyresponsewith

these erotic aids, we hypothesized greater facilitation of inte-

roceptiveawareness.Thegroupendedfollowingadiscussionof

strategiesformaintainingmindfulnesspracticeathome,andwith

the encouragement toview these four sessions as potentially the

beginningofalifelongpracticeusingmindfulnessbothinsexualand

non-sexual aspects of their lives. Whenever possible, the facilita-

tors referenced published findings on the efficacy of mindful-

ness therapy in other populations, and integrated emerging knowl-

edgeontheimpactofmindfulnesspracticeonneuralplasticityand

brain function.Allmaterialwas compiled into a facilitator and

participant manual that included space for personal practice

notes and observations (Brotto et al., 2008b).

Data Analyses

Hypothesis 1

We predicted a significant effect of MBST on increasing con-

cordance between genital and subjective sexual arousal. Mul-

tilevelmethodologywas used to assess this question as it allows

for the examination of changes within an individual (rather than

averages across individuals) and has specifically been used to

examinechangesinsexualconcordance(Clifton,Seehuus,&Rellini,

2015;Rellinietal.,2005).WeusedtheHierarchicalLinearModeling

software program (HLM 6.08) (Raudenbush, Bryk, & Cong-

don, 2004) to testwhether concordance significantly increased

from pre-treatment to post-treatment, and again at six-month

follow-up.

We used a two-levelmodel with repeatedmeasuresmodeled

atLevel1 toestimate intercepts (meanof theoutcomevariableat

the start of the erotic film) and trajectories of change (slopes) in

theoutcome.WestandardizedallLevel1variablesacrosswaves

prior toanalyses,allowingfor the interpretationof thecoefficients

as standardized betas.All coefficientsweremodeled as random

(Nezlek, 2001).

First, we assessed the effect of the intervention on the con-

temporaneous (e.g.,T30s?T30s,T60s?T60s, and soon) relation
between genital and continuous subjective arousal (i.e., whether

genital arousal predicted contemporaneous subjective arousal,

andwhether subjectivearousalpredictedcontemporaneousgenital

arousal).Themodeltestedthesimpleslopesofsexualconcordance

ineach timeperiodseparately(i.e.,againstaslopeofzero).Dummy

coded timevariableswere included tocontrol foranymeandif-

ferences in the outcome of interest at the different assessment

points.

Second, we conducted five Level 2 moderation analyses to

determine if age, homework compliance, or FSAD status [asse-

ssed in twoways; firstly, as a dichotomous variable according to

whether thewomanhad a clinical diagnosis of FSADor not, and

secondly using continuous scores on the lubrication and arousal

subscales of theFSFI (Rosen et al., 2000)] changed thedegree of

concordance between genital and subjective sexual arousal at

each of the time points.

To aid in the interpretation of the magnitude of concordance

betweengenital andsubjective sexual arousal,wealsocarriedout

within-subjects and between-subjects Pearson r correlation coef-

ficients on VPA and continuous self-reported arousal during the

erotic segmentof thefilmonly. In thisway, concordanceestimates

could be compared to the mean concordance values from a

meta-analysisofseveralpsychophysiological studies (Chivers

et al., 2010).

Hypothesis 2

We predicted that treatment would be associated with significant

improvements in self-reported sexual arousal and affect but not

with any significant changes in genital sexual responsemeasured

in-laboratory.Wetookdifferencescoresfromresponsesfollowing

the erotic stimulusminusmean scores during the baseline period,

asperCliftonetal.(2015).Wenextcarriedoutarepeatedmeasures

analysis of variance (ANOVA)across the three assessment points

on these difference scores. To examine the effects of treatment on

genital sexual response, a similarmixedwithin-between repeated

measuresANOVAwascarriedoutonVPApercent changescore,

which was calculated as follows: (mean erotic VPAminus mean

neutral VPA) divided by mean neutral VPA, as per Clifton et al.

(2015).

Hypothesis 3

Wepredictedanassociationbetweenconcordanceandclinical

symptoms—namely, sexual desire, and sex-related distress.

Firstly, Spearman’s rankcorrelationcoefficient (rho)wasusedas

the estimate of concordance between VPA and subjective aro-

usal for eachwoman at each time point (pre-, post-treatment, and

follow-up)separately.Theseconcordanceestimateswere then

used as a fixed variable in a mixed-effects model examining the

relationshipbetweeneitherSIDIscores(measuringsexualdesire)

and concordance over time points, or FSDS scores (measuring

sex-related distress) and concordance. Themodels included con-

cordance, time point (pre-, post-treatment, and follow-up), and

their interaction, as well as participant ID as a random nesting

effect.

Results

Concordance Between Genital and Continuous

Subjective Sexual Arousal (Hypothesis 1)

Results of the contemporaneous analyses are shown inTable 1

and indicated that genital and subjective arousal covaried

Arch Sex Behav (2016) 45:1907–1921 1913

123

throughouttreatment.Specifically, increasesinsubjectivearousal

predicted contemporaneous increases in genital arousal, and

increases ingenital arousal predicted contemporaneous increases

in subjective arousal.

Subjective Arousal Predicting Genital Arousal

When examining the association between subjective arousal

and contemporaneous genital arousal, SAPre-treatment (top half of

Table 1) represents this association during pre-treatment. This

coefficient was significant, indicating that for every one stan-

dardized unit of subjective arousal increase, women showed an

average corresponding increase of 0.008 millivolts in VPA,

equivalent to a 0.16 standard deviation increase inVPA.SAPost-

treatment and SAFollow-up were also statistically significant, indi-

cating that for every one standardized unit of subjective arousal

increase, women showed an average corresponding increase of

0.00525 millivolts in VPA at post-treatment and 0.00501 mil-

livolts inVPAat follow-up, respectively.This corresponds toan

average increase of 0.15 standard deviations in VPA at post-

treatment and 0.12

standard deviations at follow-up.

To examine whether sexual concordance significantly dif-

fered at pre-treatment, post-treatment, and follow-up, we

examined the model with no constraints and compared this to

models constraining every unique pair of concordance ratios to

be equal. The models were compared using standard v2 differ-
ence tests in which the goodness-of-fit for two models is differ-

enced(Schermelleh-Engel,Moosbrugger,&Müller,2003). If

themodelwithmoreconstraintsresults inasignificant increasein

theoverallv2, this is indicativeof apoorerfit, and themodelwith
no constraints is retained. After applying the conservative Bon-

ferroni correction for multiple tests (a=0.05/3= .017), results

of all v2 difference tests comparing the unconstrained and con-
strained models, pre-treatment=post-treatment, v2(1)=10.40,
p= .001; pre-treatment= follow-up,v2(1)= 10.34,p= .001;
post-treatment= follow-up,v2(1)=12.30,p\.001, showed that
theunconstrainedmodelfits thedata significantlybetter. Inother

words, thedegreeofconcordancebetweensubjectiveandgenital

arousal at each timepointwas significantlydifferent fromevery

other time point. Further, these differences were in the expected

directionsuchthatbetavaluesdecreasedovertime(i.e., therewas

less change in genital arousal associatedwith the same level of

subjective arousal over time).

Genital Arousal Predicting Subjective Arousal

In examining the association between genital arousal and con-

temporaneous subjective arousal, VPAPre-treatment (bottomhalf of

Table1) represents this association during pre-treatment. This

coefficient was significant, indicating that for every one stan-

dardized unit of genital arousal increase, women showed an

average corresponding increase of 1.79 units of subjective arou-

sal, equivalent to a 1.16 standard deviation increase in subjective

sexual arousal. VPAPost-treatment and VPAFollow-up were also sta-

tistically significant, indicating that for every one standardized

unitofphysiologicalarousal increase,womenshowedanaverage

corresponding increaseof 1.37units of subjective arousal at post-

treatment and1.08units of subjective arousal at follow-up, respec-

tively. This corresponds to an average increase of 0.76 standard

deviations in subjective sexual arousal at post-treatment and 0.64

standard deviations at follow-up.

Toexaminewhethersexualconcordancesignificantlydiffered

at pre-treatment, post-treatment, and follow-up, we again exam-

ined the model with no constraints and compared this to models

Table 1 Contemporaneous reciprocal associations between genital and subjective arousal

Coefficient SE t ratio p

SA?VPA

Pre-treatment 5.71910-2 0.005 10.92 \.001
Post-treatment 6.40910-2 0.004 16.68 \.001
Follow-up 5.98910-2 0.005 12.85 \.001
SAPre-treatment 8.12910

-3 0.004 1.99 .05

SAPost-treatment 5.25910
-3 0.001 3.50 .001

SAFollow-up 5.01910
-3 0.001 3.40 .001

VPA? SA

Pre-treatment 1.82 0.26 6.87 \.001
Post-treatment 1.88 0.23 8.22 \.001
Follow-up 1.70 0.19 8.97 \.001
VPAPre-treatment 1.79 0.50 3.58 .001

VPAPost-treatment 1.37 0.28 4.96 \.001
VPAFollow-up 1.08 0.26 4.20 \.001

df=78

VPA Vaginal pulse amplitude (genital arousal), SA subjective arousal

1914 Arch Sex Behav (2016) 45:1907–1921

123

constraining every unique pair of concordance ratios to be equal.

Results of all v2 difference tests comparing the unconstrained
modelwithconstrainedmodelsshowednostatisticallysignificant

difference in fit, pre-treatment= post-treatment, v2(1)= 0.71,
p= .40;pre-treatment= follow-up,v2(1)=-0.56,p= .46;post-
treatment= follow-up, v2(1)=1.49, p= .22, indicating that the
degree of concordance between genital and subjective arousal at

eachtimepointwasnotsignificantlydifferentfromanyothertime

point.

Wecalculated bothwithin-subjects correlations andbetween-

subjects correlations and these are shown in Table 2. Across

time points, themagnitudeof thecorrelationbetweengenital and

subjective sexual arousal was larger for within-subjects correla-

tions (range .28 to .33) than for between-subjects correlations

(range .13 to .22).Using a paired samples t test comparing pre- to

post-treatment,andaseparateonefrompost-treatmenttofollow-up

revealednostatisticallysignificantdifferencesforwithin-subjects

concordanceestimates.Thesamenon-significantresultswerefound

usingFisher’sr-to-z transformationfor thebetween-subjectscon-

cordance estimates (Table 2).

Focusing specifically on the within-subjects correlations, the

rangeofconcordanceestimatesatpre-treatmentwas-.90to?.91.

A total of 19.1% had negative concordance (defined here as

rB-.25), 10.6%had noconcordance (defined here as-.24\
r\.24), and 70.2%had positive concordance (defined here as
rC .25).Atpost-treatment, the rangewas similarly large:-.80

to .94with 15%havingnegative concordance, 20%havingno

concordance, and 65% having a positive concordance.

Moderation of the Association Between Genital and

Continuous Subjective Arousal

Five separate Level 2 moderation analyses were conducted to

determine if age (n=79), homework compliance (n=78), or

FSAD status (assessed dichotomously according towhether

women had a clinician-determined diagnosis of FSAD or not;

n= 79), and usingmean scores on the lubrication (n= 62) and

arousal (n= 62) domains of theFSFI (measured continuously)

changed the degree of concordance between genital and sub-

jective sexual arousal at eachof the timepoints.All timepoints

were included in the moderation analyses for age and FSAD

status, while only post-treatment and follow-upwere included

in the moderation analyses involving

homework compliance

(homework had not yet been assigned at pre-treatment).

Neither age, diagnosis of FSAD, continuous FSFI scores on

the lubrication and arousal domains, nor homework compliance

moderated the association between contemporaneous subjective

and genital arousal as an outcome (ps ranged from .21 to .79).

Similarly, neither age nor FSAD status (assessed dichotomously

andcontinuouslywiththeFSFI)moderatedthecontemporaneous

(ps ranged from .35 to .92) association between genital and sub-

jective sexual arousal as an outcome.Degree of homework com-

pliance was, however, found to moderate this association, such

thatgreaterhomeworkcompliancewasassociatedwithanincrease

in thenumberofsubjectivearousalunitsassociatedwithastan-

dardized unit increase in genital arousal (Table 3). Specifically,

foreverystandardizedunitincreaseofgenitalarousal,womenshowed

amarginally significantly greater increase in subjective arousal

withmorehomeworkcomplianceatpost-treatment(t=1.67,p=

.10)andasignificantlygreater increase insubjectivearousalwith

greaterhomeworkcomplianceat follow-up (t= 2.13,p= .04).

Effects of Erotic Film andTreatment on Self-Reported

Sexual Arousal and Affect (Hypothesis 2)

To test the ability of the erotic film to significantly increase self-

reportedsexualarousalandaffect,apairedsamples t testwasused

tocomparemeanscoresonFilmScaledomainsbefore theneutral

film and after the erotic film at post-treatment. There was a sig-

nificant increase in perception of genital sexual arousal, t(78)=

-10.53,p\.001,d= 1.93; subjective sexual arousal, t(78)=
-8.66, p\.001, d = 1.38; positive affect, t(78)=-6.43,
p\.001, d=1.20; autonomic arousal, t(78)=-7.36, p\.001,
d=1.23;negativeaffect, t(78)=-3.47,p= .001,d=0.59,anda

significant decrease in self-reported anxiety, t(78)=2.62, p=

.011,d=-0.42, following theeroticfilm.Thesefindingssuggest

that the erotic film was effective at eliciting a subjective sexual

response at post-treatment (Table4).

A repeatedmeasuresANOVAdid not find a significant effect

of treatment on subjective sexual arousal difference scores, F(2,

156)\1,p= .861,d=0.05 frompre- topost-treatment;d=0.06
from post-treatment to follow-up. Perception of genital sexual

arousal similarlydidnot significantlychangewith treatment,F(2,

156)\1,p= .747,d=0.07 frompre- topost-treatment;d=0.05
from post-treat

ment to follow-up.

Focusingonaffect,arepeatedmeasuresANOVAdidnotfinda

significant effect of treatment on the change in positive affect

Table 2 Concordance between genital and continuous subjective sexual
arousalcalculatedwithwithin-subjects correlationsandbetween-subjects

correlations across three time points

Pre-treatment Post-treatment

Follow-up

Within-subjects

correlations

.30 (.54)

n=47

.33 (.47)

n=60

.28 (.47)

n=76

Between-subjects

correlations

.22

n=79

.13

n=79

.14

n=79

Within-subjects correlations used responses during the erotic segment of

the film only and continuous measures of subjective sexual arousal.

Sample sizes vary due to missing data. Paired samples t test revealed no

significant difference from pre- to post-treatment, t(46)=-0.21, p=

.835;or frompost-treatment to follow-up, t(58)=0.76,p= .448.Between-

subjectscorrelationswerecalculatedwithpercentchangeingenital sexual

arousal from neutral to erotic film conditions, and using the difference

between neutral to erotic film conditions for discrete self-reported sexual

arousal. Fisher’s r-to-z transformation foundno significant difference from

pre- to post-treatment, z=0.61, p= .542; or from post-treatment to fol-

low-up, z=-0.06, p= .952

Arch Sex Behav (2016) 45:1907–1921 1915

123

fromneutral to erotic filmconditions,F(2, 156)=2.54,p= .082,

d=0.14 from pre- to post-treatment; d=0.08 from post-treat-

menttofollow-up.Asimilarpatternwasfoundfornegativeaffect,

with no significant effect of treatment, F(2, 156)\1, p= .948,
d=0.00 from pre- to post-treatment; d=0.04 from post-treat-

ment to follow-up.

EffectsofEroticFilmandTreatmentonGenitalSexual

Arousal (Hypothesis 2)

Totest theabilityof theeroticfilmtosignificantly increasegenital

sexualresponseateachtimepoint,apairedsamples t testwasused

tocomparemeanVPA(inmV) fromtheneutral to theeroticfilm.

A paired samples t test revealed that the erotic film significantly

increasedVPAatpre-treatment, t(78)=-2.00,p= .049;atpost-

treatment, t(78)=-2.00,p= .049; at post-treatment, t(78)=

-2.78, p= .007; and at follow-up, t(78)=-2.19, p= .032, veri-

fying the sexually arousing properties of our erotic stimuli

(Table 4).

To examine the effects of treatment on VPA percent change

scores, a repeatedmeasuresANOVAacross all three time points

wascarriedoutandfoundnot toreachstatisticalsignificance,F(2,

156)= 2.58, p= .079; d= 0.28 from pre- to post-treatment;

d=-0.34 from post-treatment to follow-up.

Association Between Sexual Concordance andClinical

Symptoms Using the Sexual Interest/Desire Inventory

and the Female Sexual Distress Scale (Hypothesis 3)

Significance of the interaction term and the main effects were

estimated using likelihood-ratio tests comparing the fit of the

modelcontainingthetermversusthefitofthemodelwiththeterm

removed. p-values\.05 were considered as indicating a signifi-
cant relationship between the term of interest and the outcome

variable. There was no significant interaction between time and

concordanceforeitherSIDIorFSDS(Likelihood-ratio test statis-

tic [LRT]=3.9, p= .15, and LRT=3.2, p= .21, respectively).

This suggests that any relationship between concordance and the

clinical symptoms of desire (SIDI) and distress (FSDS) did not

differ significantly over the time periods. If the interaction terms

were removed, therewas still no significant relationship between

either SIDI or FSDS and concordance (LRT=0.2, p= .68, and

LRT=0.0, p= .99, respectively); however, there was a signifi-

cant effect of time period for both outcomes (SIDI: LRT=17.3,

p= .0002; FSDS:LRT=9.0,p= .01),withSIDI scores increasing

significantly post-treatment and remaining high at follow-up,

and FSDS scores decreasing significantly at post-treatment

and remaining low at follow-up.

Table 3 Homeworkcomplianceasamoderatorof theassociationbetween
genital and contemporaneous subjective arousal as an outcome

Coefficient SE t ratio p

VPA(T)? SA(T)
Post-treatment

Low HC 1.76 0.20 8.94 \.001
High HC 2.79 0.36 2.83 .006

Follow-up

LowHC 1.45 0.14 10.46 \.001
High HC 2.50 0.33 3.22 .002

VPAPost-treatment

Low HC 0.94 0.23 4.16 \.001
High HC 1.57 0.38 1.67 .10

VPAFollow-up

Low HC 0.59 0.12 5.06 \.001
High HC 1.14 0.26 2.13 .04

df=76

VPA vaginal pulse amplitude (genital arousal), SA subjective arousal,HC

homework compliance

Table 4 Effects of erotic filmondiscretemeasures of subjective sexual arousal, perceptionof genital arousal, positive affect, negativeaffect, autonomic
arousal, anxiety, and vaginal pulse amplitude (VPA) from neutral to erotic films at pre-treatment, post-treatment, and follow-up

Pre-treatment Post-treatment Follow-up

Neutral Erotic Neutral Erotic Neutral Erotic

Subjective arousal 2.91 1.14*** 4.27 1.41 3.04 1.19*** 4.47 1.30 2.97 1.10*** 4.32 1.34

Perception of genital arousal 1.45 0.58*** 2.80 1.31 1.51 0.66*** 2.93 1.36 1.46 0.59*** 2.83 1.29

Positive affect 1.71 0.64*** 2.49 1.41 1.63 0.66*** 2.57 1.46 1.54 0.53*** 2.57 1.38

Negative affect 1.38 0.44*** 1.52 0.57 1.26 0.36*** 1.40 0.50 1.28 0.35*** 1.43 0.53

Autonomic arousal 1.58 0.54*** 2.25 0.92 1.56 0.62*** 2.37 1.00 1.52 0.61*** 2.35 0.96

Anxiety 2.06 1.08** 1.66 1.19 1.68 0.87** 1.39 0.90 1.59 0.81 1.41 0.84

VPA (mV) .044 .063* .058 .037 .043 .063** .063 .029 .044 0.67* .060 .043

Data represent means and SD

*p\.05, **p\.01, ***p\.0001 paired samples t test fromNeutral to Erotic conditions. All variables, except VPA, have a 1–7 range

1916 Arch Sex Behav (2016) 45:1907–1921

123

Discussion

We examined the effects of a group mindfulness-based sex

therapy on concordance between genital and subjective sexual

arousal inwomenseeking treatment for concernsof sexual desire

and/or arousal using a series of hierarchical linear models, first

with subjective arousal predicting genital response and then the

reverse.We found evidence of significant sexual concordance at

all time points, with subjective arousal predicting contempora-

neous genital arousal, and significant increases frompre- to post-

treatment, such that there was less change in genital arousal

associated with the same level of subjective arousal, suggesting

greater coherence between these two aspects of the sexual res-

ponse (Brottoetal.,2012b). Incontrast, althoughgenital response

predicted significant increases in subjective arousal contempo-

raneouslyatall timepoints,wefoundnochangeinthismeasureof

sexual concordance as a function of treatment. Within-subjects

correlations revealed the magnitude of the association (between

.28and.33)tobewithintherangefoundamongseveralotherpsy-

chophysiological studiesofwomen(Chiversetal.,2010).These

resultssuggestthat increasesinsexualconcordanceassociatedwith

mindfulness-basedsextherapymaybedrivenbychangesinsubjec-

tive sexual response rather than genital response.

Interestingly, although the erotic film significantly increased

self-reported sexual arousal, affect, andgenital sexual response at

each time point, there was no significant effect of treatment on

eitherself-reportedorgenital responsecomparedtobaseline,sug-

gesting that the change in sexual concordance following treat-

ment was not a straightforward consequence of increases in self-

reported or genital response. Clifton et al. (2015) also found

similar effects,withwomenhigher inSESII excitation scoresand

passionate-romantic scores showing higher genital-subjective

concordance, despite no significant association between individ-

ual predictors and genital or subjective sexual response sepa-

rately;womenwhorate themselvesasmoreeasilyarousablemay

bemore in tunewith their body’s physiological responses to sex-

ual stimuli, even though the magnitude of their actual physio-

logical or subjective sexual response is no different fromwomen

with lowerexcitation scores.Similarly,we foundasignificant effect

of mindfulness treatment on concordance (compared to pre-

treatment levels) but not on genital or subjective sexual response

separately, suggesting that treatment may have contributed to

women’s capacity to detect and integrate their experience of

sexual excitation.

FSAD diagnostic status and FSFI lubrication and arousal

domainscoresdidnot significantlymoderate sexual concordance

at any of the time points. This was a surprising result, given both

clinical domains improved after treatment (Brotto & Basson,

2014), and other research has noted relationships between sexual

functioning and sexual concordance in healthy women (Brody

et al., 2003) and inwomenwith sexual difficulties (Chivers et al.,

2010). Our findings suggest, perhaps, that sexual concordance

and self-reported clinical symptoms of (low) desire and sexual

distress reflect different, unrelated aspects of the female sexual

response, accounting for their lack of significant association.

Conversely,homeworkcompliancedid significantlymoderate

sexualconcordance,suchthat, foreverystandardizedunit increase

ofgenitalarousal,womenshowedasignificantlygreater increase

insubjectivearousalwithgreaterhomeworkcomplianceat follow-

up. This suggests that recommended daily at-home mindful-

nesspractices, designed tocultivatebetter integrationof awareness

andphysical sensations,mayhave contributed to the increase in

concordance.Ofnote, thismoderationwassignificantatfollow-up,

butnotatimmediatepost-treatment,suggestingcumulativeeffects

ofmindfulnesspracticeover the6-monthfollow-upperiod.Other

data showingadose–response relationshipbetweendurationof

mindfulnesspracticeandimprovements insymptomsofdepression

andanxiety supports this interpretation (Krusche,Cyhlarova,&

Williams,2013).Othershavealsofoundthatamountofat-home

mindfulnesspractice is associatedwith self-reportmeasuresof

affect and well-being, but not with indices of medical health

(Carmody&Baer, 2008).Ourhomeworkcompliance scores

were assigned bygroup facilitators; therefore, future studies

could have participantsmonitor amount of at-homepractice to

correlate mindfulness practice with changes in outcomes.

Sexual Concordance as a Potential Study Endpoint?

Our findings suggest that skills aimed at enhancing a woman’s

concentration training and compassionate self-acceptance may

be associated with greater integration of physical and mental

sexual responses to erotic stimuli in a laboratory setting. Con-

sidered in the context of prior research showing similar effects of

attention training on sexual arousal (Meston, Rellini, & Telch,

2008), and the specificity of mindfulness interventions (versus

cognitive behavioral sex therapy) on changes in sexual concor-

dance (Brotto et al., 2012b), we propose that sexual concordance

beconsidered ameaningful studyendpoint in sexual psychophys-

iologyresearch.Intreatmentoutcomeresearch,itisnotuncommon

toseethetreatmenteffectsonself-reportedbutnotgenitalresponse

(Diamondetal., 2006).Elsewhere,wehaveproposed that sexual

concordancemayreveal treatmenteffects thatmightotherwise

be overlookedwhen examining only self-reported or psychophysi-

ological sexual responsealone(Chivers&Rosen,2010).Others

have shown that sexual concordance ismeaningfullyassociated

withcognitiveandschematicaspectsofwomen’ssexualfunctioning,

suchashighersexualexcitationandpassion-andromance-related

cognitive schemas, in the absenceof direct effects between these

variables(Cliftonetal.,2015). Inthecurrentstudy,wedemonstrated

asimilarpatternwithsexualconcordanceincreasingaftertreatment

butnodetectablechangeineitheraspectofsexualresponsethrough-

out treatment.Taken together, thesefindingsprovidepreliminary

support for the possibility of sexual concordance being amore

relevant and sensitive study endpoint.

Arch Sex Behav (2016) 45:1907–1921 1917

123

Mechanisms of Action

The direction of concordance effects, with subjective arousal

predicting contemporaneousgenital arousal (but not the reverse),

suggests that mechanisms underlying change in sexual concor-

dance are predominantly, as expected, top-down, as opposed to

bottom-up.Aswomendeliberatelyguidedtheirattentionontodif-

ferent foci—whether the breath, body, sounds, or thoughts—this

may have translated into an improved ability to detect sensations

inthebodyassociatedwithsexualarousal.Silversteinetal. (2011)

founddecreased reaction time to ratingbodily reactions to sexual

stimuli in women followingmindfulness training. Given that the

insular cortex mediates interoceptive ability (Critchley, Wiens,

Rotshtein,Öhman,&Dolan,2004),andisassociatedwithincreased

thicknessfollowingmindfulnesspractice(Hölzeletal.,2010), it is

possiblethatinsula-mediatedincreasesininteroceptiveabilityfrom

the variousmindfulness exercises contributed to the improved

concordance between genital and subjective arousal.

Because sexual concordance was not significantly different

with treatment when genital arousal predicted subjective sexual

arousal, this suggests that it was unlikely that genital sensations

ledwomentoexperiencemoresubjectivearousal, therebydriving

concordance.Furthermore, ithasbeenarguedthat treatmentsaimed

atimprovinggenitalresponsemaybeineffectivewithoutthecapacity

todetectandpositivelyappraisethosephysiologicalchanges(Chivers

&Rosen, 2010).Thegenital arousal response to erotic cues is rela-

tivelyautomatic (Chivers&Bailey, 2005;Chivers,Rieger,Latty,

&Bailey,2004;Laan,Everaerd,vanBellen,&Hanewald,1994),

regardless ofwomen’s ageor sexual dysfunction status; indeed,

womenwithadiagnosisofFSADhadthesamemagnitudeofVPA

assexuallyhealthycontrols(Laanetal.,2008).Inthecurrentstudy,

therewasno immediateeffectof treatmentonVPA.Therefore,

it isnotlikelythatourtreatmentledtochangesingenitalresponding,

which then drove an increase in concordance. A top-downmecha-

nisminwhichwomendeliberately focusedattentiononemerging,

moment-by-moment sensations over the course of treatment,

likely led to theircontemporaneousdetectionofgenital arousal

in the laboratory setting, thereby increasing sexual concordance.

In addition to mindfulness practice increasing awareness of

visceral (and likely genital) cues, current models of the mecha-

nismsofmindfulness(Teper,Segal,&Inzlicht,2013)suggestthat

increases inacceptanceandself-compassionmayhavecultivated

anopennesstoallelementsofourparticipants’experienceofsexual

responsewithout attempting to alter them.Teper et al. surmised

thatwhenoneobserves and accepts current emotions, thismay

facilitateemotionregulation.Givenevidence thatnegativeaffect

during sexual encounters may significantly predict sexual diffi-

culties (Nobre&Pinto-Gouveia, 2006), it ispossible thatwomen

experiencedan improvedability to regulate suchemotions and

thereby tune into and accept their visceral sensations.

Limitations

Therewerelimitationsinthisstudythatmustbeconsidered.Firstly,

treatment included a combination of (primarily) mindfulness exer-

cises,psychoeducation, and sex therapy. It is unknownwhether

benefitswere due to one specific component of treatment or to

theirsynergisticeffects.Ofnote,however,previousresearchtesting

asimilar (butnot identical) treatmentprotocol foundthatpartici-

pantsself-reportedthemindfulnesscomponent tobethemosteffec-

tiveaspectof treatment(Brotto&Heiman,2007).Futureresearch

thatdismantlesthesecomponentsandteststhemagainstoneanother

isneededinorder toempiricallysubstantiate theseobservations.

Secondly,ourmeasureofsexualfunctioning(i.e., theFSFI)was

limitedbecause it excludedwomenwhowerenot sexuallyactive

in thepreceding4weeks, andassessedonly the intensityandfre-

quencyof sexual arousal,without consideration for themultiple

ways inwhichsexualarousalmaybeexperiencedinwomen.Our

ability todetectassociationsbetweenchangeinsexualconcordance

andchangeinclinicalsymptomsmayberelatedtotheselimitations.

Relatedly,wewerealsounable toexaminecorrelationsbetween

concordance and the orgasmdomain given the large proportion

ofmissingdata intheFSFI. Importantly, thissamplerepresentsonly

asmallcross-sectionofwomenwithsexualdesiredifficulties,and

we limited the upper age to 65 in recognition of the large hetero-

geneityinthewayswomenexperience(lossof)sexualdesire(Meana,

2010). It is possible that suchan interventionwouldhaveyielded

different results in amuch larger,more representative sampleof

women with sexual desire complaints.

Thirdly, our capacity to detect associations between change in

sexual concordance and sexual functioning was limited by

examining these relationships in a clinical sample only, such that

range restriction in sexual functioning may have hampered the

detectionofanassociationthatmayhavebeenobservedifwomen

without sexual dysfunctionwere included. To that end, therewas

considerable variability in the range of concordance estimates

acrossparticipants,bothatpre-andatpost-treatment, butwith the

majorityofparticipantsshowingapositiveconcordanceestimate.

Also, in the absence of a no-treatment control group, the magni-

tude of any change in subjective or genital sexual response with

treatment cannot be established and should be the focus of future

research.

To examinewhether sexual concordance changed during two

pre-treatment assessments before treatment was administered,

genitalarousalandcontinuousself-reportedsexualarousalduring

the erotic film segment were analyzed for 25 women who

receivedtwopre-treatmentassessments.Within-subjectscorrela-

tions were calculated, then statistically compared using a depen-

dent samples t test. There was no significant difference between

the concordance estimates at the two pre-treatment assessment

points (data not shown), suggesting that the repeated assessment

1918 Arch Sex Behav (2016) 45:1907–1921

123

of concordance does not significantly impact the concordance

estimates themselves. Furthermore, this finding strengthens our

conclusion that the increases in sexual concordance observed

with treatment are not likely attributable to the passage of time.

Implications

The incentivemotivationmodel (Both, Everaerd,&Laan, 2007)

proposes that sexualdesire is triggeredbysexualarousal,whereas

previously, sexual desire and arousalwere viewed as distinct and

sequential phases of sexual response (Masters& Johnson, 1966).

According to the incentivemotivationmodel that informscurrent

DSM-5definitionsofSIAD,sexualdesireandarousalarereciprocally

reinforcing,suchthatsexualdesireemergesfromexperiencingsexual

arousal (Toates,2009).Genital responsesalonemaynot,however,

besufficient forgeneratingsexualdesire; instead, theintegration

ofphysiological andpsychological sexual response (presumably

capturedwithaconcordanceestimate)maybemorestronglyassoci-

atedwith triggered sexual desire. Likewise, conscious awareness

and positive appraisal of physiological response may be integral

totheexperienceofsexualdesire. Inthisway,sexualconcordance

as a study endpoint may be fruitful for disambiguating the long-

debated relationship between sexual arousal and desire.

Theincentivemotivationmodelfurtherproposesthatlowdesire

andarousalmaybetheresultofweakassociationsbetweenasexual

stimulusandrewardorthatitmaybeassociatedwithamorenarrow

rangeofstimulithatareconsideredrewarding(McCall&Meston,

2006,2007).Thisviewproposesthatwomenwithlowarousaland

desire are capable of a physical sexual response, but stimuli are

appraisedasneutralornegative,andthusfail totriggersexualdesire.

Anotherpossible contributor to lowarousal anddesiremaybean

inability toconsciouslyexperienceandrecognizeastateof sexual

arousal. Inthecurrentstudy,cultivationofattentiontorawsensations

improvedconcordanceandfosteredgreatermind–bodyintegration.

Thesefindingsprovidesupport for treatmentsaimedat increasing

sexual interoceptionandnon-judgementalawarenessofsexual

responding.

Overall, the present findings contribute to an emerging liter-

ature supporting the clinical application of mindfulness for the

treatment of sexual dysfunction in women (Brotto, 2013; Brotto

& Goldmeier, 2015). Given women’s frequent claims of ‘‘feel-

ingdisconnected sexually’’whenpresenting for sex therapy, our

data suggest that mindfulness may improve the integration

betweengenital and self-reported sexual arousal.Although this

study did not identify individual differences predicting treat-

ment-related improvements in sexual concordance, thewide range

inconcordanceestimates across participants suggests that future

research could identify characteristics associatedwith treatment

response. Inthelong-run,andgiventherecentapprovalofthefirst-

ever medication for the treatment of women’s sexual desire (fli-

banserin; http://www.fda.gov/NewsEvents/Newsroom/Press

Announcements/ucm458734.htm), there is anopportunity for

identifying individual patient characteristics predictive of a

positive response to treatment such that therapies (whether psy-

chological or pharmacological) can be individually tailored to

women’s needs.

Acknowledgments The authors wish to thank Yvonne Erskine for
overall coordinationof this study.Wealsowish to thankgroup facilitators

MiriamDriscoll, SheaHocaloski,GailKnudson,BrookeSeal, andMorag

Yule.OurthankstoDr.RosemaryBassonandDr.MijalLuriafordeveloping

the treatmentmanualused todeliver themindfulness intervention.Funding

for this studywasprovidedbyaBCMedicalServicesGrant toLoriBrotto.

Compliance with Ethical Standards

Conflict of interest Noneof the authors have any conflicts of interest to
disclose.

References

Adams, A. E. III, Haynes, S. N., & Brayer, M. A. (1985). Cognitive dis-

traction in female sexual arousal. Psychophysiology, 22, 689–696.

AmericanPsychiatricAssociation. (2000).Diagnosticandstatisticalmanual

ofmentaldisorders (4thed., text rev.).Washington,DC:AmericanPsy-

chiatric Publishing.

AmericanPsychiatricAssociation. (2013).Diagnosticandstatisticalmanual

of mental disorders (5th ed.). Washington, DC: Author.

Basson, R. (2001). Female sexual response: The role of drugs in themanage-

mentof sexual dysfunction.Obstetrics and Gynecology, 98, 350–353.

Bishop,S.R.,Lau,M.,Shapiro,S.,Carlson,L.,Anderson,N.D.,&Carmody,

J. (2004). Mindfulness: A proposed operational definition. Clinical

Psychology:ScienceandPractice,11,230–241.doi:10.1093/clipsy/

bph077.

Both,S.,Everaerd,W.,&Laan,E. (2007).Desire emerges fromexcitement:

Apsychophysiologicalperspectiveonsexualmotivation. InE. Janssen

(Ed.),The psychophysiologyof sex (pp.327–339).Bloomington, IN:

Indiana University Press.

Boyer,S.C.,Pukall,C.F.,&Chamberlain,S.M.(2013).Sexualarousalinwomen

withprovokedvestibulodynia:Theapplicationof laserDoppler imaging

to sexual pain. Journal of Sexual Medicine, 10, 1052–1064.

Brody,S. (2007). Intercourseorgasmconsistency, concordanceofwomen’s

genital and subjective sexual arousal, and erotic stimulus presenta-

tion sequence. Journal of Sex and Marital Therapy, 33, 31–39. doi:

10.1080/00926230600998458.

Brody,S.,Laan,E.,&vanLunsen,R.H.W.(2003).Concordancebetween

women’s physiological and subjective sexual arousal is associated

with consistency of orgasm during intercourse but not other sexual

behavior. Journal of Sex and Marital Therapy, 29, 15–23. doi:10.

1080/00926230390154808.

Brotto, L.A. (2013).Mindful sex.Canadian Journal of Human Sexuality,

22, 63–68. doi:10.3138/cjhs.2013.2132.

Brotto, L. A.,&Basson, R. (2014). Groupmindfulness-based therapy signif-

icantly improves sexual desire in women. Behaviour Research and

Therapy, 57, 43–54.

Brotto,L.A.,Basson,R.,&Luria,M. (2008a).Amindfulness-basedgroup

psychoeducational intervention targeting sexual arousal disorder in

women.JournalofSexualMedicine,5,1646–1659.doi:10.1111/j.1743-

6109.2008.00850.x.

Brotto, L. A., Basson, R., & Luria, M. (2008b). Group psychoeducation

(PED) for women’s sexual desire and arousal difficulties. Unpub-

lishedtreatmentmanual.Vancouver:UniversityofBritishColumbia.

Brotto,L.A.,Erskine,Y.,Carey,M.,Ehlen,T.,Finalyson,S.,Heywood,M.,

…Miller,D. (2012a).Abriefmindfulness-basedcognitivebehavioral
intervention improves sexual functioning versus wait-list control in

Arch Sex Behav (2016) 45:1907–1921 1919

123

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm458734.htm

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm458734.htm

http://dx.doi.org/10.1093/clipsy/bph077

http://dx.doi.org/10.1093/clipsy/bph077

http://dx.doi.org/10.1080/00926230600998458

http://dx.doi.org/10.1080/00926230390154808

http://dx.doi.org/10.1080/00926230390154808

http://dx.doi.org/10.3138/cjhs.2013.2132

http://dx.doi.org/10.1111/j.1743-6109.2008.00850.x

http://dx.doi.org/10.1111/j.1743-6109.2008.00850.x

women treated for gynecologic cancer. Gynecologic Oncology, 125,

320–325. doi:10.1016/j.ygyno.2012.01.035.

Brotto,L.A.,&Goldmeier,D. (2015).Mindfulness interventions for treating

sexualdysfunctions:Thegentlescienceoffindingfocusinamulti-task

world. Journal of Sexual Medicine, 12, 1687–1689.

Brotto,L.A.,&Heiman,J.R.(2007).Mindfulnessinsextherapy:Applications

for women with sexual difficulties following gynecologic cancer.

Sexual and Relationship Therapy, 22, 3–11.

Brotto,L.A.,Heiman, J.R.,Goff,B.,Greer,B.,Lentz,G.M., Swisher,E.,

…VanBlaricom,A. (2008c). A psychoeducational intervention for
sexual dysfunction in women with gynecologic cancer. Archives of

Sexual Behavior, 37, 317–329. doi:10.1007/s10508-007-9196-x.

Brotto,L.A.,Seal,B.N.,&Rellini,A.(2012b).Pilotstudyofabriefcognitive

behavioral versus mindfulness-based intervention for women with

sexual distress and a history of childhood sexual abuse. Journal of

SexandMaritalTherapy,38, 1–27.doi:10.1080/0092623X.2011.56

9636.

Carmody,J.,&Baer,R.A.(2008).Relationshipsbetweenmindfulnesspractice

and levelsofmindfulness,medical andpsychological symptomsand

well-beinginamindfulness-basedstressreductionprogram.Journal

ofBehavioralMedicine,31, 23–33.doi:10.1007/s10865-007-9130-7.

Chivers,M.L.,&Bailey,J.M.(2005).Asexdifferenceinfeatures thatelicit

genital response.Biological Psychology,70, 115–120.doi:10.1016/j.

biopsycho.2004.12.002.

Chivers,M.L.,Rieger,G.,Latty,E.,&Bailey, J.M. (2004).Asexdifference

in thespecificityofsexualarousal.PsychologicalScience,15,736–744.

doi:10.1111/j.0956-7976.2004.00750.x.

Chivers,M.L.,&Rosen,R.C.(2010).Phosphodiesterasetype5inhibitorsand

female sexual response: Faulty protocols or paradigms? Journal of

SexualMedicine,7,858–872.doi:10.1111/j.1743-6109.2009.01599.x.

Chivers,M.L.,Seto,M.C.,Lalumière,M.L.,Laan,E.,&Grimbos,T.(2010).

Agreementof self-reportedandgenitalmeasuresof sexualarousal in

men andwomen:Ameta-analysis.Archives of Sexual Behavior, 39,

5–56. doi:10.1007/s10508-009-9556-9.

Clayton,A.H.,Segraves,R.T.,Leiblum,S.,Basson,R.,Pyke,R.,Cotton,D.,&

Wunderlich,G.R.(2006).Reliabilityandvalidityof theSexualInterest

andDesire Inventory-Female (SIDI-F), a scale designed tomeasure

severityoffemalehypoactivedesiredisorder.JournalofSexandMarital

Therapy, 32, 115–135. doi:10.1080/00926230500442300.

Clifton,J.,Seehuus,M.,&Rellini,A.H.(2015).Testingcognitivepredictors

of individual differences in the sexual psychophysiological responses

of sexually functional women. Psychophysiology, 52, 957–968.

Craig, A. D. (2002). How do you feel? Interoception: The sense of the physi-

ological conditionof thebody.NatureReviewsNeuroscience,3, 655–

666.

Critchley,H.D.,Wiens,S.,Rotshtein,P., Öhman,A.,&Dolan,R.J. (2004).

Neural systems supporting interoceptive awareness. Nature Neuro-

science, 7, 189–195. doi:10.1038/nn1176.

Davis,S.R.(2013).Androgentherapyinwomen,beyondlibido.Climacteric,

16(Suppl. 1), 18–24. doi:10.3109/13697137.2013.801736.

Davis, S. R.,&Braunstein,G.D. (2012). Efficacy and safety of testosterone

inthemanagementofhypoactivesexualdesiredisorderinpostmenopausal

women. Journal of Sexual Medicine, 9, 1134–1148. doi:10.1111/j.

1743-6109.2011.02634.x.

DeRogatis,L.R.,Rosen,R.,Leiblum,S.,Burnett,A.,&Heiman, J. (2002).

TheFemaleSexualDistressScale(FSDS):Initialvalidationofastandard-

ized scale for assessmentof sexually relatedpersonal distress inwomen.

Journal of Sex and Marital Therapy, 28, 317–330. doi:10.1080/009

26230290001448.

Diamond,L.E.,Earle,D.C.,Heiman,J.R.,Rosen,R.C.,Perelman,M.A.,

&Harning, R. (2006). An effect on the subjective sexual response in

premenopausal women with sexual arousal disorder by bremelan-

otide (PT-141), a melanocortin receptor agonist. Journal of Sexual

Medicine, 3, 628–638. doi:10.1111/j.1743-6109.2006.00268.x.

Gottman, J., & Silver, N. (1999). The seven principles for making marriage

work:Apracticalguidefromthecountry’sforemostrelationshipexpert.

NewYork: Three Rivers Press.

Grossman,P.,Niemann,L.,Schmidt,S.,&Walach,H.(2004).Mindfulness-

based stress reduction and health benefits:Ameta-analysis. Journal of

Psychosomatic Research, 57, 35–43.

Heiman, J. R.,&Rowland,D. L. (1983).Affective and physiological sexual

responsepatterns:Theeffectsof instructionsonsexually functionaland

dysfunctional men. Journal of Psychosomatic Research, 27, 105–116.

Hölzel, B.K., Carmody, J., Evans,K. C., Hoge, E.A., Dusek, J. A.,Morgan,

L.,&Lazar, S.W. (2010). Stress reduction correlateswith structural

changes in theamygdala.SocialCognitiveandAffectiveNeuroscience,

5, 11–17. doi:10.1093/scan/nsp034.

Krusche,A.,Cyhlarova,E.,&Williams,J.M.G.(2013).Mindfulnessonline:

An evaluation of the feasibility of a web-based mindfulness course

for stress, anxiety and depression. British Medical Journal Open, 3,

e003498. doi:10.1136/bmjopen-2013-003498.

Kukkonen,T.M.,Binik,Y.M.,Amsel,R.,&Carrier,S. (2010).Anevaluation

of the validity of thermography as a physiologicalmeasure of sexual

arousal inanon-universityadult sample.ArchivesofSexualBehavior,

39, 861–873.

Laan,E.,Everaerd,W.,vanBellen,G.,&Hanewald,G.(1994).Women’ssexual

and emotional responses to male- and female-produced erotica.

ArchivesofSexualBehavior,23,153–169.doi:10.1007/BF01542096.

Laan, E., van Driel, E. M., & van Lunsen, R. H. W. (2008). Genital

responsiveness in healthy women with and without sexual arousal

disorder.Journal of Sexual Medicine,5, 1424–1435.doi:10.1111/j.

1743-6109.2008.00827.x.

Masters,W.H.,&Johnson,V.E. (1966).Humansexualresponse.Boston:

Little, Brown & Co.

Masters,W.H.,&Johnson,V.E. (1970).Humansexual inadequacy.Boston:

Little, Brown.

McCabe,M.P. (2001).Evaluationofacognitivebehaviour therapyprogram

forpeoplewithsexualdysfunction.JournalofSexandMaritalTherapy,

27, 259–271.

McCall,K.,&Meston,C.(2006).Cuesresultingindesireforsexualactivity

in women. Journal of Sexual Medicine, 3, 838–852. doi:10.1111/j.

1743-6109.2006.00301.x.

McCall, K., &Meston, C. (2007). Differences between pre- and post-

menopausal women in cues for sexual desire. Journal of Sexual

Medicine, 4, 364–371. doi:10.1111/j.1743-6109.2006.00421.x.

Meana, M. (2010). Elucidating women’s (hetero) sexual desire: Defini-

tional challenges and content expansion. Journal of Sex Research,

47, 104–122. doi:10.1080/00224490903402546.

Mercer, C. H., Fenton, K. A., Johnson, A. M., Wellings, K., Macdowall,

W.,McManus,S.,…Erens,B.(2003).Sexualfunctionproblemsand
help seekingbehaviour inBritain:National probability sample survey.

BritishMedicalJournal,327,426–427.doi:10.1136/bmj.327.7412.426.

Merkes, M. (2010). Mindfulness-based stress reduction for people with

chronicdiseases.Australian Journal of Primary Health, 16, 200–210.

Meston, C.M. (2006). The effects of state and trait self-focused attention

on sexual arousal in sexually functional and dysfunctional women.

Behaviour Research and Therapy, 44, 515–532.

Meston,C.M.,Rellini,A.H.,&McCall,K.(2010).Thesensitivityofcontinuous

laboratory measures of physiological and subjective sexual arousal

fordiagnosingwomenwithsexual arousaldisorder.Journal of Sexual

Medicine, 7, 938–950. doi:10.1111/j.1743-6109.2009.01548.x.

Meston,C.M.,Rellini,A.H.,&Telch,M. J. (2008). Short- and long-term

effects of Ginkgo Biloba extract on sexual dysfunction in women.

Archives of Sexual Behavior, 37, 530–547.

Mitchell,K.R.,Mercer,C.H., Ploubidis,G.B., Jones,K.G.,Datta, J., Field,

N.,&Wellings,K. (2013).Sexual function inBritain:Findingsfromthe

ThirdNational SurveyofSexualAttitudes andLifestyles (Natsal-3).

Lancet, 382, 1817–1829. doi:10.1016/S0140-6736(13)62366-1.

1920 Arch Sex Behav (2016) 45:1907–1921

123

http://dx.doi.org/10.1016/j.ygyno.2012.01.035

http://dx.doi.org/10.1007/s10508-007-9196-x

http://dx.doi.org/10.1080/0092623X.2011.569636

http://dx.doi.org/10.1080/0092623X.2011.569636

http://dx.doi.org/10.1007/s10865-007-9130-7

http://dx.doi.org/10.1016/j.biopsycho.2004.12.002

http://dx.doi.org/10.1016/j.biopsycho.2004.12.002

http://dx.doi.org/10.1111/j.0956-7976.2004.00750.x

http://dx.doi.org/10.1111/j.1743-6109.2009.01599.x

http://dx.doi.org/10.1007/s10508-009-9556-9

http://dx.doi.org/10.1080/00926230500442300

http://dx.doi.org/10.1038/nn1176

http://dx.doi.org/10.3109/13697137.2013.801736

http://dx.doi.org/10.1111/j.1743-6109.2011.02634.x

http://dx.doi.org/10.1111/j.1743-6109.2011.02634.x

http://dx.doi.org/10.1080/00926230290001448

http://dx.doi.org/10.1080/00926230290001448

http://dx.doi.org/10.1111/j.1743-6109.2006.00268.x

http://dx.doi.org/10.1093/scan/nsp034

http://dx.doi.org/10.1136/bmjopen-2013-003498

http://dx.doi.org/10.1007/BF01542096

http://dx.doi.org/10.1111/j.1743-6109.2008.00827.x

http://dx.doi.org/10.1111/j.1743-6109.2008.00827.x

http://dx.doi.org/10.1111/j.1743-6109.2006.00301.x

http://dx.doi.org/10.1111/j.1743-6109.2006.00301.x

http://dx.doi.org/10.1111/j.1743-6109.2006.00421.x

http://dx.doi.org/10.1080/00224490903402546

http://dx.doi.org/10.1136/bmj.327.7412.426

http://dx.doi.org/10.1111/j.1743-6109.2009.01548.x

http://dx.doi.org/10.1016/S0140-6736(13)62366-1

Nezlek, J.B. (2001).Multilevel randomcoefficient analysesof event- and

interval-contingent data in social andpersonality psychology research.

Personality and Social Psychology Bulletin, 27, 771–785. doi:10.

1177/0146167201277001.

Nobre, P., & Pinto-Gouveia, J. (2006). Emotions during sexual activity:

Differences between sexually functional and dysfunctionalmen and

women. Archives of Sexual Behavior, 35, 491–499. doi:10.1007/

s10508-006-9047-1.

Raudenbush,S.W.,Bryk,A.S.,&Congdon,R. (2004).HLM6forwindows.

Lincolnwood, IL: Scientific Software International Inc.

Rellini,A.H.,McCall,K.M.,Randall, P.K.,&Meston,C.M. (2005).The

relationship between women’s subjective and physiological sexual

arousal.Psychophysiology,42,116–124.doi:10.1111/j.1469-8986.2005.

00259.x.

Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R.,

&D’Agostino,R.J. (2000).TheFemaleSexualFunctionIndex(FSFI):

Amultidimensionalself-report instrumentfor theassessmentoffemale

sexual function. Journal of Sex and Marital Therapy, 26, 191–208.

doi:10.1080/009262300278597.

Sand,M.,&Fisher,W.A.(2007).Women’sendorsementofmodelsoffemale

sexualresponse:TheNurses’SexualityStudy.JournalofSexualMedicine,

4, 708–719. doi:10.1111/j.1743-6109.2007.00496.x.

Schermelleh-Engel,K.,Moosbrugger,H.,&Müller,H. (2003).Evaluating

thefitofstructuralequationmodels:Testsofsignificanceanddescriptive

goodness-of-fitmeasures.Methods of Psychological Research Online,

8, 23–74.

Shifren,J.L.,Monz,B.U.,Russo,P.A.,Segreti,A.,&Johannes,C.B.(2008).

Sexual problems and distress in United States women: Prevalence

andcorrelates.Obstetrics andGynecology,112, 970–978.doi:10.1097/

AOG.0b013e3181898cdb.

Silverstein,R.G.,Brown,A.H.,Roth,H.D.,&Britton,W.B.(2011).Effects

ofmindfulnesstrainingonbodyawarenesstosexualstimuli: Implications

for female sexual dysfunction. Psychosomatic Medicine, 73, 817–

825. doi:10.1097/PSY.0b013e318234e628.

Sintchak, G., & Geer, J. H. (1975). A vaginal plethysmograph system.

Psychophysiology, 12, 113–115. doi:10.1111/j.1469-8986.1975.tb0

3074.x.

Teasdale, J.D.,Moore,R.G.,Hayhurst,H.,Pope,M.,Williams,S.,&Segal,

Z. V. (2002). Metacognitive awareness and prevention of relapse in

depression: Empirical evidence. Journal of Consulting and Clinical

Psychology, 70, 275–287. doi:10.1037//0022-006X.70.2.275.

Teasdale,J.D.,Segal,Z.V.,Williams,J.M.G.,Ridgeway,V.A.,Soulsby,

J.M.,&Lau,M.A.(2000).Preventionofrelapse/recurrenceinmajor

depression bymindfulness-based cognitive therapy. Journal of Consult-

ing and Clinical Psychology, 68, 615–623. doi:10.1037//0022-006X.68.

4.615.

Teper,R.,Segal,Z.V.,&Inzlicht,M.(2013). Inside themindfulmind:How

mindfulness enhances emotion regulation through improvements in

executive control.Current Directions in Psychological Science, 22,

449–454. doi:10.1177/0963721413495869.

Toates,F. (2009).An integrative theoretical framework forunderstanding

sexual motivation, arousal, and behavior. Journal of Sex Research,

46, 168–193. doi:10.1080/00224490902747768.

Trudel,G.,Marchand,A.,Ravart,M.,Aubin,S.,Turgeon,L.,&Fortier,P.

(2001). The effect of a cognitive-behavioral group treatment program

on hypoactive sexual desire in women. Sexual and Relationship

Therapy, 16, 145–164. doi:10.1080/14681990120040078.

Weiner,L.,&Avery-Clark,C. (2014).Sensate focus:Clarifying theMasters

and Johnson’smodel. Sexual and Relationship Therapy, 29, 307–319.

doi:10.1080/14681994.2014.892920.

Arch Sex Behav (2016) 45:1907–1921 1921

123

http://dx.doi.org/10.1177/0146167201277001

http://dx.doi.org/10.1177/0146167201277001

http://dx.doi.org/10.1007/s10508-006-9047-1

http://dx.doi.org/10.1007/s10508-006-9047-1

http://dx.doi.org/10.1111/j.1469-8986.2005.00259.x

http://dx.doi.org/10.1111/j.1469-8986.2005.00259.x

http://dx.doi.org/10.1080/009262300278597

http://dx.doi.org/10.1111/j.1743-6109.2007.00496.x

http://dx.doi.org/10.1097/AOG.0b013e3181898cdb

http://dx.doi.org/10.1097/AOG.0b013e3181898cdb

http://dx.doi.org/10.1097/PSY.0b013e318234e628

http://dx.doi.org/10.1111/j.1469-8986.1975.tb03074.x

http://dx.doi.org/10.1111/j.1469-8986.1975.tb03074.x

http://dx.doi.org/10.1037//0022-006X.70.2.275

http://dx.doi.org/10.1037//0022-006X.68.4.615

http://dx.doi.org/10.1037//0022-006X.68.4.615

http://dx.doi.org/10.1177/0963721413495869

http://dx.doi.org/10.1080/00224490902747768

http://dx.doi.org/10.1080/14681990120040078

http://dx.doi.org/10.1080/14681994.2014.892920

Archives of Sexual Behavior is a copyright of Springer, 2016. All Rights Reserved.

  • Mindfulness-Based Sex Therapy Improves Genital-Subjective Arousal Concordance in Women With Sexual Desire/Arousal Difficulties
  • Abstract
    Introduction
    Method
    Participants
    Measures
    Assessment of Psychophysiological Sexual Arousal
    Contemporaneous Assessment of Subjective Sexual Arousal
    Discrete Measure of Sexual Response and Affect
    Homework Compliance
    Female Sexual Arousal Disorder symptoms
    Procedure
    Mindfulness-Based Sex Therapy
    Contents
    Data Analyses
    Hypothesis 1
    Hypothesis 2
    Hypothesis 3

    Results
    Concordance Between Genital and Continuous Subjective Sexual Arousal (Hypothesis 1)
    Subjective Arousal Predicting Genital Arousal
    Genital Arousal Predicting Subjective Arousal
    Moderation of the Association Between Genital and Continuous Subjective Arousal
    Effects of Erotic Film and Treatment on Self-Reported Sexual Arousal and Affect (Hypothesis 2)
    Effects of Erotic Film and Treatment on Genital Sexual Arousal (Hypothesis 2)
    Association Between Sexual Concordance and Clinical Symptoms Using the Sexual Interest/Desire Inventory and the Female Sexual Distress Scale (Hypothesis 3)
    Discussion
    Sexual Concordance as a Potential Study Endpoint?
    Mechanisms of Action
    Limitations
    Implications
    Acknowledgments
    References

Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=whum20

Journal of Human Behavior in the Social Environment

ISSN: 1091-1359 (Print) 1540-3556 (Online) Journal homepage: https://www.tandfonline.com/loi/whum20

A literature review of forgiveness as a beneficial
intervention to increase relationship satisfaction
in couples therapy

Ross A. Aalgaard, Rebecca M. Bolen & William R. Nugent

To cite this article: Ross A. Aalgaard, Rebecca M. Bolen & William R. Nugent (2016) A
literature review of forgiveness as a beneficial intervention to increase relationship satisfaction
in couples therapy, Journal of Human Behavior in the Social Environment, 26:1, 46-55, DOI:
10.1080/10911359.2015.1059166

To link to this article: https://doi.org/10.1080/10911359.2015.1059166

Published online: 25 Jul 2015.

Submit your article to this journal

Article views: 1152

View related articles

View Crossmark data

Citing articles: 7 View citing articles

https://www.tandfonline.com/action/journalInformation?journalCode=whum20

https://www.tandfonline.com/loi/whum20

https://www.tandfonline.com/action/showCitFormats?doi=10.1080/10911359.2015.1059166

https://doi.org/10.1080/10911359.2015.1059166

https://www.tandfonline.com/action/authorSubmission?journalCode=whum20&show=instructions

https://www.tandfonline.com/action/authorSubmission?journalCode=whum20&show=instructions

https://www.tandfonline.com/doi/mlt/10.1080/10911359.2015.1059166

https://www.tandfonline.com/doi/mlt/10.1080/10911359.2015.1059166

http://crossmark.crossref.org/dialog/?doi=10.1080/10911359.2015.1059166&domain=pdf&date_stamp=2015-07-25

http://crossmark.crossref.org/dialog/?doi=10.1080/10911359.2015.1059166&domain=pdf&date_stamp=2015-07-25

https://www.tandfonline.com/doi/citedby/10.1080/10911359.2015.1059166#tabModule

https://www.tandfonline.com/doi/citedby/10.1080/10911359.2015.1059166#tabModule

A literature review of forgiveness as a beneficial intervention to
increase relationship satisfaction in couples therapy
Ross A. Aalgaard, Rebecca M. Bolen, and William R. Nugent

College of Social Work, University of Tennessee, Knoxville, Tennessee, USA

ABSTRACT
Forgiveness between couples is identified as a strong predictor of relation-
ship satisfaction. Yet forgiveness is often overlooked as a potential inter-
vention to help couples increase their relational satisfaction. The purpose of
this literature review is to examine the use of forgiveness as a therapeutic
intervention to increase relational satisfaction for opposite- and same-sex
couple dyads. Forgiveness is also introduced as an effective component of
marital interventions in the context of infidelity. Specific areas that are
addressed within this article include forgiving personalities, which benefits
stress and health, forgiveness affecting marital and family functioning,
forgiveness and relationship satisfaction with mediating mechanisms, and
limitations of forgiveness interventions.

  • Recommendations
  • for practice are
    offered.

    KEYWORDS
    Couples therapy;
    forgiveness; marital conflict;
    marriage; relationship
    satisfaction

    Exploring relationships that are compromised by interpersonal conflicts and transgressions offers
    opportunities to examine forgiveness as an effective therapeutic component for enhancing relational
    satisfaction. Paleari, Regalia, and Fincham (2009) described three pathways in which people offer
    forgiveness to others. Offense-specific forgiveness is a particular forgiving act for a precise offense
    within a defined interpersonal framework. Dyadic forgiveness is the inclination to forgive one’s
    partner for numerous offenses. Trait forgiveness relates to the comprehensive disposition of a person
    who has the tendency to forgive individuals for offenses across multiple circumstances, including
    interpersonal situations that involve a variety of relationships. Despite the pathway that forgiveness
    is derived, Maio, Thomas, Fincham, and Carnelley (2008) note the process of forgiveness encom-
    passes consciously moving away “from negative thoughts, feelings, and behaviors toward the
    transgressor to more positive thoughts, feelings, and behaviors” (p. 307).

    Considering the different contexts in which forgiveness occurs, Gordon, Burton, and Porter
    (2004) explored whether the concept of forgiveness among women experiencing domestic violence
    is truly forgiveness or a conscious rationalization to help them move on. Their results showed that
    “The less women interpreted their partner’s behavior as malicious and intentional, the more likely
    they were willing to forgive the behavior and consider continuing the relationship” (p. 336). Since
    forgiveness should never be used to excuse endangering or harmful behaviour, clinicians may
    identify times within couples’ therapy to explore clients’ interpretations of their partners’ behavior
    and address enabling responses (e.g., forgiveness) to help maintain their safety.

    If forgiveness however can offer longevity, health, and healing within relationships, then adding
    this component to assist couples with enhancing their relationship satisfaction and maintaining their
    marriage is worthy for consideration. The purpose of this literature review is to examine current
    evidence related to the effectiveness of forgiveness as a therapeutic intervention to increase relational
    satisfaction for opposite- and same-sex couple dyads. Additionally, forgiveness is introduced as a

    CONTACT Ross A. Aalgaard ross.aalgaard@mnsu.edu Minnesota State University, Mankato, TN358 Trafton Science Center
    North, Mankato, MN 56001-6055, USA.
    © 2015 Taylor & Francis

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT
    2016, VOL. 26, NO. 1, 46–55
    http://dx.doi.org/10.1080/10911359.2015.1059166

    component of marital interventions in the context of infidelity, which supports the concept of
    forgiveness as a cornerstone of relationship success (Baucom, Gordon, Snyder, Atkins, &
    Christensen, 2006). This literature review does not address forgiveness within relational contexts
    that involve threatening behavior or domestic violence.

  • Method
  • A database search for peer-reviewed articles was conducted using PsycARTICLES, PsycINFO, Social
    Service

  • Abstract
  • s, Sociological Abstracts, ERIC, and Campbell Collaboration. Keywords used for the
    search included couple*, therapy OR counseling OR intervention, forgiveness, and satisfaction. The
    search was limited to articles from 2001 to 2013. A distinction was made between forgiveness as a
    religious concept and as a therapy intervention. Titles and abstracts were reviewed for forgiveness
    and relational/relationship/marital satisfaction. The three terms for the types of satisfaction were
    considered interchangeable in this search. Articles that did not identify one of the three types of
    satisfaction were excluded. The articles found were than reviewed to ensure that relational satisfac-
    tion was an outcome and forgiveness as an intervention was discussed. After applying inclusion and
    exclusion criteria four papers qualified for review.

  • Literature review
  • Forgiveness, relationship quality, stress, imagination, and physical and mental health

    Berry and Worthington (2001) studied 19 undergraduate men and 20 undergraduate women ranging
    in age from 18 to 42 years old (M = 22.9) who were attending a mid-Atlantic urban state university.
    The sexual orientation of the participants was not identified. Students were initially recruited
    through posted announcements on campus and information shared in class to let potential partici-
    pants self-select themselves for consideration. Without knowing the nature of the study or the
    inclusion criteria for involvement, potential participants were asked to fill out a screening form that
    included questions regarding demographics, information about current or recent romantic relation-
    ships, and a measurement to detect happiness. To qualify for the study, potential participants had to
    endorse that they had been in a relationship for at least 6 months and provide responses to questions
    related to their romantic relationships. If someone’s relationship had ended, he or she could still
    qualify provided his or her relationship had lasted at least 6 months and ended no more than 3
    months prior to the study. To assess the health impact, participants also had to agree to have their
    cortisol levels tested and blood samples drawn. Researchers later decided to abandon the blood
    samples and refocus the study on the detection of relationship stress through salivary cortisol
    because of time constraints.

    A nurse collected baseline saliva cortisol samples by having participants chew a cotton swab from
    a salivette kit for one minute. The samples of saliva on the swabs were then stored in a freezer.
    Participants next engaged in an imagery activity that involved imagining a typical scene that was
    common to their relationship they had with their partners. They were instructed to consider as many
    details as possible and to reexperience the feelings that emerged as strongly as possible for 5 minutes.
    The time between baseline saliva samplings and postimagery samples varied from 5 to 40 minutes
    (Berry & Worthington, 2001).

    Participants also completed several standardized tools to fulfill the study. The Trait Anger Scale
    (Spielberger, Jacobs, Russell, & Crane, 1983) was administered to measure anger as a personality
    disposition of participants. The Transgression Narrative Test of Forgiveness (α = .82), (Berry,
    Worthington, Parrott, O’Connor, & Wade, 2001) was used to assess the ability to forgive transgres-
    sions across situations and over time. The Trait Unforgiveness-Forgiveness Scale (α = .89) (Berry &
    Worthington, 2001) was given to assess the disposition to forgive of participants. The Dyadic
    Adjustment Scale (α = .98) (Spanier, 1976) was used to measure relationship adjustment. The Love

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 47

    Scale (α = .96) and Liking Scale (α = .98) (Rubin, 1970) were utilized to measure the participants’
    current attitudes about the relationship partner. The Relationship Imagery Questionnaire (α = .83)
    from the Vividness of Visual Imagery Questionnaire (Marks, 1973) captured how vividly respondents
    imagined their relationship interactions.

    The study by Berry and Worthington (2001) confirmed that trait anger and dispositional
    forgiveness personality predicted the quality of close relationships and impacted a person’s mental
    and physical health. Subjects who were asked to imagine past transgressions by a partner that had
    not been forgiven increased cortisol levels, which supports a stress-related response. The hypothesis
    that an intimate relationship of poor quality is associated with physiological stress was supported,
    because higher cortisol reactivity was associated with poorer quality of relationship. The research
    results further supported that individuals who had more dispositional forgiveness had a higher
    quality of romantic relationship.

    Researchers have concluded that the personality traits of being forgiving or unforgiving predicted
    both physical and mental health (Berry & Worthington, 2001; Thoresen, Harris, & Luskin, 2000;
    Williams, 1989). Although forgiving personality and loving relationship did not predict cortisol
    reactivity, Berry and Worthington (2001) stated, “Statistically, the results could suggest that a loving
    relationship affects cortisol reactivity indirectly through affecting a forgiving personality” (p. 452).
    The explanation given for this was that personalities predate relationships. The study provided
    support linking one’s better health outcomes with better quality of close relationships and with more
    forgiving personality traits. The reverse was not supported, because those with chronic relationship
    stress did not have poorer health outcomes.

    Berry and Worthington (2001) identified three limitations of this study: the assumption that a
    brief imagery task can produce the same stress response as an ongoing relationship, the varied time
    intervals for collecting the cortisol samples, and the small participant sample size. Although the
    researchers made adjustments for the varied time intervals when determining the cortisol reactivity
    results, a standardized approach would have made this a stronger study. In addition, the use of a
    convenience sample does not allow for generalization of conclusions beyond the study.

    Potential costs to forgiveness

    McNulty (2008) investigated the effects of heterosexual spouses’ tendencies to forgive their partners
    in a longitudinal study of 72 couples over a 2-year period. The newlywed couples who participated
    had been married an average of 3.2 months. McNulty hypothesized that forgiveness could have long-
    term costs. The research found forgiveness having long-term costs when moderated by the role of
    negativity and the context in which the forgiveness occurred, including the frequency of the spouse’s
    offenses. He also hypothesized that greater forgiveness among couples would be related to more
    stable marital outcomes and satisfaction in marriages where negative verbal behavior is reduced.

    Couples were mailed a questionnaire packet with a letter asking each partner to complete them
    independently. The completed surveys were taken to a laboratory meeting where couples partici-
    pated in two 10-minute videotaped discussions designed to assess the frequency of negative verbal
    behavior. One was a private taping of each spouse identifying what she or he considered the source
    of tension in the marriage. The other recording was of the couple together working out a resolution
    or agreement about the previously acknowledged cause of tension. Each videotaped discussion was
    coded for observed behaviors by trained raters. Following the initial evaluation, couples continued to
    complete questionnaires every 6 months over 2 years to assess marital satisfaction and problems
    (McNulty, 2008).

    Couples completed the following inventories regarding marital satisfaction and marital problems
    (McNulty, 2008). Assessment of marital satisfaction was conducted using the Quality Marriage Index
    (Norton, 1983). The internal consistency ranged from .93 to .96 for husbands and .94 to .95 for wives
    over the four phases. Marital forgiveness was measured using Transgression Narrative Test of
    Forgiveness (α = .89 for husbands and α = .86 for wives) (Berry et al., 2001). The spouses’ negative

    48 R. A. AALGAARD ET AL.

    verbal behaviors were measured using the Verbal Aggression Subscale of Form N of the Conflict
    Tactics Survey (CTS) (α =.84 for husbands and α = .84 for wives) (Straus, 1979). Trained observers
    used the Verbal Tactics Coding Scheme (Sillars, Coletti, Parry, & Rogers, 1982), which is defined to
    have adequate reliability, for the recorded videos.

    McNulty (2008) found that spouses who reported being more forgiving were happier in their
    relationships, had less severe problems, and behaved less negatively. Over time however, wives
    became significantly less satisfied in their marriages. Results showed that wives perceived relation-
    ship problems as more severe while husbands viewed relationship problems as having no significant
    change. Within this study, gender influenced relationship satisfaction.

    McNulty’s (2008) study results further revealed that increased forgiveness by spouses for partners
    who engaged in reduced negative behavior was beneficial over time but less forgiveness was harmful
    to the relationship. For spouses married to partners who often enacted negative behavior without
    reduction, increased forgiveness became harmful to the relationship, and the quality of the relation-
    ship deteriorated over time. Conversely, decreased forgiveness for those who frequently enacted
    negative behavior was beneficial over time. Finally, relatively healthy marriages experienced more
    positive benefits than troubled relationships from the effects of forgiveness.

    McNulty (2008) suggested that an intervention that includes forgiveness might help bring
    relationship stability over time for benevolent partners. However, these findings question whether
    forgiveness interventions in high-conflict marriages will have positive outcomes, especially in light of
    the potential for forgiveness to cause a decline in marital satisfaction over time.

    Although researchers used a longitudinal design, the study was limited by the use of a conve-
    nience sample (McNulty, 2008). Still, these research results provide some evidence for adding
    forgiveness interventions as a component to couples therapy. Future research should investigate
    the effects of incorporating forgiveness interventions with same same-sex couples.

    Forgiveness in marital and family functioning

    Gordon, Hughes, Tomcik, Dixon, and Litzinger (2009) examined the role of forgiveness in marital
    and family functioning by utilizing a cross-sectional study that was conducted as part of a larger,
    longitudinal study on relational family functioning. Emphasis was placed on “devastating relational
    conflicts” such as “infidelities, major lies, drastic unilateral financial decisions, and other similar
    humiliations and betrayals,” which often have long-term negative effects on marital functioning (p.
    1). Forgiveness was conceptualized as two constructs—negative forgiveness and positive forgiveness.
    Negative forgiveness was defined by grudges, withdrawal or avoidance, and the desire for revenge or
    punishment toward the betraying partner. Positive forgiveness was delineated as the readiness to
    forgive, increased empathy, greater dyadic trust, and release of anger. Both negative and positive
    forgiveness were examined for the impact they have on couples’ relationships and how they affect
    elements of both dyadic and family functioning (Gordon et al., 2009).

    Gordon et al. (2009) hypothesized that couples’ self-report of relationship satisfaction would
    increase, with both more positive forgiveness and less negative forgiveness occurring within the
    relationship. Going beyond the couples’ intimate relationship, the parenting alliance was predicted to
    become stronger when more positive forgiveness occurred. Finally, it was expected that marital
    conflict would be related to more negative child functioning. Therefore, reports by the parents of
    more positive forgiveness and less negative forgiveness were anticipated to coincide with the
    children’s reports of less negative interactions and less familial threats.

    Participants were recruited from mailing lists of families in the researchers’ community and were
    contacted by phone to determine interest for involvement. To qualify for inclusion one member of
    each couple had to report a betrayal, as defined by the participants, in the relationship and that the
    couple had a child in the home from ages 11 to 16. Packets including the measurement tools, consent
    forms, and a cover letter asking for surveys to be completed independently were mailed to a group of
    111 married couples and their children. Separate envelopes were made available for husbands, wives,

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 49

    and children. Only fully completed materials that were returned qualified for the study. The final
    total sample included 91 couples and youth. Couples averaged 16 years of marriage and 2.6 children.
    Nine families were blended families. Eighty-seven wives and 74 husbands reported a betrayal
    (Gordon et al., 2009). The Forgiveness Inventory (Gordon & Baucom, 2003) was used to measure
    both positive and negative forgiveness. The alpha coefficient on the negative forgiveness subscale was
    .91 for women and .87 for men. The alpha coefficient for the positive forgiveness subscale was .84 for
    women and .87 for men (Gordon et al., 2009).

    Gordon et al. (2009) found that both husbands and wives reported that greater negative forgive-
    ness predicted poorer perception of marital satisfaction. The subjects’ perception of their relation-
    ship remained the same when marital conflict and dyadic trust variables were evaluated. Husbands
    and wives that reported greater positive forgiveness predicted their own perceptions of the higher
    quality of the parenting alliance. Further, husbands’ greater positive forgiveness predicted their
    perception of greater dyadic trust, whereas the husbands and wives’ greater negative forgiveness
    predicted their reports of greater conflict behaviors and lesser dyadic trust levels. When dyadic
    conflict was controlled, both husbands’ and wives’ reports of greater negative forgiveness predicted
    their perceptions of poorer marital satisfaction, with dyadic trust and conflict behaviors partially
    mediating the relationships. These results support the possibility that failing to resolve betrayals may
    impact a couple’s relational functioning and, in turn, lower relationship satisfaction.

    Gender differences were found within this study. For wives, greater negative forgiveness predicted
    their perceptions of poorer marital satisfaction, greater trust, and greater conflict behaviors. The
    husbands’ patterns were slightly different, but only for greater dyadic trust, which was also predicted
    by greater positive forgiveness. In separate analyses, wives and husbands’ greater negative forgiveness
    predicted their children’s views of greater parental conflict but only when forgiveness dimensions
    were the only variables entered into the regression. When wives’ forgiveness was entered together
    with the husbands’ reports of marital conflict and parental alliance, only the husbands’ reports of
    greater conflict predicted the children’s perceptions of marital conflict. When the husbands’ for-
    giveness was entered together with the wives’ reports of marital conflict and parental alliance, only
    the wives’ reports of marital conflict and the parental alliance were significant. Wives’ report of
    greater conflict and a worse parental alliance were related to children’s reports of greater marital
    conflict (Gordon et al., 2009).

    In cross-spousal reports, the husbands’ greater negative forgiveness was mediated as a strong
    predictor of their wives’ reports of poorer parenting alliances, and the wives’ greater negative
    forgiveness strongly predicted their husbands’ reports of poor parenting alliances. Further, wives’
    lesser negative forgiveness predicted the husbands’ greater relational satisfaction, and husbands’
    lesser negative forgiveness predicted the wives’ greater relational satisfaction. For both wives and
    husbands, their greater negative forgiveness predicted the opposite partner’s reports of marital
    conflict (Gordon et al., 2009).

    One concern with these results is that wives’ positive and negative forgiveness were strongly
    correlated, as was the wives’ and husbands’ negative forgiveness, suggesting that multicollinearity
    might be a concern in certain analyses. Further examination however found that multicollinearity
    diagnostics did not suggest a problem (Gordon et al., 2009). Further research needs to be conducted
    to explore the role of positive forgiveness in women’s relational functioning.

    Because this study is cross-sectional (Gordon et al., 2009), findings cannot be taken to suggest
    direction of effect. A longitudinal study should be conducted to see if these findings can be replicated
    and to determine direction of effect and causality. Since no comparison group of couples with low or
    no betrayal was included, it is not clear whether these findings are specific only to couples in which
    one member committed a significant betrayal. This study was also limited geographically, and the
    data were collected from a convenience sample indicating that findings cannot be generalized. Since
    these results were based on self-report measures they need to be interpreted cautiously. Notably,
    however, previous research results does support the findings of this study and adds support to the
    importance of adding a forgiveness component as a therapeutic intervention with couples.

    50 R. A. AALGAARD ET AL.

    In summary, forgiveness of major betrayals by a spouse was significantly related to marital
    satisfaction, the parenting alliance, and to children’s perceptions of marital functioning (Gordon
    et al., 2009). In addition, gender differences may exist in areas such as conflict behaviors and
    relationship trust. These gender differences need further examination not only with heterosexuals,
    but also with same-sex couples. If these findings continue to be replicated, they will lend support for
    using forgiveness as an intervention within family therapy as well as with couples.

    Forgiveness and relationship satisfaction

    More recently, Braithwaite, Selby, and Fincham (2011) studied the mediating mechanisms of the
    pathway between trait forgiveness and relationship satisfaction. They conceptualized forgiveness as
    promoting not only a reduction in negative responses but also “increased goodwill toward the
    transgressor” (p. 551). They also considered possible mediators between trait forgiveness and
    relationship satisfaction, specifically interpersonal conflict and self-regulation. Important interperso-
    nal conflict tactics examined were positive communication, negative communication, and physical
    assault. “Altering behavior to inhibit a dominant response, usually in the service of longer term
    goals” was the definition used for self-regulation (p. 552). They believed that relationship satisfaction
    was improved by relationship efforts to reduce problematic conflict patterns.

    Braithwaite et al. (2011) completed two studies. The first study included 523 young adult
    participants who reported they were currently in a committed romantic relationship. This sample
    was part of a larger study being conducted in a university introductory family studies course. The
    second study gathered data from 446 young people who were followed for 2 months to evaluate the
    relationships among forgiveness, conflict tactics, relationship effort, and relationship satisfaction.
    The potential role of commitment was also included.

    The researchers utilized a number of measures to assess the primary constructs of the studies
    (Braithwaite et al., 2011). Within the first study, trait forgiveness (i.e., the tendency to forgive) was
    captured using a four-item scale of dispositional or trait forgiveness with an alpha of .66 (Brown,
    2003). In Study 2, the nine-item forgiveness tool had a consistent alpha of .85 over an 8-week test-
    retest period of time. The CTS-2 (Revised Conflict Tactics Scales) (Straus, Hamby, Boney-McCoy, &
    Sugarman, 1996) was used to capture how couples resolved conflict and how much an individual
    works at their relationship by regulating behavior to improve the relationship quality. The CTS-2 had
    an alpha score of .94 in Study 1 and an alpha score of .84 in Study 2. Other constructs captured were
    constructive communication patterns with the Communication Patterns Questionnaire (Heavey,
    Larson, Zumtobel, & Christensen, 1996), self-regulation with the Behavioral Self-Regulation for
    Effective Relationships Scale—Effort Scale (Wilson, Charker, Lizzio, Halford, & Kimlin, 2005),
    relationship satisfaction with the Couples Satisfaction Index (Funk & Rogge, 2007), and the desire
    to persist in spite of obstacles in a romantic relationship (Finkel, Rusbult, Kumashiro, & Hannon,
    2002). All alpha scores ranged between .80 and .94 (Braithwaite et al., 2011).

    The first study (Braithwaite et al., 2011) collected data from participants through online surveys.
    Forgiveness was not directly related to relationship satisfaction but was related to increased beha-
    vioral self-regulation and decreased negative interpersonal behaviors, which were in turn related to
    relationship satisfaction in the expected directions. Thus, these mediating relationships were sup-
    ported. Because the first study could not establish causality, the variable of commitment to the
    relationship was not included, and the relationships between forgiveness and the other variables were
    small a second study was conducted.

    For Study 2 Braithwaite et al. (2011), followed the same procedures that were conducted in the
    first study with the exception of adding a second time period 2 months after the first. The
    researchers designed and utilized a nine item, six-point scale measure on forgiveness which had a
    consistent alpha score of .85 and strengthened construct validity and increased confidence in the
    observed findings. This measure operationalized forgiveness by assessing respondents’ avoidance,
    benevolence, and retaliation, unlike the first study, which compared vengeance and neuroticism,

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 51

    dispositional forgiveness, perspective taking, and agreeableness. Stanley and Markman’s (1992) four-
    item scale to assess the desire to persist in romantic relationships despite obstacles was used to
    determine commitment. Braithwaite et al. (2011) extended the findings of the first study by revealing
    a longitudinal relationship between forgiveness with correlations of self-regulation and negative
    interpersonal tactics mediating relationship satisfaction and forgiveness. The tendency to forgive
    related to later relationship satisfaction. Limitations of the second study included the use of a
    convenience sample and not having a control group.

  • Discussion
  • This literature review examined the effectiveness of forgiveness as an intervention and the correla-
    tion between forgiveness and relationship satisfaction. Berry and Worthington (2001); Braithwaite
    et al. (2011); Gordon et al. (2009); and McNulty (2008) all concluded that forgiveness offers a way of
    dealing with a transgression and is related to a positive relational outcome. Braithwaite and
    colleagues (2011) described that “Forgiveness seems to short circuit the use of negative conflict
    strategies allowing the couple to exit from the negative reciprocity cycle that leads to distressed
    relationships” (p. 557). Relationship effort was found to strongly improve relationship satisfaction
    (Braithwaite et al., 2011). Relationship satisfaction was related to the reduction of negative inter-
    personal behaviors and an increase in the use of self-regulation. Relational effort was also related to
    increases in relationship satisfaction (Braithwaite et al., 2011). McNulty (2008) found that forgive-
    ness benefited healthy relationships rather than troubled ones.

    McNulty (2008) cautions that using forgiveness as part of an intervention is not beneficial for
    all relationships, but there is evidence that it can be positive for couples who have experienced
    minor transgressions and major betrayals between them (Braithwaite et al., 2011; Gordon et al.,
    2009). Having unresolved betrayal lingering within a relationship hinders relational satisfaction
    (Gordon et al., 2009). Therefore, when conflict occurs between couples in therapy, it may be
    wise to explore if any previous unresolved betrayals exist. If betrayal is acknowledged, therapists
    should explore forgiveness as an intervention to increase relational quality for couples because
    forgiveness appears to help couples move forward and enhance their relationships.

    On the other hand, when forgiveness is constantly given to a partner without any evidence of a
    reduction of negative behavior, it may become detrimental to the relationship (McNulty, 2008). This
    may be one reason relationship effort mediates the role of forgiveness in relationship satisfaction
    (Braithwaite et al., 2011). The effort by both partners to change can bring about positive enhance-
    ment to a relationship. However, when only one person makes such an investment, the likelihood of
    relational success is reduced (McNulty, 2008). Nonetheless, research evidence shows when an effort
    is made by one partner to reduce negative behavior and act more kindly, the other partner often
    reciprocates (Braithwaite et al., 2011).

    These examined studies further indicate that individuals with more forgiving tendencies (i.e.,
    traits) are more likely to self-regulate and set a goal of improving their relationship (Braithwaite
    et al., 2011; Berry & Worthington, 2001). In addition, they are more likely to inhibit behavior
    that would damage their relationship and more likely to abandon negative interpersonal strate-
    gies such as hitting, berating, and avoiding their partners. Braithwaite and colleagues (2011)
    suggest that trait forgiveness is primary to motivational transformation, which is defined as
    being operational in repressing negative instincts and enhancing positive action. To use forgive-
    ness as a way to increase relationship satisfaction for couples, counselors can encourage clients
    to repress negative instincts and instead behave positively toward their partner.

    Suggested interventions

    Forgiveness interventions in couples counseling are currently available, specifically in the area of
    marital infidelity (Baucom et al., 2006). For less severe transgressions, or when couples therapy is at a

    52 R. A. AALGAARD ET AL.

    stalemate, a psychoeducation component on forgiveness could be introduced (Braithwaite et al.,
    2011). This is especially relevant for correcting misconceptions about forgiveness (e.g., that forgive-
    ness is a sign of weakness or an excuse for bad behavior). Braithwaite et al. (2011) advocated for
    providing a psychoeducational approach to assist couples with forgiveness and work toward
    increased relationship satisfaction. Evidence-based research, however, still needs to determine the
    effectiveness of psychoeducation.

    Berry and Worthington (2001), Gordon et al. (2009), and Braithwaite et al. (2011) all supported
    including forgiveness as an intervention in couples counseling. Berry and Worthington (2001)
    suggested addressing stress-related health conditions due to relationship distress, as well as the
    positive effect of forgiveness on relationship quality. They suggested that counselors use modeling
    and encouragement to advance forgiveness for clients who may be inclined not to forgive. Gordon
    and colleagues (2009) pointed out that Emotionally Focused Therapy (Makinen & Johnson, 2006)
    addresses past attachment issues and includes a forgiveness component to help couples with
    current problems. Braithwaite et al. (2011) also discussed a cognitive-behavioral and insight-
    oriented marital intervention by Baucom et al. (2006) that uses forgiveness as a technique for
    couples experiencing the substantial distress of infidelity. This intervention guides couples through
    a change of understanding for the reason the infidelity occurred and creates a new meaning for the
    affair.

    Other psychotherapy methodologies have been advocated for as potential approaches for advan-
    cing forgiveness with couples in treatment. These methodologies include the aforementioned
    Emotionally-Focused Therapy (Makinen & Johnson, 2006), Bowenian Therapy, and mindfulness
    or acceptance-based approaches to therapy (Sandage & Jankowski, 2010). Carson, Carson, Gil, and
    Baucom (2004) studied a mindfulness-based relationship enhancement approach. The research
    found that relationship satisfaction increased through the use of mindfulness techniques with
    relatively happy, nondistressed couples. The participants benefited by enhancing current relationship
    functioning and improving personal well-being.

    Recommendations

    A limitation of this study is the small number of research studies reviewed. To strengthen future
    literature reviews, the search criteria need to include evidence-based forgiveness interventions and
    the date parameters of the search should be expanded. Two limitations that were identified across all
    the studies reviewed included the use of convenience samples and the lack of comparison groups.
    These methodological issues lower the level of confidence in their findings, and they do not allow for
    generalization of findings.

    Forgiveness appears to enrich close intimate relationships, personal health, and well-being (Berry
    & Worthington, 2001). Although helpful in supporting the benefits of forgiveness within relation-
    ships, this study’s search did not find any studies that tested an intervention that included forgive-
    ness as a component, nor did the search locate any forgiveness therapies that provided an increase in
    relationship satisfaction as an outcome. Thus, this research reveals that there is a gap in the literature
    regarding the value, utility, efficacy, and effectiveness of using forgiveness as an intervention with
    couples to increase relational satisfaction.

    Additionally future research needs to be conducted within clinical settings with couples utilizing
    forgiveness as a component of the intervention. The creation of new interventions that includes
    forgiveness as part of the treatment process for couples is also needed. Evidence-based practice
    theories, such as cognitive-behavioral therapy, mindfulness, or acceptance-based therapies, may be
    conducive to developing and implementing a forgiveness component to an intervention with a goal
    of facilitating increased relationship satisfaction for couples.

    Finally, researchers conducting studies on couples therapy need to include both heterosexual and
    same-sex couples within their samples. Considering marriage equality advancing in the United
    States, gay and lesbian couples need to be included as participants in the research regarding

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 53

    forgiveness and marital satisfaction. Same-sex couples were blatantly absent in the papers reviewed.
    By comparing the effects of forgiveness interventions on opposite-sex relationships, lesbian relation-
    ships, and gay relationships, counselors can become more culturally sensitive in their practice. With
    the prominent changes our society is encountering, helping couples that are beginning newly defined
    relationships is an important step forward.

  • References
  • Baucom, D. H., Gordon, K. C., Snyder, D. K., Atkins, D. C., & Christensen, A. (2006). Treating affair couples:
    Clinical considerations and initial findings. Journal of Cognitive Psychotherapy, 20(4), 375–392. doi:10.1891/
    jcpiq-v20i4a004

    Berry, J. W., & Worthington, E. L., Jr. (2001). Forgivingness, relationship quality, stress while imagining relationship
    events, and physical and mental health. Journal of Counseling Psychology, 48(4), 447–455. doi:10.1037/0022-
    0167.48.4.447

    Berry, J. W., Worthington, E. L., Parrott, L., III, O’Connor, L. E., & Wade, N. G. (2001). Dispositional forgivingness:
    Development and construct validity of the transgression narrative test of forgivingness (TNTF). Personality and
    Social Psychology Bulletin, 27(10), 1277–1290. doi:10.1177/01461672012710004

    Braithwaite, S. R., Selby, E. A., & Fincham, F. D. (2011). Forgiveness and relationship satisfaction: Mediating
    mechanisms. Journal of Family Psychology, 25(4), 551–559. doi:10.1037/a0024526

    Brown, R. P. (2003). Measuring individual differences in the tendency to forgive: Construct validity and links with
    depression. Personality and Social Psychology Bulletin, 29(6), 759–771. doi:10.1177/0146167203029006008

    Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H. (2004). Mindfulness-based relationship enhancement.
    Behavior Therapy, 35(3), 471–494. doi:10.1016/s0005-7894(04)80028-5

    Finkel, E. J., Rusbult, C. E., Kumashiro, M., & Hannon, P. A. (2002). Dealing with betrayal in close relationships: Does
    commitment promote forgiveness? Journal of Personality and Social Psychology, 82(6), 956–974. doi:10.1037/0022-
    3514.82.6.956

    Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item response theory: Increasing precision of measurement
    for relationship satisfaction with the Couples Satisfaction Index. Journal of Family Psychology, 21(4), 572–583.
    doi:10.1037/0893-3200.21.4.572

    Gordon, K. C., & Baucom, D. H. (2003). Forgiveness and marriage: Preliminary support for a measure based on a
    model of recovery from a marital betrayal. American Journal of Family Therapy, 31(3), 179–199. doi:10.1080/
    01926180301115

    Gordon, K. C., Burton, S., & Porter, L. (2004). Predicting the intentions of women in domestic violence shelters to
    return to partners: Does forgiveness play a role? Journal of Family Psychology, 18(2), 331–338. doi:10.1037/0893-
    3200.18.2.331

    Gordon, K. C., Hughes, F. M., Tomcik, N. D., Dixon, L. J., & Litzinger, S. C. (2009). Widening spheres of impact: The
    role of forgiveness in marital and family functioning. Journal of Family Psychology, 23(1), 1–13. doi:10.1037/
    a0014354

    Heavey, C. L., Larson, B. M., Zumtobel, D. C., & Christensen, A. (1996). The communication patterns questionnaire:
    The reliability and validity of a constructive communication subscale. Journal of Marriage and Family, 58(3), 796–
    800. doi:10.2307/353737

    Maio, G. R., Thomas, G., Fincham, F. D., & Carnelley, K. B. (2008). Unraveling the role of forgiveness in family
    relationships. Journal of Personality and Social Psychology, 94(2), 307–319. doi:10.1037/0022-3514.94.2.307

    Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using emotionally focused therapy:
    Steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology, 74(6), 1055–1064.
    doi:10.1037/0022-006x.74.6.1055

    Marks, D. F. (1973). Visual imagery differences in the recall of pictures. British Journal of Psychology, 64(1), 17–24.
    doi:10.1111/j.2044-8295.1973.tb01322.x

    McNulty, J. K. (2008). Forgiveness in marriage: Putting the benefits into context. Journal of Family Psychology, 22(1),
    171–175. doi:10.1037/0893-3200.22.1.171

    Norton, R. (1983). Measuring marital quality: A critical look at the dependent variable. Journal of Marriage and the
    Family, 45(1), 141–151. doi:10.2307/351302

    Paleari, F. G., Regalia, C., & Fincham, F. D. (2009). Measuring offence-specific forgiveness in marriage: The marital
    offence-specific forgiveness scale (MOFS). Psychological Assessment, 21(2), 194–209. doi:10.1037/a0016068

    Rubin, Z. (1970). Measurement of romantic love. Journal of Personality and Social Psychology, 16(2), 265–273.
    doi:10.1037/h0029841

    Sandage, S. J., & Jankowski, P. J. (2010). Forgiveness, spiritual instability, mental health symptoms and well-being:
    Mediator effects of differentiation of self. Psychology of Religion & Spirituality, 2(3), 168–180. doi:10.1037/a0019124

    54 R. A. AALGAARD ET AL.

    http://dx.doi.org/10.1891/jcpiq-v20i4a004

    http://dx.doi.org/10.1891/jcpiq-v20i4a004

    http://dx.doi.org/10.1037/0022-0167.48.4.447

    http://dx.doi.org/10.1037/0022-0167.48.4.447

    http://dx.doi.org/10.1177/01461672012710004

    http://dx.doi.org/10.1037/a0024526

    http://dx.doi.org/10.1177/0146167203029006008

    http://dx.doi.org/10.1016/s0005-7894(04)80028-5

    http://dx.doi.org/10.1037/0022-3514.82.6.956

    http://dx.doi.org/10.1037/0022-3514.82.6.956

    http://dx.doi.org/10.1037/0893-3200.21.4.572

    http://dx.doi.org/10.1080/01926180301115

    http://dx.doi.org/10.1080/01926180301115

    http://dx.doi.org/10.1037/0893-3200.18.2.331

    http://dx.doi.org/10.1037/0893-3200.18.2.331

    http://dx.doi.org/10.1037/a0014354

    http://dx.doi.org/10.1037/a0014354

    http://dx.doi.org/10.2307/353737

    http://dx.doi.org/10.1037/0022-3514.94.2.307

    http://dx.doi.org/10.1037/0022-006x.74.6.1055

    http://dx.doi.org/10.1111/j.2044-8295.1973.tb01322.x

    http://dx.doi.org/10.1037/0893-3200.22.1.171

    http://dx.doi.org/10.2307/351302

    http://dx.doi.org/10.1037/a0016068

    http://dx.doi.org/10.1037/h0029841

    http://dx.doi.org/10.1037/a0019124

    Sillars, A. L., Coletti, S. F., Parry, D., & Rogers, M. A. (1982). Coding verbal conflict tactics: Nonverbal and perceptual
    correlates of the “avoidance-distributive-integrative” distinction. Human Communication Research, 9(1), 83–95.
    doi:10.1111/j.1468-2958.1982.tb00685.x

    Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar
    dyads. Journal of Marriage and the Family, 38(1), 15–28. doi:10.2307/350547

    Spielberger, C. D., Jacobs, G., Russell, S., & Crane, R. S. (1983). Assessment of anger: The state-trait anger scale. In J.
    N. Butcher & C. D. Spielberger (Eds.), Advances in personality assessment (vol. 2, pp. 161–189). Hillsdale, NJ:
    Erlbaum.

    Stanley, S. M., & Markman, H. J. (1992). Assessing commitment in personal relationships. Journal of Marriage and the
    Family, 54(3), 595. doi:10.2307/353245

    Straus, M. A. (1979). Measuring interfamily conflict and violence: The conflict tactics (CT) scales. Journal of Marriage
    and the Family, 41(1), 75–88. doi:10.2307/351733

    Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The revised conflict tactics scales (CTS2):
    Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283–316. doi:10.1177/
    019251396017003001

    Thoresen, C. E., Harris, A. H. S., & Luskin, F. (2000). Forgiveness and health: An unanswered question. In M. E.
    McCullough, K. I. Pargament, & C. E. Thoresen (Eds.), Forgiveness: Theory, research, and practice (pp. 254–280).
    New York, NY: Guilford.

    Williams, R. B. (1989). The trusting heart. New York, NY: Random House.
    Wilson, K. L., Charker, J., Lizzio, A., Halford, K., & Kimlin, S. (2005). Assessing how much couples work at their

    relationship: The behavioral self-regulation for effective relationships scale. Journal of Family Psychology, 19(3),
    385–393. doi:10.1037/0893-3200.19.3.385

    JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 55

    http://dx.doi.org/10.1111/j.1468-2958.1982.tb00685.x

    http://dx.doi.org/10.2307/350547

    http://dx.doi.org/10.2307/353245

    http://dx.doi.org/10.2307/351733

    http://dx.doi.org/10.1177/019251396017003001

    http://dx.doi.org/10.1177/019251396017003001

    http://dx.doi.org/10.1037/0893-3200.19.3.385

      Abstract
      Method
      Literature review
      Forgiveness, relationship quality, stress, imagination, and physical and mental health
      Potential costs to forgiveness
      Forgiveness in marital and family functioning
      Forgiveness and relationship satisfaction
      Discussion
      Suggested interventions
      Recommendations
      References

    What Will You Get?

    We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

    Premium Quality

    Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

    Experienced Writers

    Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

    On-Time Delivery

    Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

    24/7 Customer Support

    Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

    Complete Confidentiality

    Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

    Authentic Sources

    We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

    Moneyback Guarantee

    Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

    Order Tracking

    You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

    image

    Areas of Expertise

    Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

    Areas of Expertise

    Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

    image

    Trusted Partner of 9650+ Students for Writing

    From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

    Preferred Writer

    Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

    Grammar Check Report

    Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

    One Page Summary

    You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

    Plagiarism Report

    You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

    Free Features $66FREE

    • Most Qualified Writer $10FREE
    • Plagiarism Scan Report $10FREE
    • Unlimited Revisions $08FREE
    • Paper Formatting $05FREE
    • Cover Page $05FREE
    • Referencing & Bibliography $10FREE
    • Dedicated User Area $08FREE
    • 24/7 Order Tracking $05FREE
    • Periodic Email Alerts $05FREE
    image

    Our Services

    Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

    • On-time Delivery
    • 24/7 Order Tracking
    • Access to Authentic Sources
    Academic Writing

    We create perfect papers according to the guidelines.

    Professional Editing

    We seamlessly edit out errors from your papers.

    Thorough Proofreading

    We thoroughly read your final draft to identify errors.

    image

    Delegate Your Challenging Writing Tasks to Experienced Professionals

    Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

    Check Out Our Sample Work

    Dedication. Quality. Commitment. Punctuality

    Categories
    All samples
    Essay (any type)
    Essay (any type)
    The Value of a Nursing Degree
    Undergrad. (yrs 3-4)
    Nursing
    2
    View this sample

    It May Not Be Much, but It’s Honest Work!

    Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

    0+

    Happy Clients

    0+

    Words Written This Week

    0+

    Ongoing Orders

    0%

    Customer Satisfaction Rate
    image

    Process as Fine as Brewed Coffee

    We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

    See How We Helped 9000+ Students Achieve Success

    image

    We Analyze Your Problem and Offer Customized Writing

    We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

    • Clear elicitation of your requirements.
    • Customized writing as per your needs.

    We Mirror Your Guidelines to Deliver Quality Services

    We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

    • Proactive analysis of your writing.
    • Active communication to understand requirements.
    image
    image

    We Handle Your Writing Tasks to Ensure Excellent Grades

    We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

    • Thorough research and analysis for every order.
    • Deliverance of reliable writing service to improve your grades.
    Place an Order Start Chat Now
    image

    Order your essay today and save 30% with the discount code Happy