Journal of Sex & Marital Therapy

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Low sexual desire in women: The effects of marital

therapy

David C. Macphee , Susan M. Johnson & Monika M.C. van Der Veer

To cite this article: David C. Macphee , Susan M. Johnson & Monika M.C. van Der Veer (1995)
Low sexual desire in women: The effects of marital therapy, Journal of Sex & Marital Therapy, 21:3,
159-182, DOI: 10.1080/00926239508404396

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 Low Sexual Desire in Women:
The Effects of Marital Therapy
DAVID C. MacPHEE, SUSAN M . JOHNSON,
and MONIKA M. C. VAN DER VEER

A total o f 4 9 couples, i n which the women were experiencing inhibited

sexual desire (ISD), received Emotionally Focused Therapy for Couples
(m) or were assigned to a wait-last control group. An additional 15
couples were recruited as a non-ISD comparison sample. Only very
modest treatment and control group dij'ferences were found aJier treat-
ment. Females treated with marital therapy made sig-ntjicant gains on
one measure of sexual desire and on level of depressive symptomatologp
Overall, the marital treatment group seemed to make clinically sign$-
cant gains from pre- to posttreatment which were lurgely maintained at
follow-up. Lower levels of initial marital distress resulted in greater
treatment gains, and better pretreatment marital adju,stment predicted
better posttreatment overall sexual adjustment. The main difference
found between IJID and non-ISD couples was that ISD couples had
signaficantly more sexual distress. Results are discussed in light of the
unique features of this subject population, and suggestions are p v e n
for future research.

Inhibited sexual desire (ISD) has attracted a great deal of theoretical and
clinical attention. Although the precise incidence of ISD in the genera1
population is unknown, ISD is considered to be the most common com-
plaint among couples seeking sex therapy.' Surveys of sex therapy centers
have reported that up to 49% of female clients and 16% of male clients
reported desire-phase sexual difficulties either alone or in combination
with other sexual dysfunctions.' Most studies have indicated that the
diagnosis of ISD is more common among women than men; however,

This study was performed as part of the first author's Ph.D. dissertation research and the third
author's honors thesis. This study was supported in part by a [Jniversity uf'Omwa Graduate Srudies
and Research grant U-02104 to the second author, who was supervisor of the dissertation. Inquiries
concerning this study should be addressed to Susan M. Johnson, Ed.D., Centre for Psychological
Services, 1Jniversity of Ottawa, 11 Maric Curie, Ottawa, Ontario, Canada, K1N 6NS. The authors
would like to acknowledge Dwayne Schindler for his statistical consultation and scholarly assistance
in this study.

Journal of Sex & Marital Therapy, Vol. 21, No. 3, Fall 1995 0 Brunner/Mazel, Inc.

159
160 Journal of Sex &Marital Them@, Vol. 21, No. 3, Full 1995

an increasing number of men also appear to be reporting ISD.3 Com-

pared to other disorders, ISD has also been re orted to be difficult to
treat using a sex therapy treatment approachJ5 Kaplan6 suggests that
ISD can be caused or maintained by physiological factors, intrapsychic
conflicts, pathological interpersonal interactions with the sexual partner,
or a mixture of these factors.
Although physiological factors, such as hormonal imbalance, aging,
and chronic pain,',' and intrapsychic factors, such as unconscious con-
flicts and/ or fears concerning intima~y,~,' the emotional repercussions
of child sexual abuse,'" and depression,' have been related to the develop-
ment of ISD, the role of the marital system in etiology, maintenance,
and treatment has been emphasized more and more in the ISD literature.
Increasingly, clinicians have moved toward interpersonal conce tualiza-
tions of ISD and have developed systemic treatment strategies.' P
A number of relationship issues have been identified as having associa-
tion with the development and maintenance of ISD. ISD may reflect a
larger pattern of marital ~onflict.'~J' Issues such as the expectation that
affection must lead to intercourse, unsatisfactory ability to listen and
resolve conflicts, and lack of emotional closeness may deprive women of
the original stimulants for sexual desire.' It has also been argued that
anger toward one's partner and anger-related issues such as power strug-
gles and disappointments are prevalent causes of ISD. Angry partners
lack the trust and vulnerability required for sexual a b a n d ~ n m e n tLow
.~
sexual desire may also be a way to maintain an emotionally safe distance
when intimacy is too threatening.'
&plan4 has described how the usual reaction of the nonsymptomatic
spouse can maintain ISD. Many partners feel threatened and rejected by
their spouse's lack of sexual desire. These feelings can lead to a destruc-
tive cycle of pressure to have sex from one spouse and increased reluc-
tance from the other. Kaplan states that such a cycle can cause ISD and/
or aggravate the condition when it already exists in a mild form.
The subtype of ISD that has been most closely linked theoretically to
interpersonal issues has been partner-specific ISD.4The symptomatology
of this subtype strongly suggests that the quality of the overall relationship
is a powerful causal and maintenance factor in ISD.
Theorists have also described how marital therapy may be useful in
the treatment of ISD. Many contend that low sexual desire can rarely be
treated successfully if a sexual problem is isolated from the context of
the marital relation~hip."~'~,'~
Some proponents of this view have recom-
mended the integration of marital therapy into the sex therapy treatment
of partner-specific ISD.'' Others have recommended treatment ap-
proaches focused on the marital relationship and addressing level of
emotional relatedness, the symbolic significance of sex, and systemic in-
teraction patterns."~" They conceptualize ISD from an interpersonal per-
spective and suggest that ISD can often be treated most effectively within
that context.
Despite the high level of clinical and theoretical interest in the topic
of ISD, there is a marked lack of clinical outcome studies in this area.
Low Sexual Desire in Women 161

O'Carroll'* concluded in his review of the literature that there have been
no adequately controlled clinical outcome studies in this area. The treat-
ment studies that do exist have largely assessed the effectiveness of sex
therapy, or a combination of sex therapy and pharmacological treatment.
For example, Schover and LoPiccolo' used archival data to assess the
effectiveness of sex therapy in the treatment of ISD. The results were
characterized as reflecting a respectable but less than optimal decrease
in distress. Recently, Hurlbert" compared the effects of a combined sex
and marital therapy group treatment program for couples in which the
woman had ISD to a combined sex and marital therapy treatment group
program that also included orgasm consistency training. The marital
therapy aspect of treatment was based on social exchange theory. Both
treatments were found to produce positive results in areas such as sexual
desire and sexual arousal, with superior results for the treatment that
included orgasm consistency training, especially at follow-up. However,
this study did not include a control group comparison.
There have as yet been no attempts to empirically assess the effective-
ness of marital therapy alone in the treatment of ISD. There is, however,
evidence to suggest that such a treatment approach may be useful. For
example, Hawton and Catalan'" found that the quality of the general
relationship may be an especially important predictor of the outcome of
sex therapy when the sexual problem is low sexual interest in women.
Based on the results of their outcome study of the effect of sex therapy
and pharmacological treatment of low sexual interest and arousal,
Whitehead and Mathews2' suggested that relationship factors may reflect
greater general pathology or aspects of etiology that need to be reversed
before treatment can be effective. In addition, marital therapy alone has
been found to increase sexual satisfaction in subject populations that
consisted of couples who presented with global relationship distress and
not for specific sexual distress.'2,'3In these studies, however, couples re-
porting desire-phase difficulties were excluded, or the effect of marital
therapy on sexual desire was not specifically assessed. No study has yet
specifically examined the effectiveness of marital therapy in the treat-
ment of sexual desire problems.
The present study was a controlled outcome study examining the effect
of marital therapy on inhibited sexual desire in women. It was expected
that marital therapy would have a positive effect on marital adjustment,
partners' overall level of sexual adjustment, and female level of sexual
desire, as compared to a wait-list control group condition. The level of
pretreatment marital adjustment and type of ISD were expected to pre-
dict levels of sexual desire and overall sexual adjustment after treatment;
that is, lower initial marital adjustment and partner-specific ISD, both of
which would heighten the relevance of marital therapy, were expected
LO predict higher levels of desire and adjustment at posttreatment. Treat-
ment effects were also expected to be stable at three-month follow-up.
In addition to the treatment component in this study, the marital,
sexual, and psychological adjustment of couples experiencing female
partner ISD was compared to that of couples not in treatment for ISD.
162 Journal of Sex &Marital Therapy, Vol. 21, No. 3, Fall 1995

Only a limited number of studies have examined this issue. Stuart and
colleague^'^'^ examined differences in a number of areas between couples
in which the woman was diagnosed as having ISD and couples receiving
sex therapy in which the woman did not have ISD. No differences were
found on the Minnesota Multiphasic Personality Inventory (MMPI). The
most striking difference between the two groups was that the marital
adjustment of both partners in the ISD group, as measured by the Dyadic
Adjustment Scale (DAS),'4was significantly lower than that of the non-
ISD group. Schreiner-Engel and Schiavi" compared women with ISD to
women free of any sexual or psychological difficulties and found no
significant differences between the two groups with respect to current
level of depression or global psychological distress.
In the present study, couples in treatment for ISD were compared to
couples in which the woman or couple were receiving psychotherapy for
a concern other than ISD. The potential confound of the ISD group
being in therapy was taken into account as it was by Stuart et al.,' and
the type of therapy was expanded beyond their criteria of sex therapy
alone. In addition, comparison group subjects were not excluded on the
basis of ISD symptoms. This permitted an investigation of differences in
ISD symptomatology found between women receiving treatment for ISD
and those seeking treatment for other psychological concerns. Further-
more, comparisons were made between ISD and non-ISD male partners
on measures other than marital adjustment alone. No specific hypotheses
were made in this exploratory comparison.

METHOD
Subeets

ISD Couples. Females in the ISD group met diagnostic criteria for ISD
based on DSM-III-R'6 criteria for hypoactive sexual desire disorder and
the Multi-Axial Descriptive System for the Sexual Dysfunctions (M-
ADSSD) criteria for low sexual desire.27ISD was defined as a self-report
from the female member of couple of a total absence of, or decline in,
her level of sexual desire. In addition, the total absence of, or decline
in, level of sexual desire was distressing to both the symptomatic individ-
ual and her partner. Furthermore, there was a report of a low level of
sexual activity (less than once every two weeks), unless a higher frequency
was reported by the female partner for reasons other than a desire to
engage in sexual activity (e.g., pressure from spouse, fear of losing
spouse, guilt, sense of duty, an attempt not hurt spouse's feelings). Lastly,
the total absence of, or decline in, the females member's sexual desire
was of at least six months' duration. Exclusion criteria included the pres-
ence of medical conditions or medication usage that may cause loss of
sexual desire, such as diabetes and antihistamines.' Clinical subtype of
ISD (i.e., lifelong-global, non-lifelong-global, lifelong-situational, non-
lifelong-situational) was noted, but all subtypes were included under the
general definition of ISD.
Low Sexual Iksirf in Womm 163

ISD couples all met the following additional inclusion criteria: pres-
ently living together and having cohabitated for a minimum of two years;
free of drug- and alcohol-related problems; no history of physical abuse
in the relationship; neither member of the couple involved in an extra-
marital relationship; presently not receiving other psychological treat-
ment; female partner was not pregnant, and had not given birth within
the last six months; any other sexual problem that the couple had, such
as female anorgasmia, was judged by the couple and the experimenter
not to be responsible for the female partner’s diminished level of sexual
desire; and couple’s initial level of marital adjustment (DAS scores) was
above 70, that is, they scored above levels typical of divorcing couples.
Both maritally distressed and non-maritally distressed couples, as assessed
by the DAS, were accepted as subjects; both members of the couple
were willing to attempt to resolve the problem of female ISD through
marital therapy.
Couples were recruited through newspaper advertisements describing
a research project for couples wishing free treatment for sexual desire
problems. A total of 54 couples met the inclusion criteria and were ran-
domly assigned to either the treatment or control group condition. Dur-
ing the treatment process, four couples withdrew from the project. One
couple was withdrawn from statistical analysis after their pretreatment
outcome measure scores identified them as being multivariate outliers.
A total of 49 couples completed the treatment and wait-list control proce-
dures and were used in subsequent statistical analyses: treatment group
(n = 25), control group (n = 24). At three-month follow-up, 23 treat-
ment couples completed follow-up outcome measures (92% of original
sample).
The average age of female and male subjects was 40.65 (SD = 8.37)
and 42.27 (SD = 8.45), respectively. ISD couples had been married an
average of 14.00 (SD = 8.60) years. The typical level of income was above
55,000 Canadian dollars a year. Most subjects had a college or university
education. The average duration of ISD was 6.68 (SL)= 4.54) years. The
typical ISD female desired sex less than once a month. The typical ISD
couple reported engaging in sex less than once a month and were moder-
ately dissatisfied with their overall sexual relationship.
With respect to ISD diagnosis, six females (12%) reported lifelong-
global ISD, 16 females (32%) reported non-lifelong-global ISD, and 28
females (56%)reported non-lifelong-situational ISD of a partner-specific
nature. In subsequent analyses, ISD couples were divided into two sub-
types, namely a general global type combining lifelong-global and non-
lifelong-global ISD subjects (44% of sample) and partner-specific ISD
(56% of sample).
Non-ISD Couples. Non-ISD couples met the general inclusion criteria
for couples (e.g., no history of physical abuse in marriage). In addition,
at least the woman in the couple was receiving psychotherapy for issues
other than ISD. The female partner’s level of ISD symptomatology was
allowed to vary. The group referent of non-ISD denoted that none of
164 Journal of Sex & Marital Therapy, Val. 21, No. 3, Fall 1995

these women were in treatment for ISD, but made no assumptions con-
cerning their level of ISD symptomatology. A total of 17 women and 15
spouses not in treatment for ISD completed the outcome measures used
in this study.
The subjects were currently receiving psychotherapy for a wide range
of issues: self-esteem issues (n = 2), child sexual abuse (n = l ) , child
emotional abuse (n = l ) , depression (n = l ) , panic attacks (n = l ) ,
and personal growth issues (n = 2). In addition to these individual issues,
nine women and their spouses (53% of total sample) were receiving
marital counseling (total n = 17). The mean couple DAS score for the
total non-ISD sample was 92.73 (SD = 13.39). The mean couple DAS
scores for those non-ISD couples in marital therapy and those non-ISD
couples not in marital therapy were 91.22 (SD = 12.80) and 95.00 (SD
= 15.16),respectively. A one-way analysis of variance revealed no signifi-
cance difference between the DAS scores of those couples receiving and
those not receiving marital therapy (F(1,13) = 0.27, p > 0.05).
The average ages of the non-ISD females and males were 39.75 (SD =
10.92) and 45.25 (SD = 12.77), respectively. Couples in the non-ISD
group had been married an average of 12.81 (SD = 10.25) years. The
typical level of income was above 55,000 Canadian dollars a year. The
typical non-ISD couple reported desiring to engage in sex at least once
a week. The typical non-ISD couple reported engaging in sex once every
two weeks to once a month, and were slightly satisfied to slightly unsatis-
fied with their overall sexual relationship.

Treatment Modality

The study was conducted at an MA-accredited doctoral training facility

at the University of Ottawa serving a general adult population. Treatment
for the treatment group consisted of 10 sessions of Emotionally Focused
Therapy for Couples (EFT). EFT is an integration of the experiential
and systemic traditions in psychotherapy.28The experiential tradition
emphasizes the role of affect and the reprocessing of intrapsychic experi-
ence in the change process, whereas the systemic tradition emphasizes
the organization of interactions in system maintenance. EFT has been
found to be an effective marital therapy, and to produce significant posi-
tive results in as few as 10 session^.^^^^^
Ten therapists (seven female and three male) administered the EFT
interventions. Each therapist treated at least two couples, five therapists
treated three couples each. Therapists were clinical psychology doctoral
students who had previously administered EFT. Clinical supervision was
provided on a weekly basis.

Instruments

A demographic data questionnaire used previously in marital therapy

research3’was used to collect demographic information. A standardized
Low Sexual Desire in Women 165

interview schedule, based on Friedman and Hogan,%was used to estab

lish rapport, explore the nature of the female’s loss of sexual desire,
explore the nature of other sexual problems the couple may have had,
and ensure that inclusion criteria were met.
Dyadic Adjustment Scale (DAS). The DASZ4was used as a screening and
outcome measure. The DAS is a self-report questionnaire used to assess
the quality of marital adjustment.
Sexual Hzsto?y Form ( S W ) . The SHF is a self-report measure that assesses
specific areas of sexual functioning and sexual problems in individu-
a l ~ . ~ ’In
, ~ ‘this study it was used as a screening and outcome measure.
Each of 28 items independently assesses an aspect of sexual functioning
that is relevant to clinicians and can contribute to an overall clinical
description of a couple’s or individual’s areas of sexual functioning. Al-
though there has been little attempt to determine the psychometric prop-
erties of the SHF, items have been used as an outcome measure in sex
and marital therapy r e ~ e a r c h . ~ , ‘ ~
The Golombok Rust Inventory of Sexual Satisfaction (GRISS). The GRISS
is a 56-item (28 for men and 28 for women) self-report measure which
assesses the quality of a sexual relationship and a person’s functioning
within it.34The GRISS was used as an outcome measure. The GRISS
main scale was used to assess overall sexual functioning, and the sexual
avoidance (GRISS-AVD) and sexual infrequency subscales were used to
assess areas of special relevance to the problem of ISD. Higher scores
indicate greater sexual problems in the areas assessed. In addition to the
assessment of the scale’s psychometric properties performed by Rust and
G~lombok,~‘ the internal consistency and test-retest reliability of this scale
were explored using the present population. Internal consistency was
determined by calculating the Crombach alpha levels for the main scale
and subscales used in this study, using the pretreatment responses of
subjects. Crombach alpha levels were found to be above 0.70. Test-retest
reliability was determined using initial and post-wait scores for the con-
trol group. Test-retest reliability was found to be above 0.70 for the main
scale and the sexual avoidance and sexual infrequency subscales.
Sexual Desire Toward Partner Scale (SDTPS). The SHF and GRISS pro-
vided measures useful in assessing the response to treatment for ISD.
These measures address overall sexual functioning and have items or
scales related to sexual desire. In order to specifically assess level of sexual
desire, however, the SDTPS was designed for use in this study. The
SDTPS consisted of 10 items related to the respondent’s level of sexual
desire toward his or her spouse. As with the GRISS scale, the time frame
involved is “recently.” For each item, respondents rate themselves on a
scale ranging from 1 to 5 (1 = never or almost never to 5 = always or
almost always). For example, subjects are asked, “Do you feel a desire to
have sex with your spouse?” The possible scores ranged from 10 to 50,
with higher scores indicating a higher range of sexual desire.
The items selected were designed to assess a wide range of variables
related to one’s level of sexual desire toward one’s partner. Areas assessed
included desire to have sex with partner, feelings of sexual attraction
166 Journal of Sex & Maritat Therapy, Vol. 21, No. 3, Fat1 1995

toward partner, desire to accept spouse’s advances, and satisfaction with

level of sexual desire toward partner.
A factor analysis with principal axis factoring and varimax rotation was
performed in order to investigate the underlying factor structure of this
instrument. Subjects’ first scores on the SDTPS were used (n = 129).Two
factors were obtained. It was found that the first factor loaded heavily on
all 10 items except item 8, had an eigenvalue of 6.94, and accounted for
67.20% of the variance. Communality values for all items except item 8
were in excess of 0.60. Factor 2 had an eigenvalue 0.52, accounted for
only 5.20% of the variance, and was most clearly differentiated from
factor 1 by item 8 (communality 0.50). These findings were judged to
reflect a largely homogeneous item pool, with one main factor, interpre-
ted as representing level of sexual desire toward partner, underlying the
SDTPS. A correlation coefficient of 0.99 was found between the 10-item
SDTPS total score and the SDTPS total score omitting item 8. Therefore,
it was decided to use the original 10-item total SDTPS score in all subse-
quent analyses.
With respect to internal consistency, Cronbach alphas, calculated from
subjects’ first scores on the SDTPS, resulted in alpha levels above 0.70.
Control group initial and end-of-wait scores were used to investigate test-
retest reliability. Test-retest correlation coefficients of 0.79 and 0.86 were
found for females and males, respectively, indicating an adequate level
of test-retest reliability.
Beck Depression Inventov (BDQ The BDI is a widely used self-report
measure of the severity of depressive symptomatology. The BDI was used
in this study as an outcome measure and to investigate treatment re-
sponse rates.
Symptom CheckZzst-90-Rmzsed (SCL90-R). The SCLSO-R is a self-report
symptom inventory designed to assess the symptom patterns of psychiat-
ric and medical patients. The Global Severity Index (SCLGSI) was used
in this study as an outcome measure.

Procedure

ISD Couples. Following telephone screening procedures, couples en-

gaged in an interview process involving a couple interview and individual
interviews with the male and female members. Couples were first sup-
plied with information concerning the major procedures and require-
ments of the study, and they read and signed a consent form. In each
case, the standardized interview protocol was administered. Couples com-
pleted all outcome measures and, if they met the inclusion criteria, were
randomly assigned to the treatment or wait-list control. Couples in the
treatment group were given 10 weekly sessions of marital therapy. After
the tenth (final) session, each member of the couple was asked to again
complete the outcome measures (DAS, SHF, GlUSS, SDTPS, BDI, SCL
90-R) , A three-month follow-up was conducted by contacting subjects
and asking them to make an appointment to again complete the outcome
measures. Couples assigned to the control group were informed that
Low Sexual Desire in Women 167

they were in the wait-list condition and contacted following the 10-week
waiting period to again complete the outcome measures.
Non-ISD Couples. Non-ISD couples responded to newspaper advertise-
ment offering assessment of relationship and sexual functioning to cou-
ples in which at least the female partner was receiving some form of
psychotherapy. Following the telephone screening procedure, couples
were invited to an assessment interview in which the measures used in
this study were administered. Following this assessment session, couples
were invited to attend a feedback session concerning the results of
their assessment.
Data Analysis. Data analysis included 1) treatment and control group
equivalence at pretreatment; 2) a comparison of treatment and control
group differences on outcome measures after the 10-week period; 3) a
comparison of treatment couples high and low in marital distress to the
total control group at posttreatment; 4) an investigation of treatment
group gains from pretreatment to posttreatment to follow-up; 5) hierar-
chical multiple regression analyses examining whether pretreatment lev-
els of dyadic adjustment and type of ISD predicted treatment group
female posttreatment levels of sexual desire and sexual adjustment; and
6) a comparison of ISD and non-ISD couples on demographic and out-
come measures. Analyses were also conducted to compare ISD subtypes
(global and partner-specific) to non-ISD couples and to each other. In
addition to statistically significant change, clinically significant change
was also examined. Methods for examining the clinical indicators of re-
covery, improvement, and deterioration were derived from Jacobson and
T r u a ~Pre-hoc
. ~ ~ statistical power estimates were calculated to be above
0.70, indicating an adequate level of statistical power.

RESULTS

The existence of initial differences between the treatment and control

groiips on demographic variables was explored. An alpha level of p <
0.05 was maintained despite the number of tests performed in order to
maximize the likelihood of detecting pretreatment differences. The only
difference found was that the treatment group had a significantly greater
number of children than the control group, F(1,47) = 6.10, p < 0.05.
This variable was entered as a covariate in subsequent analyses. No sig-
nificant differences were found between groups on outcome measures
at pretreatment. For example, the means for the treatment and control
groups at pretreatment on the DAS combined total score were 98.60 and
102.56, respectively, and this difference was not statistically significant,
F(1,4’7) = 1.38, p > 0.05.
Outcome Variables

A multivariate analysis of covariance was performed to investigate group

differences at posttreatment and post-wait on outcome measures. In ad-
dition to number of children, all of the initial measures on outcome
168 Journal of Sex &Marital Therapy, Vol. 21, No. 3, Fall 1995

variables were used as covariates to increase the likelihood that any differ-
ences found after treatment were due to therapy rather than error vari-
ance. Separate analyses were performed for female and male subjects in
each experimental group. This strategy allowed for the examination of
possible sex differences in subjects’ response to therapy. Combined cou-
ple total DAS scores were also examined, as is common in the marital
therapy literature.”
The primary multivariate analysis of covariance performed was a treat-
ment and control group posttreatment comparison on the continuous
outcome measures (DAS, GRISS, SDTPS, SCLGSI, BDI). Secondary anal-
ysis consisted of treatment and control group comparisons on selected
subscales of the GRISS (i.e., Sexual Infrequency and Sexual Avoidance
subscales). In each of these analyses the assumptions of multivariate anal-
ysis of covariance were met. Levels of normality, linearity, and homogene-
ity were satisfactory. However, since several of the primary outcome
measures were significantly correlated with each other at intake, the Roy-
Bargman stepdown procedure was used to interpret main effects and
thus correct for the problem of inflated type 1 error rates on univariate
F tests.36The ordering of dependent variables for the primary analyses
were DAS, GRISS, SDTPS, SCLGSI, and BDI. For the secondary analyses
involving the GRISS subscales, there were no significant correlations
among the dependent variables, and thus a stepdown procedure was
unnecessary.
For all multivariate analyses of covariance main effects, an alpha level
of p < 0.05 was chosen. The alpha levels for main effect post-hoc analyses
were adjusted using the Bonferroni correction procedure to accommo-
date the number of dependent variables used in each analysis (0.05/
number of dependent variables).
Before presentation of the results of the separate analyses for females
and males, the results of the combined DAS score analyses at posttreat-
ment will be reported. The combined DAS score adjusted means for the
treatment and control groups at posttreatment were 105.05 and 102.02,
respectively. This difference was not statistically significant, F( 1,43) =
0.98, p > 0.05.
Treatment and control group means and adjusted means for females
at posttreatment on the DAS, GRISS, SDTPS, SCLGSI, and BDI are pre-
sented in Table 1. For the DAS and SDTPS, higher scores indicate less
distress, whereas lower scores reflect less distress on the GRISS, SCLGSI,
and BDI.
For females, the results of the multivariate analysis of covariance re-
vealed a significant main effect for group at posttreatment, F(5,3’7) =
5.32, p < 0.05. Roy-Bargman stepdown analysis revealed a significant
difference between the two groups at posttreatment on the BDI, F(1,37)
= 15.36, p < 0.01. Thus, treated female partners exhibited significantly
less distress than the control group on the BDI.
No significant main effect for group was found for females on the
GRISS subscales at posttreatment, F(2,43) = 0.99, p > 0.05. On the non-
parametric sexual desire item from the SHF, a Mann Whitney U test
Low Sexual Desire in Women 169

TABLE 1
Means and Adjusted Means for Females on
Continuous Outcome Measures at Posttreatmenta
Measureb Variable Treatment Control
DM M 101.88 101.63
SD 13.97 14.80
Adjusted M 103.68 99.83
GRIS* M 37.60 45.38
SD 11.68 12.12
Adjusted M 38.05 44.93
SDTPS M 28.92 23.67
SD 8.79 7.51
Adjusted M 28.48 24.10
SCL-GSI* M 50.68 56.75
SD 9.38 7.25
Adjusted M 51.68 55.75
BDI* M 4.00 11.42
SD 3.59 7.32
Adjusted M 4.44 10.97
GRISSINF* M 5.80 6.58
SD 2.06 1.75
Adjusted M 5.87 6.52
GRISSAVD* M 6.92 7.79
SD 3.20 3.79
Adjusted M 7.18 7.53

“Posttreatment for treatment group = end of 1O.week wait-list period for control group.
”DM = Dyadic Adjustment Scale; GRISS = Golombok-Rust Inventory of Sexual Satisfaction; SDTPS = Sexual
Desire Toward Partner Scale; SCL-GSI = Symptom Checklist-SO-RGlobal Severity Index; BDI = Beck Depression
Inventory; GRISSINF = GRISS Sexual Infrequency Subscale; GRISSAVD = GRISS Sexual Avoidance Subscale.
*Lower scores reflect less distress.

found that treated females reported significantly more sexual desire at

posttreatment than control group females (U = 149.50, p = 0).
For males, the multivariate analysis of covariance failed to reveal any
significant effect for group at posttreatment, F(5,3’7) = 0.87, p > 0.05,
on the DAS, GRISS, SDTPS, SCLGSI, and BDI. Similarly, no group differ-
ences were found for males on the GRISS subscales, F(2,43) = 1.59, p >
0.05, or on the SHF sexual desire item (U = 233.00, p > 0.05).
To examine the role of level of marital distress in treatment response,
treatment subjects were divided into two groups, those with DAS scores
less than or equal to the cutoff for distress (97) (high marital distress
group, n = 9) and those with DAS scores greater than the distress cut-
off (low marital distress group, n = 16).The posttreatment scores of these
two groups of treatment subjects were separately compared to the entire
control group sample (n = 24).
No significant differences were found for the high marital distress
group on general outcome measures, GRISS subscales, or SHF scores
when compared to controls. For low marital distress treatment females,
however, a significant overall main effect was found for the DAS, GRISS,
I70 Journal of Sex &?Marital Therapy, Vol. 21, No. 3, Fall I995

SDTPS, SCL9O-R, and BDI, F(5,28) = 5.49, p < 0.05. Roy-Bargman step-
down analysis revealed a significant difference on the GRISS main scale,
indicating better overall sexual adjustment at posttreatment for low mari-
tal distress treatment females than for control group females, F(1,31) =
15.06, p = 0.001. A significant main effect was also found for the three
GRISS subscales examined, F(3,32) = 3.70, p < 0.05. Post-hoc analysis
revealed a significant difference on the sexual infrequency subscale,
F(1,34) = 7.41, p = 0.01, indicating that the low marital distress treat-
ment females reported greater posttreatment frequency of sex than con-
trol group females. Similarly, low marital distress treatment females also
reported a higher level of posttreatment sexual desire on the SHF sexual
desire item than did control group females, U = 69.5, p < 0.001,
For low marital distress treatment males, no significant main effect was
found on the DAS, GRISS, SDTPS, SCL9O-R, or BDI, F(5,22) = 0.75, p
> 0.05. A significant main effect was found, however, for the three GRISS
subscales examined, F(3,32) = 5.17, p < 0.05. Post-hoc analysis indicated
that low marital distress treatment males reported significantly greater
posttreatment sexual activity on the sexual infrequency scale than did
the control group males, F(1,34) = 7.24, p = 0.01, and better posttreat-
ment sexual communication, F(1,34) = 11.61, p < 0.01. No significant
difference was found between these two groups on the SHF sexual desire
item, U = 135.0, p > 0.05.

Clinical Signtjicance at Posttreatment

Clinically significant differences between treatment and control subjects

at posttreatment were assessed. These analyses were performed separately
for males and females. Jacobson and T r ~ a x ’ operationalization
s~~ of re-
covery, improvement, and deterioration was used. In their procedure, a
cutoff score is determined to indicate percentage of individuals recov-
ered, and a reliable change index is used to indicate percentage of indi-
viduals improved and deteriorated. Recovery rates are reported only on
those measures for which the term “recovery” was deemed appropriate
(i.e., those measures with mean pretreatment scores that reflected dis-
tress-the sexual outcome measures). Rate of improvement could not
be calculated for the BDI because subtraction of the reliable change
index resulted in a value of less than zero for many subjects’ scores.
Table 2 shows the percentage of treatment and control group females
clinically recovered, improved, or deteriorated at posttreatment. A
greater percentage of treatment females than control females recovered
and/or improved on almost all outcome measures. Improvement rates
for treatment females were most pronounced on the SDTPS (48%) and
the DAS (40%).
In general, recovery and improvement rates were also higher for treat-
ment males. Improvement rates for treatment males were most pro-
nounced on the DAS (40%, 25% in control group) and the SCLGSI
(36%, 17% in control group).
Low Sexual Dpsire in Women 171

TABLE 2
Percentage of Females Who Recovered, Improved,
and/ or Deteriorated on Outcome Measures at Posttreatment”
~~ ~

Recovered Improved Deteriorated

Measureb Treatment Control Treatment Control Treatment Control
DAS 40 17 4 8
GRISS 4 0 24 8 0 4
GIUSSINF 4 4 20 0 0 4
GRISSAVD 16 0 4 4 4
SDTPS 36 0 48
32 17 4 4
SHFD 12 0 24 8 0 4
SCLGSI 32 8 0 16

”Posttreatmentfor treatment group = end of 10-week wait period for control group.
“DAS = Dyadic Adjustment Srale; GFUSS = Golombok-Rust Inventory of Sexual Satisfaction; GRISSINF =
GRISS Sexual Inb-equency Subsralc; GFUSSAVD = GFUSS Sexual Avoidance Subscale; SDTPS = Sexual Desire
,.
loward Partner Scale; SHFD = Sex History Form-Desire Item; SCLGSI = Symptom Checklist-SO-R Global
Severity Index.
No& Treatment, n = 25; rontrol, II = 24.

Treatment Group Statistical and Clinical Changes Across Time

Analyses were performed to investigate treatment group changes over

the three time periods of pretreatment, posttreatment, and follow-up.
These analyses did not allow for a control group comparison and in-
volved data for only 23 of the original 25 treatment subjects. A trend
analysis was performed to examine these changes across time.
The mean combined total DAS couples scores at pretreatment, post-
treatment, and follow-up were 99.26 (SD = 11.28), 103 (SD = 11.59),
and 105 (SD = 12.13), respectively. Analysis of variance with repeated
measures across time resulted in a significant linear trend, indicating
that treatment couples improved significantly on the DAS across all time
periods, F(1,22) = 10.89, p < 0.05.
An examination of scores for female subjects on outcome variables
found a significant main effect for time on primary outcome variables,
F( 10,13) = 3.03, p < 0.05. Univariate Ftests revealed a significant linear
trend, F(1,22) = 16.09, p < 0.01, and a significant quadratic trend,
F(1,22) = 17.32, p < 0.01, for the SDTPS. By examining the means, it
can be seen that female treatment subjects did improve across time, but
that at follow-up the level of improvement was less than that found at
posttreatment, but still above pretreatment levels. A significant quadratic
trend across time on the BDI, F(1,22) = 21.22, p < 0.01, suggested
that the treatment females’ mean level of depressive symptomatology
decreased from pretreatment to posttreatment, but that this improve-
ment was no longer present at follow-up.
For female subjects, a main effect for time was found for GRISS s u b
scales, F(4,19) = 3.35, p < 0.05. Univariate F-tests revealed a significant
linear trend across time for the sexual avoidance subscale, F(1,22) =
11.13, p < 0.01, suggesting that subjects continued to improve across
172 Journal of Sex b’Marital Therapy, Val. 21, No. 3, Fall 1995

time, but that improvement from posttreatment to follow-up is less than

that found from pretreatment to posttreatment.
Wilcoxon within-group tests assessed change across time for females
on the SHF sexual desire item. A statistically significant difference was
found on this measure from pretreatment to posttreatment, z = -3.74,
p = 0, and from pretreatment to follow-up, z = -3.52, p = 0. Examina-
tion of the median values indicated that gains made by female treatment
subjects from pretreatment to posttreatment were maintained at fol-
low-up.
For treatment males, multivariate analysis with repeated measures
across time revealed a significant main effect for time, F( 10,13) = 6.70,
p < 0.05. Univariate Ftests demonstrated significant linear trends on the
DAS, F(1,22) = 16.86, p < 0.01; the SCLGSI, F(1,22) = 49.02, p < 0.01;
and the BDI, F(1.22) = 14.94, p < 0.01. On the DAS, male subjects’
scores improved at all three time periods. On the SCLGSI and the BDI,
however, inspection of the means revealed that male treatment subjects’
follow-up scores were slightly lower than those at posttreatment, sug-
gesting that at follow-up the level of improvement found at posttreatment
was maintained but had leveled out. No significant effects were found
on the GRISS sexual avoidance and sexual infrequency subscales or on
the SHF desire item.

Predictors of Posttreatment Scores

For female subjects, analyses were performed to investigate pretreatment

predictors of sexual desire (SDTPS) and sexual adjustment (GRISS) at
posttreatment (n = 25). Two hierarchical regression analyses were per-
formed. In the first, female SDTPS scores at posttreatment were entered
as predicted criterion variables and female partner DAS scores at pre-
treatment and type of ISD were entered as predictors. In the second
hierarchical regression analysis, female GRISS scores as posttreatment
were entered as the predicted criterion variable, and, once more, female
partner DAS scores at pretreatment and type of ISD were entered as
predictors. In each case, the ratio of subjects per predictor was well above
the five-to-one ratio suggested by Tabachnik and Fide11.36The alpha level
was maintained at p < 0.05 for both analyses.
In the first analysis, neither pretreatment female partner DAS scores
nor type of ISD accounted for a significant proportion of the variance
in female partner SDTPS scores at posttreatment.
In the second analysis, female partner DAS scores at pretreatment did
account for a significant proportion of the variance in female partner
GRISS scores at posttreatment (0.43%,p < 0.05). The negative correla-
tion found between female partner DAS scores at pretreatment and fe-
male partner GRISS scores at posttreatment (-0.43) suggested that
treatment females with higher DAS scores (less marital distress) at pre-
treatment had lower GRlSS scores (better sexual adjustment) at post-
treatment. Type of ISD did not account for a significant proportion of
the variance in GRISS scores at posttreatment.
Low Sexual Desire in Women 173

ISD us Non-ISD Comparison

In addition to the treatment component of this study, a comparison was

made between ISD and non-ISD couples. The ISD group consisted of
the treatment and control group subjects used in the treatment compo-
nent of this study (n = 49). The non-ISD group consisted of couples in
which the woman or couple was receiving psychotherapy for a concern
other than ISD (females, n = 17; participating male partners, n = 15).
These couples were compared on the outcome measures and demo-
graphic variables used in the treatment component of this study. ISD
couples’ pretreatment scores were used in this analysis.
This comparison was conducted using two different methods. First,
the non-ISD couples were compared to the entire treatment sample of
ISD couples. Second, the non-ISD couples were compared to the ISD
couples according to ISD subtype. For this purpose, ISD couples were
divided into two groups: partner-specific ISD couples (n = 27) and global
ISD couples (n = 22). Global nonlifelong ISD and global lifelong ISD
couples were combined to form the global ISD group. Separate analyses
were carried out for female and male subjects.
The results of these two methods were identical. Therefore, only the
results of the primary ISD vs non-ISD comparison will be reported in
detail. The results of the comparison utilizing ISD subtypes will be sum-
marized.
Analysis of variance revealed no differences between ISD and non-
ISD couples on demographic variables. In addition, chi-square analysis
revealed no group differences in presence of sexual trauma in the female
partners’ past x2 = 2.72, p > 0.01.
Analysis of differences between ISD and non-ISD groups on combined
couple DAS scores were examined. The mean combined DAS couple
scores for the ISD and non-ISD groups were 100.54 (SD = 11.85) and
92.73 (SD = 13.39), respectively. This difference was found to be statisti-
cally significant, F( 1,62) = 4.69, p < 0.05, demonstrating that the non-
ISD group had significantly more marital distress than the ISD group.
The combined DAS scores of the non-ISD group receiving marital ther-
apy (n = 9, M = 91.22, SD = 12.80) were compared to the combined
DAS scores of the non-ISD group not receiving marital therapy (n = 6:
two male partners’ scores unavailable, M = 95.00, SD = 15.16), and no
significant difference was found, F(1,13) = 0.27, p > 0.05.
When the means for female ISD and non-ISD subjects on outcome
variables (DAS, GRISS, SDTPS, SCLGSI, BDI) were examined, a signifi-
cant main effect for group, F(5,59) = 16.40, p < 0.05, was found. S u b
sequent Roy-Bargman stepdown Rests revealed statistically significant
group differences on the GRISS, F( 1,62) = 26.86, p < 0.01, and SDTPS,
F(1,61) = 34.11, p < 0.01. Thus, the ISD females reported significantly
more distress on the GRISS and SDTPS than did non-ISD females.
For females, multivariate analysis of variance also revealed a significant
main effect for group, F(2,62) = 13.16, p < 0.05, on the GRISS subscales.
A significant group difference was also found on the sexual avoidance
174 Journal of Sex &Marital Therapy, Vol. 21, No. 3, Fall 1995

subscale, F(1,63) = 26.23, p < 0.01, indicating that ISD females avoided
sex more than non-ISD females. The univariate result for the sexual
infrequency subscale was at the exact Bonferroni corrected alpha level
for this analysis, F( 1,63) = 5.29, p = 0.025. A statistically significant group
difference was also found for the SHF sexual desire item, U = 83.00, p
= 0. N o significant differences were found for males partners on any of
the outcome measures examined.

ISD Subtypes vs Non-ISD Group

No statistically significant differences were found between non-ISD, part-

ner-specific ISD, and global ISD couples on demographic variables. Part-
ner-specific and global ISD couples did not have statistically significant
different scores on duration of ISD.
For females, non-ISD subjects were found to be significantly less dis-
tressed on the GRISS and the SDTPS than were partner-specific or global
ISD subjects (at the Bonferroni corrected alpha level of p < 0.01). Female
non-ISD subjects were also significantly less distressed than both of the
ISD subtype groups on the GlUSS sexual avoidance scale ( p < 0) and
the SHF sexual desire item ( p < 0). In addition, no statistically significant
differences were found on any demographic or outcome variable when
partner-specific ISD females were compared with global ISD females (i.e.,
no differences between subtypes). For males, no statistically significant
differences were found between non-ISD male partners and their part-
ner-specific ISD and global ISD counterparts. No statistically significant
differences were found between the partner-specific ISD male partners
and global ISD male partners on any of the variables investigated.

Summary of Results

Overall, the main posttreatment differences found between treatment

and control group subjects were that the treatment group females re-
ported a significantly higher level of sexual desire on one measure of
sexual desire and a lower level of depressive symptomatology. Descrip-
tively, the results of the analysis of clinical significance demonstrated
greater gains for the treatment group.
When the treatment couples were divided into those high and those
low in marital distress, based on combined couple DAS scores, and com-
pared to the total control group at posttreatment, low marital distress
female treatment subjects were found to have significantly better overall
sexual adjustment and reported a higher frequency of sex and a higher
level of sexual desire on one measure of sexual desire. Low marital d i s
tress males were found to report a higher frequency of sex and better
sexual communication than the control group males at posttreatment.
Analysis of treatment group gains across time showed significant gains
in several areas that were largely maintained over time, but these analyses
lacked a control group comparison. Regression analysis demonstrated
that treatment female pretreatment marital adjustment scores accounted
Low Sexual Desire in Women 175

for a significant portion of the variance in their overall sexual adjustment

scores at posttreatment, in that treatment females with better marital
adjustment scores initially tended to have better overall sexual adjust-
ment scores at posttreatment. Comparisons of ISD and non-ISD couples
demonstrated that the main differences between ISD and non-ISD fe-
males were found on the sexual measures, with ISD females reporting
more distress. No differences were found between ISD and non-ISD male
partners or between females and males in the ISD subtype categories.

DISCUSSION

In general, only very modest treatment gains were made by couples fol-
lowing marital therapy. When compared to control group couples at the
end of the wait-list period, the treatment couples were found to report
significantly higher levels of female global sexual desire and less female
depressive symptomatology. No significant differences were found in sev-
eral important areas such as overall sexual adjustment, sexual desire to-
ward partner, and frequency of sex. An examination of clinically
significant gains at the end of treatment showed a consistent trend in
favor of the treatment group, but these results are purely descriptive
in nature.
There are several possible explanations for these results. Positive
changes in sexual functioning and level of sexual desire were expected
to occur in response to heightened marital adjustment; however, the
treatment subjects' DAS scores were not significantly higher than those
of the control group at posttreatment. If greater gains in marital adjust-
ment had been made by the treatment group, greater positive change
on the sexual measures might also have occurred.
The level of improvement found in marital adjustment following ther-
apy was surprising, given that the type of marital thera used (EFT) has
been shown to be effective in as few as 8-10 session^.^'.t yIn these studies,
'
however, couples presented with the specific complaint of marital dis-
tress, expressed a specific need to improve marital functioning, and/or
presented with DAS scores that were clearly within the distressed range.
In the present study, the presenting concern was loss of sexual desire
and not marital conflict. The couples who received EFT in this study
were therefore different from couples in most other EFT outcome studies
in three ways: 1) they were not presenting with a primary complaint of
marital distress, 2) they did not have to be in the distressed range of the
DAS, and 3) they all presented with a primary complaint of ISD. These
differences, alone Qr in combination, may have resulted in the nonsig-
nificant effects found here.
The finding that marital therapy did not improve marital functioning
is also contrary to most of the existing literature examining the effect of
marital therapy on the marital functioning of couples experiencing sex-
ual problems. In most studies, marital therapy has led to a significant
increase in marital functioning for such couples.22In most studies, how-
ever, the subject population consisted of couples who presented with
I76 Journal of Sex 6'Marital Therapy, Vol. 21, No. 3, Fall 1995
- .___

marital distress and also had sexual concern^,^^,^^ and either couples with
ISD were excluded or there was no investigation of how the res onded
7
in comparison to couples with other sexual problem^.^^*^". 738 Low fre-
quency of sexual intercourse, a defining characteristic of couples in this
study, has been found to be a predictor of poor pro nosis in behavioral
marital therapy and communication skills training3 Low frequency of
sexual contact has also been identified in the marital therapy literature40
as symptomatic of a lack of emotional engagement, which appears to be
a powerful predictor of lack of success in marital therapy in general and
of marital disruption and distress.41Clinical observations suggested that
these partners had greater difficulty with contact, emotional and physical,
than couples in previous EFT outcome studies and made less progress
in 10 sessions of therapy. Hence, once more the findings in this study
may be due to the nature of the subject population: couples seeking
treatment for a sexual problem rather than marital distress, and all expe-
riencing ISD.
Discussion of how the subject population may have influenced the
effectiveness of EFT is purely speculative, but considering the amount
of clinically relevant information gained working with these couples, it
appears worthwhile to offer some comment. Female subjects commonly
reported that the symptom of ISD developed in response to unresolved
relationship issues or interpersonal conflict. Couples often chose to cen-
ter conflict around the rigid and escalating pattern associated with the
concrete symptom of ISD rather than underlying issues. With a limit of 10
EFT sessions, it was difficult to reduce tension around the ISD interaction
pattern to a point that allowed couples to work on underlying issues,
achieve resolution of underlying relationship issues, and integrate these
gains into sexual functioning.
The finding that treatment couples in the low marital distress group
made gains above those in the high marital distress group, when com-
pared to the control group, would appear to support the proposition that
those couples with less conflict-oriented relationships tended to make
the greatest gains in a relatively brief treatment. The regression analysis
findings that treatment females with lower pretreatment marital distress
tended to have better overall sexual adjustment at posttreatment would
appear to support this conclusion. Couples with higher levels of marital
distress in this population may have required a longer duration of treat-
ment to manifest improvement comparable to that found for low distress
couples. It is very possible that a longer duration of treatment may have
resulted in greater treatment gains. Recently, Johnson and Greenberg42
have stated that although EFT has been shown to be effective in as few
as eight sessions, 20 sessions are considered optimal.
Examination of the median values for the SHF sexual desire item dem-
onstrated that before treatment the typical treatment group female de-
sired to have sex less than once a month, whereas after treatment she
desired sex once every two weeks. This represented a statistically signifi-
cant positive change in reported level of sexual desire, as compared to
control group females, if not an optimal increase. However, the lack of
Low Sexual Desire an Women 177

significant differences in the sexual frequency of treatment and control

subjects at termination limits the practical significance of changes on the
SHF sexual desire item,
The discrepancy between the two direct measures of sexual desire
(SDTPS and SHF sexual desire item) in the results of the treatment and
control group comparisons may have been due to differences in what
the two measures attempt to assess. On the SHF sexual desire item, which
addresses the area of sexual desire in general, a significant difference was
found between treatment and control group females at posttreatment,
whereas no significant difference was found on the SDTPS. It is possible
that after therapy, treatment females experienced an increase in overall
level of sexual desire that had not yet fully developed enough to lead to
a specific increase in sexual desire for their partners.
The results of the analyses of treatment subjects over the three time
periods of pretreatment, posttreatment, and follow-up were encouraging.
Treated females made gains in several important areas such as global
sexual desire, sexual desire toward partner, and sexual avoidance.
Changes in marital functioning were again modest for females, and may
have limited gains in other areas, These analyses were also without the
benefit of a control group; therefore, their usefulness is limited.
Examining the within-group treatment group comparisons alone, how-
ever, the results of this study are comparable to those of Schover and
LoPiccolo.’ In their archival study of the effects of sex therapy on ISD,
pretreatment, posttreatment, and follow-up within-group comparisons
revealed posttreatment improvement that was maintained at follow-up.
As in this study, within-group improvement in their study was character-
ized as reflecting significant positive changes that were less than optimal.
In their study, however, significant improvements were also found in
frequency of intercourse. Like Hurlbert’~’~ study examining the effects
of combined sex and marital therapy, and combined sex and marital
therapy and orgasm consistency training, the present study also found
significant within-group improvement in sexual desire. Hurlbert’s study
examined other areas of change that were not assessed in this study,
such as sexual assertiveness and sexual arousal. In Hurlbert’s study no
significant change was found in sexual satisfaction from pretreatment to
posttreatment, and in the present study there was no significant change
found in overall sexual adjustment. Hurlbert found that at six-month
follow-up, the women who received orgasm consistency reported greater
sexual satisfaction than those who did not, but it is not clear whether this
represented a significant change from initial level of sexual satisfaction.
It was interesting that type of ISD was not found to predict female
level of sexual desire or sexual adjustment at posttreatment. Schover and
LoPiccolo~also found that type of ISD did not predict treatment outcome
for sex therapy. It may be that type of ISD is not a major predictor of
response to treatment. Alternatively, the probability of obtaining differ-
ential outcome effects based on ISD subtype may have been lowered by
the overall modest gains found in this study.
I78 Journal of Sex &Marital ‘I’hmupy, Vol. 21, No. 3,Fall 1995

In the existing literature, comparisons have been made between’ ISD

females and females not experiencing ISD and not receiving psychother-
apyZ5and 2) ISD females and females not experiencing ISD who were
part of a couple receiving therapy for another sexual problem.’3In previ-
ous studies, reports of desire disorders and ISD symptomatology were
absent in non-ISD couples. In the present study, subjects were not ex-
cluded on the basis of ISD symptoms. This permitted an investigation of
variables distinguishing between women seeking treatment for ISD and
women seeking treatment for other concerns. The potential confound
of receiving psychotherapy was taken into account as it was by Stuart et
al.,’>l3and the range of psychotherapy was expanded beyond just sex
therapy for sexual problems. In addition, comparisons were made be-
tween ISD and non-ISD male partners on measures other than simply
marital adjustment. Overall, the non-ISD sample used in this study adds
a new comparison to the existing literature. It must be noted, however,
that, as in previous comparisons reported in the literature, the sample
size was small, and this limits generalization of the results obtained. In
addition, over half of the non-ISD subjects were receiving marital ther-
apy, and although data on ISD symptomatology were obtained for sub-
jects in the non-ISD group, a reliable diagnosis of presence or absence
of ISD could not be made for all subjects.
The only major differences found between ISD and non-ISD subjects
were in the area of sexual desire and sexual adjustment. ISD females
were significantly more distressed on measures of overall sexual adjust-
ment, sexual desire, and sexual avoidance. This suggests that, on average,
females seeking treatment for ISD have at least more intense sexual de-
sire problems than women seeking therapy for other concerns. These
findings suggest that ISD is a separate diagnostic entity and not just a
group of sexual symptoms common to women seeking therapy in
general.
As in Stuart et al.,’ no significant differences were found between the
two groups on the frequency of sex. Stuart et al.’s sample of non-ISD
women were receiving sex therapy. It may be that couples involved in
the process of therapy do not have a high rate of sexual engagement.
The lack of significant differences on measures of depression (BDI)
and level of physical or psychological distress (SCLGSI) was consistent
with the results obtained by Schreiner-Engel and S~hiavi.*~ These findings
suggested that, although level of depression and psychological distress
may be related to some cases of ISD, these variables alone do not distin-
guish between women with high levels and lower levels of ISD symptom-
atology.
Although neither male nor female DAS scores were found to differenti-
ate between ISD and non-ISD couples, combined couple DAS scores
were found to be significantly higher (better) for the ISD group. These
findings were contrary to those of Stuart et al.,’ who found ISD couples
to have significantly lower female and male DAS scores than non-ISD
couples (combined couple scores were not examined). This discrepancy
may be explained by differences in the non-ISD comparison sample. In
Low Sexual Desire an Women 179

the present study, over half of the non-ISD couples were receiving marital
therapy, and this may have biased their DAS scores toward distress.
In the present study, the mean DAS score for ISD women was 99.37
(SD = 13.21). This was comparable to Stuart et al.’s’mean DAS score of
98.21 (SD= 16.23) for ISD women. Hurlbert’slgmean DAS score for ISD
women was somewhat higher, 103.32 (SD not provided). In the present
study, 69% of both male and female subjects had total DAS scores at
intake that were above the 97 point cutoff for marital distress recom-
mended by S~anier.‘~ In addition, ISD couples’ total DAS scores were
sometimes reflective of good marital adjustment; however, couple focus
on the symptom of ISD may have served to reduce the level of overall
relationship distress reported by these couples. Taken together, these
findings suggested that, although in many cases ISD may be related to
marital distress, the presence of marital distress in a relationship is nei-
ther necessary nor sufficient to produce high levels of ISD symptom-
atology.
As a final note on the results of this comparison, the incidence of
reported sexual trauma in the female partner’s past was not found to be
significantly different, but the difference was striking. Twenty-four per-
cent of ISD females reported ast sexual trauma, as compared to only
E
6% of non-ISD females. Maltz suggested that past sexual trauma may
be an important etiological factor in the development of ISD. Future
studies comparing ISD and non-ISD females may wish to assess this
variable.
Results of the comparison between non-ISD couples and couples with
global or partner-specific ISD were identical to the results of the overall
ISD vs non-ISD comparison. Comparison between the two subtypes re-
sulted in no statistically significant differences. These findings support
the views of Friedman and Hogan,32who argue against linking different
subtypes to specific potential etiological factors.

Strengths, Limitations, and Future Research

As suggested by O’Carroll,lBthe definition of ISD used in this study was

operationalized to include both subjective self-reports of desire and ob-
jective criteria. In addition, the present study used a homogeneous s u b
ject population, in that all women in the treatment and control groups
were experiencing ISD. Furthermore, the present study was the first ISD
treatment outcome study to use wait-list control group comparisons. The
treatment administered in this study was standardized, there was a treat-
ment manual, and therapist interventions were monitored.
This study was also subject to a number of limitations. Subjects had to
be willing to undergo a rigorous assessment process, and represented a
well-educated middle-class sample. These considerations may have influ-
enced the degree to which couples in this project were representative of
ISD and non-ISD couples in general. In addition, the DAS was useful in
assessing couple marital adjustment, but future research may wish to
incorporate measures of couple attachment or intimacy that may be
180 Journal of Sex &’ Marital Therapy, Vol. 21, No. 3, Fall 1995

more sensitive to detecting changes in emotional closeness or trust,

which may be important in understanding response to treatment in this
area. Therapist ratings of distress may also make a useful contribution.
The length of treatment in this study was fairly brief (10 sessions).
Future investigations may wish to extend the duration of treatment to
20 sessions. This study compared the effectiveness of only one type of
treatment to a wait-list control condition. Future research in this area
may wish to compare the effectiveness of different types of marital ther-
apy (e.g., EFT vs behavioral marital therapy) and different types of ther-
apy (e.g., marital therapy, sex therapy, combined sex and marital therapy,
and therapy for depression).
As suggested by O’Carroll,’* a multidimensional approach to sexual
desire assessment was used. The assessment tool developed for this
study-SDTPS-was found to be psychometrically sound and was able to
differentiate between ISD and non-ISD females. With further psychomet-
ric evaluation and the development of norms, the SDTPS may be of
further use in this area.
The sample size used in the treatment component of this study was
fairly large, but the comparison sample of non-ISD couples was small (n
= 17 females and 15 male partners), and the results must be interpreted
with this limitation in mind.
In conclusion, this study found marital therapy to have only modest
results in the treatment of ISD. It is hoped that this study will encourage
others to correct the limitations of this project and conduct additional
controlled outcome studies in this challenging area.

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