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Sexual problems among midlife and older adults: individual differences in sexual distress, comorbidity patterns and risk factors, and dyadic pathways linking to sexual dissatisfaction

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Sexual problems among midlife and older adults: individual differences in sexual distress, comorbidity patterns and risk factors, and dyadic pathways linking to sexual dissatisfaction

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Content 1

Sexual problems among midlife and older adults: individual differences in sexual distress,
comorbidity patterns and risk factors, and dyadic pathways linking to sexual dissatisfaction

by
Christine Juang

A DISSERTATION Presented to the
Faculty of the USC Graduate School
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF PHILOSOPHY (Psychology)

Degree being conferred
UNIVERSITY OF SOUTHERN CALIFORNIA
May 2018
2

Acknowledgements
I would like to express my gratitude for my adviser, Dr. Bob Knight, who has provided
consistent support since I entered the Clinical Science Ph.D. program. Bob has guided me
through various milestones and challenges during graduate school, and I particularly appreciate
his continued mentorship after he retired and moved to Australia.
I would also like to thank my committee members, Drs. Gayla Margolin, Richard John,
and John Walsh, who have provided important critiques and guidance for my dissertation. In
particular, I would like to thank Gayla, who has generously included me as part of her lab when
Bob retired. During that transition period, Dr. Tara Gruenewald was also incredibly helpful and
resourceful.
Finally, I would like to thank my friends and family. My parents have encouraged me and
cheered me on enthusiastically throughout the years. My parents-in-law have also provided me
with much needed support. My dear friends have helped me maintain work-life balance and a
sense of belonging in Los Angeles. Lastly, my husband, Chun-Kan, has been an extraordinary
source of joy, warmth, inspiration, comfort, and support.

3

Table of Contents
Acknowledgements ......................................................................................................................... 2
Overall Introduction ........................................................................................................................ 5
Manuscript 1: Sexual problems and sexual distress among older adults: the importance of sex
matters ........................................................................................................................................... 11
Abstract ..................................................................................................................................... 12
Introduction ............................................................................................................................... 13
Methods ..................................................................................................................................... 16
Results ....................................................................................................................................... 20
Discussion ................................................................................................................................. 23
References ................................................................................................................................. 28
Table 1 ................................................................................................................................... 32
Table 2 ................................................................................................................................... 34
Table 3 ................................................................................................................................... 35
Table 4 ................................................................................................................................... 36
Table 5 ................................................................................................................................... 37
Table 6 ................................................................................................................................... 38
Figure 1 .................................................................................................................................. 39
Figure 2 .................................................................................................................................. 40
Manuscript 2: Comorbidity patterns and risk factors of sexual problems among midlife and older
adults: a latent class analysis ......................................................................................................... 41
Abstract ..................................................................................................................................... 42
Introduction ............................................................................................................................... 43
Methods ..................................................................................................................................... 47
Results ....................................................................................................................................... 51
Discussion ................................................................................................................................. 53
References ................................................................................................................................. 60
Table 1 ................................................................................................................................... 65
Table 2 ................................................................................................................................... 67
Table 3 ................................................................................................................................... 68
Table 4 ................................................................................................................................... 69
4

Figure 1 .................................................................................................................................. 71
Manuscript 3: Pathways linking sexual problems to sexual dissatisfaction among older couples:
the mediating roles of physical pleasure and discontent with infrequent sex ............................... 72
Abstract ..................................................................................................................................... 73
Introduction ............................................................................................................................... 74
Methods ..................................................................................................................................... 78
Results ....................................................................................................................................... 81
Discussion ................................................................................................................................. 84
References ................................................................................................................................. 90
Table 1 ................................................................................................................................... 97
Table 2 ................................................................................................................................... 99
Table 3 ................................................................................................................................. 101
Table 4 ................................................................................................................................. 103
Figure 1 ................................................................................................................................ 105
Overall Discussion ...................................................................................................................... 106
Reference for overall introduction and discussion ...................................................................... 116
Appendix A: Sexuality-related variables .................................................................................... 121
Appendix B: Chronic health conditions and health behaviors .................................................... 124
Appendix C: 11-item Center for Epidemiological Studies- Depression (CES-D) scale ............ 126
Appendix D: Relationship quality .............................................................................................. 127
5

Overall Introduction
This dissertation examines sexuality in late-life. Sex is important for individuals across the
lifespan. At the individual level, sexuality is crucial to older people’s quality of life, well-being,
and physical health (Brody, 2010; Fisher, 2010). At the dyad level, sexual satisfaction and
expression have significant implications for relationship satisfaction and stability (Sprecher &
Cate, 2004). The relationship with one’s partner becomes more salient in late life, particularly
when new life stages, such as “empty nest” and “retirement,” emerge. In these stages, older
individuals spend more time with their partners due to increased life expectancy, decreased
family size and reduced need to raise children in adult years (Burgess, 2004). Hence, the need to
develop and foster intimacy becomes more important as older adults shift to these life stages.
However, stigma against older adults’ sexuality is pervasive, including beliefs that older
adults are asexual and that sexual problems in late-life are inevitable (Huffstetler, 2006; Syme &
Cohn, 2016). These stereotypes can have detrimental consequences to older adults. At the
individual level, older adults may internalize these stereotypes, disregarding their sexual health
and diminishing their capacity for sexual satisfaction (Kass, 1981; Weeks, 2002). At a societal
level, stereotypes may result in limited resources allocated to sexual health care for older adults
(Angus & Reeve, 2006). Thus, more research is needed to provide accurate information about
older adults’ sexual behaviors, attitude and functions.
Much is known about the prevalence rates of sexual activities and sexual problems in late-
life. The rates of sexual activity decline from younger to older adulthood, such that 73% of
middle-aged adults, 53% of older adults aged 65 to 74, and 26% older adults aged 75 or above
remain sexually active (Lindau et al., 2007). In a sample of adults over 70 years-old,
approximately one-third of older adults were sexually active, and approximately two-thirds were
6

satisfied with the frequency of sex (Matthias, Lubben, Atchison, & Schweitzer, 1997). In
general, sex remains at least somewhat important for 87% of older men and 65% of older women
(Matthias et al., 1997).
Common sexual problems in late-life include lack of sexual desire, inability to climax, and
erectile difficulties for men and lubrication problems for women (Hillman, 2012). Among
middle-aged and older adults, the prevalence rates of lack of sexual desire range from 25-29%
for men and 38-49% for women. The prevalence rates for arousal difficulties, or inability to
climax, range from 16-34% for men and 32-39% for women. For men’s erectile difficulties,
prevalence rates range from 30-45%, and for women’s lubrication problems, it ranges from 35-
44% for women (Lindau et al., 2007).
Interestingly, the rates varied when sexual distress is included as part of the definition for
sexual dysfunctions (Hayes, Dennerstein, Bennett, & Fairley, 2008). In the DSM-IV and DSM-5,
the presence of sexual distress, or feeling bothered by sexual problems, is required in order for a
sexual problem to be considered a sexual dysfunction. Thus, estimates of sexual dysfunctions are
lower when sexual distress is considered. For example, 48% of women reported low sexual
desire, but only 16% of women reported hypoactive sexual desire disorder (Hayes et al., 2008).
These findings highlight individual differences in the level of sexual distress, but it is unclear
who are more likely to be distressed and why. The overwhelmingly descriptive nature of these
studies is an example of a limitation commonly found in the aging and sexuality literature
(DeLamater, 2012). Thus, it is critical to move beyond descriptions of phenomena and explore
why certain phenomena exist. Thus, Manuscript 1 aims to investigate the underlying mechanisms
explaining why some individuals are more or less likely to be distressed.
7

While research primarily examines sexual problems separately, recent studies indicate that
sexual problems rarely occur in isolation (Bancroft, Graham, & McCord, 2001). For example,
erectile difficulties often coexist with lack of sexual desire and premature ejaculation (Corona et
al., 2013); women’s lack of sexual desire often coexists with sexual arousal difficulties (Peixoto
& Nobre, 2015). However, no systematic investigations have been conducted to explore what
sexual problems tend to cluster together and why these problems co-exist. As the extent to which
older adults experience multiple comorbid sexual problems is unclear, Manuscript 2 aims to
identify comorbid patterns of sexual problems and associated risk factors among older adults.
Sexual problems have been a big focus in the sexuality literature in part because there is a
strong association between sexual problems and sexual dissatisfaction (Fisher et al., 2015;
Heiman et al., 2011; Rosen, Heiman, Long, Fisher, & Sand, 2016). Thus, treatment efforts have
been focused on treating the sexual problems directly. For example, medical treatments for
erectile difficulties, such as Sildenafil, have been successful at treating erectile difficulties
(Heiman, 2002). Yet the effects of medications on other sexual problems, such as lack of sexual
desire or arousal difficulties, are small if not minimal (Frost & Donovana, 2015; Heiman, 2002).
In a meta-analysis, psychological interventions were found to have an average of a medium
effect size of reducing symptom severity of sexual dysfunctions, but the evidence varied across
the type of problems (Frühauf, Gerger, Schmidt, Munder, & Barth, 2013). The variable treatment
effects not only highlight the continued need to optimize these treatments but also reflect the
reality that some sexual problems are difficult to treat.
Thus, another important treatment goal, in addition to altering sexual function directly, is to
enhance sexual satisfaction in the presence of sexual problems. Psychological interventions, or
sex therapy, are seated at a unique position, such that they have the potential to improve sexual
8

function as well as help individuals learn to live and cope with sexual problems. Writings on sex
therapy stemmed from decades ago (Masters & Johnson, 1976), but components of sex therapy
are often drawn from clinical experience rather than from empirical findings. One way to address
the gap is to investigate pathways through which sexual problems shape sexual satisfaction in
order to identify and disrupt the pathways toward sexual dissatisfaction. For example, if sexual
problems are associated with sexual dissatisfaction because of reduced physical pleasure, finding
alternative ways to enhance physical pleasure may hold key to help clients lead a satisfying sex
life in the presence of sexual problems.
Yet exploring the mechanisms of one’s sexual problems on his or her own sexual
dissatisfaction may only be half the solution. A sexual problem is often not an individual
problem but a joint problem for the couple. Yet most studies either focus on individuals and
individual-level processes or fail to consider both partners simultaneously in the analyses
(Mustanski, Starks, & Newcomb, 2014). This calls for more research to view couples as dynamic
systems, in which both partners contribute to each other’s sexual experiences. Thus, Manuscript
3 examines the dyadic pathways linking sexual problems to sexual dissatisfaction.
Of note, it is important to acknowledge that the sexual experiences of older men and women
may be different. The gendered sexuality over the life course (GSLC) model (Carpenter &
DeLamater, 2012) suggests that men and women develop different patterns of sexual desires,
attitudes, and behaviors over the life course. The model posits that sexuality is shaped by life
transitions as well as individuals’ lifelong accumulations of advantageous and disadvantageous
experiences, which are often not the same for men and women. For instance, men and women
differ in their biology, such that chronic health conditions can be associated with men’s and
women’s sexual problems differently. For example, some studies have shown that physical
9

health is more closely linked with men’s sexual function than women’s (Dunn, Croft, & Hackett,
1999; Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, Wang, et al., 2005). In addition, older
women go through unique physiological changes during menopause, which can also be a
psychological event, as they are liberated from the fear of pregnancy.
Furthermore, the sociocultural contexts in which men and women live in are often quite
different when it comes to expectations and standards of sexual expressions. Sexual double
standards are well documented and even persist in the modern world, such that women’s sexual
expressions are often judged more negatively than men’s (Brodini & Sperb, 2013; Crawford &
Popp, 2003). These sexual double standards may be inappropriately internalized, such that an
older widow may believe that she should remain “faithful” to her deceased husband and not
express the desire for sex (Carpenter, 2010). Further, widowhood may impact sexuality at an
earlier age for women than men. While partner loss is more likely to occur in late-life,
widowhood frequently begins earlier for women than men (Das, Waite, & Laumann, 2012).
These examples highlight the need to acknowledge and address gender differences in older
adults’ sexual expressions.
Summary
In summary, this dissertation consists of three studies broadly focusing on sexual problems in
late-life. In Manuscript 1, we investigate individual differences in the level of sexual distress as
well as mediators that would explain such individual differences. In Manuscript 2, we explore an
understudied phenomenon of the comorbidity between sexual problems by identifying patterns
of comorbid sexual problems and their risk factors. In Manuscript 3, we investigate how sexual
problems shape older couples’ sexual experiences by examining the dyadic pathways linking
10

sexual problems to sexual dissatisfaction. Across these studies, gender differences will be
addressed.
These three studies are conducted using the sample or subsample from the National Social
Life, Health, and Aging Project (NSHAP; Waite et al., 2014a; Waite et al., 2014b). DeLamater
(2012) noted that most studies in the aging and sexuality literature used quasi-representative
sample, limiting the generalizability of study findings. As participation bias is more likely to
occur in surveys of sensitive issues (Dunne et al., 1997), it is crucial to use nationally-
represented samples in order to generalize the findings to the general population.
The three studies address conceptual and methodological limitations that have plagued the
literature. This dissertation hopes to explore pathways and mechanisms, beyond providing
descriptive statistics about older adults’ sexual activities and problems. In addition, this
dissertation also aims to view sexual problems differently: first as a constellation of problems
rather than separate problems and second as a joint problem within a dyadic system rather than
an individual-only problem. With these improvements, this dissertation aims to provide an
accurate understanding of the patterns and correlates of sexual problems in late-life, challenging
popular myths of older adults’ sexuality and offering important insights for assessing and
treating older adults’ sexual problems.
Running head: Sexual problems, sexual distress, and the importance of sex 11

Sexual problems and sexual distress among older adults: the importance of sex matters

Christine Juang
1
& Bob G. Knight
2

1
Department of Psychology, University of Southern California, Los Angeles
2
School of Psychology and Counseling, University of Southern Queensland, Australia

Correspondence concerning this article should be addressed to Christine Juang,
Department of Psychology, University of Southern California, Los Angeles CA 90089. Email:
juangc@usc.edu

Sexual problems, sexual distress, and the importance of sex 12

Abstract
Introduction: Sexual distress, or feeling bothered by sexual problems, is not always present
when individuals have sexual problems. It is unclear who are more or less likely to be sexually
distressed. Investigating individual differences in sexual distress allows us to further probe the
mechanisms that would lead to higher sexual distress. The study examines whether sexual
distress vary by gender, age group and partner status and further explores whether one’s attitude
towards the importance of sex explain these individual differences.
Methods: Sample included 2218 participants (1000 men and 1218 women) who reported at least
one sexual problem in our analyses drawn from the National, Social Life, Health, and Aging
Project (NSHAP) at Wave 2. Analyses of variance were conducted to test the effects of gender,
age group, and partner status. Multiple regression and mediation analyses were conducted to test
the mediating role of the importance of sex.
Results: We found that only 47% of men and 19% of women reported being distressed by their
sexual problems. Females, older adults, and those without partners were found to be less sexually
distressed, and the effects of gender, age group, and partner status on sexual distress were
partially mediated by the sexual attitude towards the importance of sex.
Conclusions: These results showed that attitude towards the importance of sex helped explain
why sexual distress varied by gender, age group and partner status. These findings highlighted
that viewing sex to be important can come at a cost, echoing recent concerns about society’s
overly strong emphasis on the importance of sex in late-life. Results provided clinical insight on
ways to reduce sexual distress through adjusting the importance of sex in late-life.
Keywords: Sexual problems, sexual dysfunctions, sexual distress, importance of sex, older adult
Sexual problems, sexual distress, and the importance of sex 13
Introduction
Older adults frequently report sexual problems, including lack of sexual desire, inability to
climax, men’s erectile difficulties and women’s lubrication problems. A wide range of
prevalence rates have been found. For example, women’s desire problems ranged from 12%
(Shifren, Monz, Russo, Segreti, & Johannes, 2008) to 55% (J. Richters, Grulich, de Visser,
Smith, & Rissel, 2003). Interestingly, research has found that the rates varied when sexual
distress is included as part of the definition for sexual dysfunctions (Hayes et al., 2008).
In the DSM-IV and DSM-5, the presence of sexual distress, or feeling bothered by his or her
sexual problems, is required in order for a sexual problem to be considered a sexual dysfunction.
Consequently, prevalence rates are typically lower when sexual distress is being considered. For
example, 48% of women reported low sexual desire, but when sexual distress was considered,
only 16% of women reported hypoactive sexual desire disorder. Similarly, the prevalence rate of
female sexual arousal disorder dropped from 24% to 7%, and the prevalence rate of female
orgasmic disorder dropped from 25% to 8% when sexual distress was included as part of the
definition of sexual dysfunction (Hayes et al., 2008).
Most research on sexual distress primarily focused on women, so it is unclear whether these
results are generalizable to men. Nevertheless, these findings indicate that a portion of
individuals with sexual problems do not perceive the problems to be bothersome or distressing.
In a Swedish nationally- representative sample, only 15% of women with low sexual interest
were distressed by the sexual problem significantly, whereas the majority were either not
distressed (39%) or only mildly distressed (46%) by low sexual interest (Oberg & Sjogren Fugl-
Meyer, 2005). This is also consistent with findings showing that 81% of women were satisfied
Sexual problems, sexual distress, and the importance of sex 14
with their sexual function, even though 70% of women reported having at least one sexual
problem (Ferenidou et al., 2008).
As sexual distress becomes an important dimension for sexual dysfunctions, reducing sexual
distress can be a key aspect of treatment for sexual dysfunction. Thus, it is important to
understand who are more likely to be distressed and why. Studying individual differences in the
level of sexual distress is vital as it demonstrates the heterogeneous experiences of having sexual
problems. Understanding who are more likely to be distressed allows us to further probe the
mechanisms that are linked with higher sexual distress, providing insights on ways to reduce
sexual distress. Thus, this study aims to investigate sources of individual differences of sexual
distress among older adults with sexual problems.
The intersections between age group, gender, and partner status
The gendered sexuality over the life course (GSLC) model suggests that sexual
experiences vary by age group and gender (Carpenter & DeLamater, 2012). From a life course
perspective, sexual experiences are influenced by life transitions, societal and historical contexts,
and age-related physiological changes. These influences are often gender-specific, resulting in
different patterns of sexual desires, attitudes, and behaviors for men and women. For instance,
partner loss is a life transition more common in late-life than midlife and more prevalent among
older women than older men. This is in part due to the fact that widowhood often occurs earlier
for women than men and in part due to the fact that it is harder for older women to find a new
partner (Carpenter & DeLamater, 2012). Furthermore, when faced with partner loss, there are
often different sexual standards for men and women. For example, an older widow may believe
that she should remain “faithful” to her deceased husbands, whereas it is appropriate for an older
widower to express sexual desire (Carpenter, 2010). Thus, men and women may exhibit different
Sexual problems, sexual distress, and the importance of sex 15
sexual trajectory following partner loss. This complex web of relationships between age group,
gender, and partner status highlight the need to take into account their effects when aiming to
understand individual differences in sexual distress.
Research has shown that older women tend to report lower levels of sexual distress in
response to low sexual desire than their younger counterparts (Connor et al., 2011; Hayes et al.,
2007; Leiblum, Koochaki, Rodenberg, Barton, & Rosen, 2006; Rosen et al., 2009). In one study,
49% of middle-aged women were distressed by low sexual desire, whereas only 12% of older
women were sexually distressed (Shifren et al., 2008). As older adults’ sexual experiences are
also closely linked with partner availability, having a partner is related to significantly more
sexual distress for females (Rosen et al., 2009), suggesting that those without partners may be
less distressed. As research on men’s sexual distress is scarce, it is unclear whether these
findings are generalizable to men. One study found that a larger proportion of men were found to
be sexually distressed than women across the lifespan (Alarcão, Machado, & Giami, 2016).
Thus, it is hypothesized that females, older adults, and individuals without partners are less likely
to be distressed about their sexual problems. As these differences not only operate
simultaneously but also intersect with one another, this study also explores how older adults’
sexual experiences intersect with gender, age group, and partner status.
Mediating pathway: the importance of sex
Although data suggests that females, older adults, and individuals without partners are
less likely to be distressed about their sexual problems, it remains unclear why. Hayes and
Dennerstein (2005) suggested that individuals who view sex as important will be more distressed
by their sexual problems. Presumably, if sex is not important, having sexual problems is likely
not bothersome. Indirect evidence has shown support for this view, such that those who report
Sexual problems, sexual distress, and the importance of sex 16
less distress also rate sex as less important. For example, women rated sex to be less important
than men (Müller, Nienaber, Reis, Kropp, & Meyer, 2014). In addition, older adults rated sex to
be less important than their younger counterparts (Bergström-Walan & Nielsen, 1990).
Additionally, older adults without a partner were more likely to view sex to be unimportant than
those with partners as suggested by a qualitative study (Gott & Hinchliff, 2003). Thus, it is
hypothesized that the importance of sex mediates the association between sexual distress and age
group, gender, and partner status.
Current study
The current study examines who are more likely to be sexual distressed about their sexual
problems and why. It is hypothesized that older age, being female, and lack of partner would be
associated with lower levels of sexual distress. The effects of age groups, gender, and partner
status on sexual distress are hypothesized to be mediated by the importance of sex. Specifically,
individuals who are older, who are females, and who do not have a partner will rate sex to be less
important, resulting in lower levels of distress about their sexual problems. We further explored
interactions between these factors to acknowledge that dynamic interplay between age groups,
gender, and partner status.
Methods
Participants
The proposed sample is from the National Social Life, Health, and Aging Project
(NSHAP) (Waite et al., 2014b). NSHAP is a study that aims to investigate health, social-life and
well-being among older adults using a nationally-representative sample. There are two waves in
this study. The first wave was conducted during July 2005, and the second wave was collected
during August 2010 to May 2011. The second wave of data was utilized in this study because
Sexual problems, sexual distress, and the importance of sex 17
sexual problems were only assessed among individuals who were sexually active in Wave 1. The
second wave of data had 3,377 total respondents (1538 men and 1839 women), including 955
couples.
Descriptive data of demographic information for Wave 2 respondents are presented in
Table 1. Other analyses focused primarily on individuals who reported at least one sexual
problem at Wave 2 (n=2218), including 1000 men and 1218 women. For analyses including both
men and women in the same analytic sample, we randomly selected one person per household,
because a subset of participants were heterosexual couples, suggestive of non-independence in
the data. Thus, the final sample included 1777 respondents, including 996 women and 781 men.
Measures
Self-report of sexual problems. All respondents were asked, “sometimes people go
through periods in which they are not interested in sex or are having trouble with sexual
gratification. We have just a few questions about whether during the last 12 months there has
ever been a period of several months or more when you…” experienced the following sexual
problems: lack of sexual interest, inability to climax, climax too quickly, pain during intercourse,
lack of sexual pleasure, anxiety about performance, erectile problems (men only), and lubrication
problems (women only). These questions included all respondents, regardless of their partner
status and sexually active status. The total number of sexual problems was calculated by
summing the number of endorsed sexual problems.
Sexual distress. Individuals who reported at least one sexual problem were asked, “how
much did this/these sexual problems bother you?” Participants responded on a 5-point scale: (0)
not at all, (1) slightly, (2) moderately, (3) very, and (4) extremely.
Sexual problems, sexual distress, and the importance of sex 18
Importance of sex. All participants were asked, “for some people sex is a very important
part of their lives and for others it is not very important at all. How important a part of your life
would say that sex is?” Participants responded on a 5-point scale, (1) not at all, (2) somewhat
important, (3) moderately important, (4) very important, and (5) extremely important.
Demographic information and covariates. We included demographic variables
reported at Wave 2. Age group included middle-aged adults (age≤65), young-old adults (ages
between 65-74), and old-old adults (age≥ 75; reference). Partner status was coded as yes if
participants reported being married, living with a romantic partner, having an intimate partner
(not living together), and no if reported being divorced, widowed, or never married and also not
having an intimate partner. Ethnicity included white (reference), black, and other. Education was
categorized into four groups: no high school degree (reference), high school degree, some
college, and college degree. Self-rated health examined individuals’ global perception of their
health. Participants were asked to rate their physical health on a 5-point scale of poor, fair, good,
very good, and excellent. Depression was assessed using the sum of the 11-item Center for
Epidemiological Studies Depression (CESD) on a scale of 0 (rarely or none of time) to 2
(occasionally/ most of the time).
Analyses
Prevalence rates. SPSS (Version 21) was used to calculate the prevalence rates of sexual
problems and sexual distress. Percentages were all weighted to provide a more accurate estimate
of the prevalence rates. We first provided the prevalence rates of sexual problems by age groups
and partner status separately for men and women. χ
2
tests were used to compare age group and
partner status differences in the prevalence rates of sexual problems.
Sexual problems, sexual distress, and the importance of sex 19
Among those who reported at least one sexual problem, we reported the percentages of
individuals who were sexually distressed about their sexual problems by age groups and partner
status separately for men and women. In this study, individuals were considered “distressed” if
they reported being at least moderately bothered by the sexual problem(s). Mildly bothered was
not considered distressed because the DSM-5 requires that “significant distress” is present for
diagnosis of sexual dysfunction. χ
2
tests were used to compare age group and partner status
differences in the percentages of individuals who are distressed by their sexual problems.
Analyses of variance (ANOVA). We conducted analyses of variance (ANOVA) for two
dependent continuous variables: sexual distress and the importance of sex. We included the same
independent variables for the two ANOVAs, including gender, age group, and partner status.
ANOVA was conducted using SPSS (Version 21).
Mediation analyses. To test the mediating role of the importance of sex, we first
conducted a multiple regression model on sexual distress without the importance of sex. A
subsequent mediation model was estimated to examine indirect effects of age group, gender, and
partner status on sexual distress via importance of sex (see Figure 1 for a depiction of this
mediation model). The analyses included covariates, including ethnicity, education, depression,
self-rated health, and the number of sexual problems.
Indirect effects were tested using the bootstrapping method. This method allowed for
empirical, nonparametric approximations of the sampling distributions of the indirect effects of
interest by repeatedly sampling the dataset 5000 times. This produced point estimates and 95%
confidence interval of the indirect effects. Bias-corrected (BC) confidence intervals were used as
that performed well in terms of both power and Type I error rates (Preacher & Hayes, 2008).
These analyses were conducted using Mplus (Version 7.31).
Sexual problems, sexual distress, and the importance of sex 20
Results
Descriptive statistics Table
Prevalence rates of sexual problems. In general, 69% of men (n=1000; unweighted
percentage= 70%) and 74% of women (n=1218; unweighted percentage= 72%) reported at least
one sexual problem. Prevalence rates for sexual problems by age group and partner status were
reported in Table 2 for men and Table 3 for women. The most common sexual problems for men
were erectile difficulties (43%), lack of sexual desire (34%), and inability to climax (32%).
These sexual problems were more prevalent with age. Having a partner was associated with
more prevalent erectile difficulties, anxiety about performance, and climaxing too quickly. Lack
of sexual desire was more prevalent among older men without partners than those with partners.
For women, the most common sexual problems for women were lack of sexual desire
(60%), inability to climax (34%) and lubrication problems (26%). Lack of sexual desire was
more prevalent with age, whereas lubrication problems were less prevalent with age among this
sample of midlife and older adults. All sexual problems were more prevalent among women with
partners, with the exception of lack of sexual desire. Lack of sexual desire was more prevalent
among older women without partners.
Percentages of sexual distress. The weighted percentage of individuals who were
sexually distressed by age groups and partner status for men and women were presented in Table
4 and Table 5. Among individuals with at least one sexual problem, 47% of men and 19% of
women reported being distressed by their sexual problems. The sexual problems with the highest
proportion of men being distressed were anxiety about performance (65%) and erectile problems
(60%). The least distressing sexual problem (40%) for men was lack of sexual desire. Older age
was associated with less prevalent sexual distress for most of men’s sexual problems. Partner
Sexual problems, sexual distress, and the importance of sex 21
status was not associated with the rates of sexual distress for most sexual problems, with the
exception of lack of sexual desire.
For women, the sexual problems with the highest proportion of sexual distress were
sexual pain (55%) and anxiety about performance (50%). Lack of sexual desire (17%) was the
least distressing sexual problem. For women with lack of sexual desire and inability to climax,
sexual distress was less prevalent in older age groups. Sexual distress was more prevalent among
with women with partners than those for those who reported lack of sexual desire, inability to
climax, and sex not pleasurable.
Analyses of variance (ANOVA).
Sexual distress. A three-way ANOVA, with the dependent variable being sexual distress,
was conducted. Results indicated a significant main effect of age group, F(2, 1788)=6.1, p <.001.
The Tukey post-hoc tests of multiple comparison indicated that the three age groups differed
significantly, such that older age groups reported lower sexual distress. A significant main effect
of gender was also found, F(1, 1788)=93.0, p <.001, such that men reported higher levels of
sexual distress than women. Having a partner was also associated with higher levels of sexual
distress, F(1, 1788)= 56.9, p <.001. No interaction effects between the three factors were
significant.
Importance of sex. A three-way ANOVA, with the dependent variable being the
importance of sex, was conducted. Results indicated a significant main effect of age group, F(2,
1641)=11.5, p <.001. The Tukey post-hoc tests of multiple comparison indicated that all three
age groups differed from each other significantly, with the older age groups rating sex to be less
important. A significant main effect of gender was found, F(1, 1641)=50.2, p <.001, such that
men rated sex as more important than women. Having a partner was also associated with a
Sexual problems, sexual distress, and the importance of sex 22
higher rating of the importance of sex, F(1, 1641)=82.2, p <.001. A significant interaction effect
between gender and partner was found, F(1, 1641)=8.6, p <.01, such that the differences between
partner status was larger for women than for men (see Figure 2). Neither Gender x Age group
interaction, Partner x Age group interaction nor Gender x Age group x Partner status interaction
were statistically significant.
Mediation analyses
To test the mediating role of the importance of sex, we first conducted a multiple
regression (Model 1. The dependent variable, sexual distress, was regressed on age group,
gender, partner status and other covariates (ethnicity, education, partner status, self-rated health,
depressive symptoms, and total sum of sexual problems). Age group, gender and partner status
were all significant predictors of sexual distress (see Table 6).
In the second model, we conducted a path analysis using structural equation modeling to
test whether the importance of sex mediated the association between sexual distress and the
following variables: age group, gender, partner status. Results indicated that higher perceived
importance of sex predicted higher levels of sexual distress (β= .22, p< .001). When importance
of sex was included in the model, there was no significant difference between the age groups.
Men still reported higher sexual distress than women (β= .20, p< .001). Having a partner was
also associated with higher levels of sexual distress (β= .10, p< .001). We also found that
middle-aged (β= .13, p< .001) and young-old adults (β= .13, p< .001) rated sex to be more
important than the old-old adults. Men also rated sex to be more important than women (β= .24,
p< .001). Partner status was also a significant predictor, such that those with a partner rated sex
to be more important than individuals without (β= .32, p< .001)
Sexual problems, sexual distress, and the importance of sex 23
Analyses of indirect effects showed the importance of sex was a significant mediator. We
found a significant indirect effect from middle-aged age group to sexual distress via the
importance of sex, B= .08, 95% CI [.05, .13], and also a significant indirect effect from young-
old age group to sexual distress, B= .06, 95% CI [.03, .09]. These findings suggested that
middle-aged and young-old adults reported higher sexual distress than old-old adults because
they rated sex as more important than old-old adults. Indirect effects from gender to sexual
distress via importance of sex was also significant, B=.11, 95% CI [.08, .15], such that men
reported higher sexual distress due to higher ratings of the importance of sex. Results also
indicated that importance of sex also partially mediated the association between partner status
and sexual distress, B= .14, 95% CI (.10, .19). These findings highlighted that the importance of
sex partially mediated the effects of age group, gender, and partner status on sexual distress.
Discussion
This study demonstrated that less than half of the older adults found sexual problems to
be bothersome. The level of sexual distress varied by gender, age group, and partner status.
Specifically, sexual distress was lower for females, older adults, and individuals without partners
compared to their counterparts. These differences suggested that sexual problems are not
universally problematic. Rather, the experiences of having sexual problems are heterogeneous.
These individual differences have important implications for interpreting the prevalence
rates and risk factors of sexual problems because findings vary whether sexual distress is being
considered. A review of population-based studies found that the rate of female low sexual desire
increased with age, but there was no consistent association between age and hypoactive sexual
desire disorder (Hayes & Dennerstein, 2005). This mixed pattern of older age can be explained
by the current findings. In our study, although sexual problems were more prevalent in older age
Sexual problems, sexual distress, and the importance of sex 24
groups, older age was associated with lower sexual distress. Thus, the rates of sexual
dysfunctions, or distressing sexual problems, were not expected to increase with old age. These
findings provided insights to the inconsistent findings of risk factors and their relations to the
prevalence rates of sexual problems.
We further demonstrated that sexual distress was closely linked to the importance of sex,
providing explanation for why individual differences in sexual distress existed. The greater
importance one places on sex, the more likely one is bothered by the sexual problems. The
importance of sex mediated the effects of gender, age group and partner status on sexual distress.
In other words, older adults, females, and individuals without a partner reported lower sexual
distress because they also rated sex to be less important. Thus, the sexual attitude towards the
importance of sex partially explained why sexual distress varied by age group, gender, and
partner status. It should be noted, however, that the mediations were partial, suggesting that there
may be alternative explanations for why sexual distress differed by gender and partner status, in
addition to differences in the attitude towards the importance of sex.
Of note, women without partners, regardless of age group, viewed sex to be less
important, as demonstrated by the gender and partner status interaction. Partner availability
appeared to matter more for women than men, consistent with prior findings showing that lack of
partner predicted lower sexual desire for women but not for men (J. D. DeLamater & Sill, 2005).
As lack of partner is associated with fewer opportunities for sex, it is possible that women adjust
to these circumstances by lowering their level of interest in and importance of sex. This is
supported by another study showing that women after age 40 adapted their level of sexual desire
to their opportunities for sex, such that fewer opportunities were associated with lower sexual
desire. In contrast, men reported higher sexual desire when men had fewer opportunities for sex
Sexual problems, sexual distress, and the importance of sex 25
(Gebauer, Baumeister, Sedikides, & Neberich, 2014). Our results indicated that partner loss is a
significant transition that affects the sexual trajectories and likely sets men and women further
apart, supporting the views of the gendered sexuality over the life course (GSLC) model.
In summary, these results indicated that how one views sex, or how important sex is,
shapes one’s experiences with sexual problems. When one places overly strong emphasis on the
importance of sex, they may be more distressed when they are faced with barriers of sexual
activities, such as sexual problems. This is consistent with a study suggesting that anxiously-
attached individuals experienced higher sexual distress when they have sexual problem because
they viewed sex as important means to maintain the relationship, fearing that sexual problems
will lead to rejection and abandonment (Stephenson & Meston, 2010).
While lower ratings of the importance of sex found among females, older adults, and
individuals without partners reflect a realistic appraisal of the role sex plays in their lives, we
cannot rule out the possibility that rating sex as less important is an enactment of stereotypes
against older adults, females, and those without partners. Older adults are frequently the subject
of ageist stereotypes, implicating that they are asexual. Further, society often impose restrictions
on the sexual expressions of females and those without partners, such as judging women’s sexual
expression more negatively than men’s or discouraging sex to take place outside a marital
context. This may help explain why females without partners, in particular, are more likely to
rate sex as less important. Thus, it is possible that differences in the importance of sex may be
reflective of the internalization of stereotypes and societal expectations.
Nevertheless, the results suggest that viewing sex to be important can come at a cost,
echoing recent concerns about society’s overly strong emphasis on the importance of sex in late-
life. Societal narratives emphasizing sexual vitality across the lifespan encourage a positive
Sexual problems, sexual distress, and the importance of sex 26
attitude towards older adults’ sexuality and empower older adults to assert their sexual needs.
Yet these messages also inadvertently establish a new sexual norm for older adults, resulting in
more pressure to stay sexually active (Marshall, 2006). Thus, the current study highlights that
there may be disadvantages of viewing sex to be important when faced with sexual problems.
The cost of viewing sex as important does not indicate that one should abandon the idea
of having sexual intercourse. Rather, a sense of healthy and balanced attitude towards sex is
encouraged. On the one hand, sex is important, but on the other hand, satisfaction and intimacy
can be achieved without having frequent sex. Qualitative studies have documented that older
couples adjust to sexual changes by de-emphasizing the importance of sexual intercourse,
emphasizing other types of physically intimate activities, and redefining the role of sex in their
lives (Gilbert, Ussher, & Perz, 2010; Gott & Hinchliff, 2003; Lodge & Umberson, 2012). Thus,
adjusting the importance of sex can be an important treatment goal to alleviate sexual distress.
Limitations.
There are some limitations. All items included in the analyses were single self-reported
items which may be prone to measurement error. In addition, data was cross-sectional, so we
cannot differentiate aging versus cohort differences or determine the directionality between the
importance of sex and sexual distress.
Conclusion
Despite the limitations, our study is the first, to our knowledge, to explore the
mechanisms that explain why sexual distress varied by gender, age group, and partner status. We
found that females, older adults, and individuals without partners reported less sexual distress in
part because they rated sex to be less important than their counterparts, highlighting that
subjective appraisals about the importance of sex matter for the adjustment of sexual problems.
Sexual problems, sexual distress, and the importance of sex 27
These results provided clinical insights on ways to alleviate sexual distress. More importantly,
the results highlighted the need to recognize the heterogeneous experiences of older adults with
sexual problems.

Sexual problems, sexual distress, and the importance of sex 28
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Sexual problems, sexual distress, and the importance of sex 32
Table 1. Unweighted descriptive statistics for demographic variables
Frequency (%) or Mean (SD; Min-Max)
Men (n=1538) Women (n=1839)
Age 73.1 (7.5; 38-99) 71.8 (8.5; 36- 91)
<65 217 (14.1%) 377 (20.5%)
65-74 689 (44.8%) 782 (42.5%)
>=75 632 (41.1%) 680 (37.0%)
Ethnicity
White 1104 (71.8%) 1299 (70.6%)
Black 217 (14.1%) 300 (16.3%)
Hispanic 174 (11.3%) 193 (10.5%)
Other 39 (2.5%) 39 (2.1%)
Education
< High school 304 (19.8%) 341 (18.5%)
High school degree 350 (22.8%) 483 (26.3%)
Some college 430 (28.0%) 642 (34.9%)
College degree 454 (29.5%) 373 (20.3%)
Marital status
Married 1201 (78.1%) 1085 (59.0%)
Living with a partner 39 (2.5%) 46 (2.5%)
Separated 17 (1.1%) 16 (.9%)
Divorced 96 (6.2%) 154 (8.4%)
Widowed 154 (10.0%) 492 (26.8%)
Sexual problems, sexual distress, and the importance of sex 33
Never married 31 (2.0%) 46 (2.5%)
Have intimate partner
1
67 (22.5%) 49 (6.9%)

Sexual problems, sexual distress, and the importance of sex 34
Table 2. Weighted prevalence rates of sexual problems by age groups and partner status for men.
Sexual problems
All Age Group (%) χ
2
test
2
Partner status All
n
1
% < 65 65-74 >75 χ
2
(2)= no yes χ
2
(1)=
At least one 1431 68.8 59.4 70.0 72.7 ns 63.7 69.9 ns
Lack of sexual desire 1407 33.8 22.4
a
33.5
a
40.5
c
25.0*** 44.1 31.7 13.3***
Inability to climax 1304 31.9 19.2
a
32.8
b
38.6
b
29.6*** 26.3 32.9 ns
Climax too quickly 1298 19.9 19.5
a,b
23.9
b
14.4
a
13.8*** 8.2 21.9 19.5***
Pain during intercourse 1351 1.9 3.4 1.1 2.2 ns 1.6 2.0 ns
Sex not pleasurable 1296 10.0 10.6 10.3 9.2 ns 8.1 10.3 ns
Anxiety about performance 1312 27.3 23.9
a,b
31.1
b
23.8
a
9.0* 19.8 28.6 6.5*
Erectile problems 1324 42.6 34.8
a
41.2
a
49.3
a
15.1* 28.6 45.2 19.1***
*p< .05, **p < .01, ***p < .001.
1
n is the unweighted frequency of valid responses.
2
χ
2
test was conducted to see whether the percentage of sexual problems/ sexual dysfunctions differed by age group. Percentages with
the same subscript letter

do not differ significantly from each other at the .05 level.
Sexual problems, sexual distress, and the importance of sex 35
Table 3. Weighted prevalence rates of sexual problems by age groups and partner status for women.
Sexual problems
All Age Group (%) χ
2
test
2
Partner status χ
2
test
2

n
1
% < 65 65-74 >75 χ
2
(2)= no yes χ
2
(1)=
At least one 1687 74.1 74.4 74.2 73.7 ns 73.6 74.4 ns
Lack of sexual desire 1654 59.5 51.9
a
59.2
b
65.8
b
18.8*** 70.1 52.8 48.8***
Inability to climax 1396 34.0 36.9 35.4 29.4 ns 24.1 39.2 32.8***
Climax too quickly 1435 5.0 7.9
a
4.8
a,b
2.5
b
12.4** 2.5 6.3 9.9**
Pain during intercourse 1488 10.5 15.8
a
10.5
b
5.8
c
23.2*** 3.4 14.3 43.2***
Sex not pleasurable 1414 16.7 17.5 18.5 13.3 ns 9.2 20.5 29.2***
Anxiety about performance 1468 7.6 11.3 7.9 6.0 ns 3.7 9.8 18.1***
Lubrication problems 1409 26.2 35.6
a
27.6
b
14.2
c
52.1*** 5.9 36.6 156.5***
*p< .05, **p < .01, ***p < .001.
1
n is the unweighted frequency of valid responses.
2
χ
2
test was conducted to see whether the percentage of sexual problems/ sexual dysfunctions differed by age group. Percentages with
the same subscript letter

do not differ significantly from each other at the .05 level.
Sexual problems, sexual distress, and the importance of sex 36
Table 4. Weighted percentages of men who are sexually distressed by age group and partner status.
% Age Group (%) χ
2
test
2
Partner status χ
2
test
2

n All < 65 65-74 >75 χ
2
(2)= no yes χ
2
(2)=
At least 1 sexual problem 1000 46.8 62.3
a
45.9
b
40.8
b
21.0*** 37.1 48.5 5.7*
Lack of sexual desire 495 39.8 56.0
a
40.5
a,b
33.9
b
9.1* 26.2 43.1 8.4**
Inability to climax 427 54.7 70.7
a
56.0
a,b
47.8
b
8.4* 60.6 53.9 ns
Climax too quickly 276 50.8 52.9 48.4 54.5 ns 40.8 51.5 ns
Pain during intercourse
3
28 45.0 - - - - - - -
Sex not pleasurable 127 56.4 80.3
a
50.2
b
48.9
b
7.9* 39.1 57.9 ns
Anxiety about performance 356 65.3 79.1
a
60.5
b
66.2
a,b
6.7* 56.9 66.4 ns
Erectile problems 555 60.2 80.9
a
60.6
a
51.1
b
23.6*** 60.5 60.1 ns
*p< .05, **p < .01, ***p < .001.
1
n is the unweighted frequency of valid responses

2
χ
2
test was conducted to see whether the percentage of sexual problems differed by age group. Percentages with the same subscript
letter

do not differ significantly from each other at the .05 level.
3
The number of individuals in some cells are below 15 due to small sample size. Thus, no percentages were calculated.
Sexual problems, sexual distress, and the importance of sex 37
Table 5. Weighted percentages of women who are sexually distressed by age group and partner status.
Age Group (%) χ
2
test
2
Partner status χ
2
test
2

n All < 65 65-74 >75 χ
2
(2)= no yes χ
2
(2)=
At least 1 sexual problem 1218 19.2 28.0
a
19.4
b
11.3
c
29.1*** 4.3 27.6 95.8***
Lack of sexual desire 955 16.6 24.4
a
17.8
a
9.8
b
19.6*** 3.2 26.8 89.8***
Inability to climax 471 26.8 34.1
a
26.5
a,b
18.2
b
7.9* 5.1 33.5 33.5***
Climax too quickly 78 22.2 - - - - - - -
Pain during intercourse
3
166 54.9 48.9 57.7 62.6 ns 37.4 56.9 ns
Sex not pleasurable
3
253 33.7 38.8 34.8 24.7 ns 16.2 37.5 6.8*
Anxiety about performance 139 49.6 43.9 50.5 56.2 ns 37.3 52.2 ns
Lubrication problems 358 40.8 41.4 47.6 35.0 ns 31.3 41.6 ns
*p< .05, **p < .01, ***p < .001.
1
n is the unweighted frequency of valid responses

2
χ
2
test was conducted to see whether the percentage of sexual problems differed by age group. Percentages with the same subscript
letter

do not differ significantly from each other at the .05 level.
3
The number of individuals in some cells are below 15 due to small sample size. Thus, no percentages were calculated.

Sexual problems, sexual distress, and the importance of sex 38

Table 6. Standardized coefficients and standard errors of weighted regression analyses
Model 1 Model 2
Sexual Distress Sexual Distress Importance of sex
Age group (ref=old-old)
Middle aged adults .08 (.03)** .05 (.03) .13 (.03)***
Young-old adults .06 (.03)* .03 (.03) .12 (.03)***
Gender .25 (.03)*** .20 (.03)*** .22 (.03)***
Partner status .17 (.03)*** .10 (.04)*** .32 (.03)***
Importance of sex - .22 (.03)*** -
Ethnicity
Black -.07 (.02)** -.08 (.02)*** .06 (.02)*
Other -.03 (.03) -.04 (.03) .06 (.03)*
Education
High School .04 (.03) .03 (.03) .02 (.04)
Some college .07 (.04) .05 (.03) .09 (.05)
College .12 (.04)** .11 (.04)** .03 (.05)
Self-rated health -.02 (.03) -.03 (.03) .05 (.03)
Depressive symptoms .10 (.03)*** .10 (.03)*** -.01 (.03)
Sum of sexual problems .33 (.03)*** .35 (.03)*** -.09 (.03)***
*p< .05, **p < .01, ***p < .001.

Sexual problems, sexual distress, and the importance of sex 39

Figure 1. Conceptual model for the mediation model. Importance of sex as a mediator for the
effects of age group, gender, and partner status on sexual distress.

Sexual problems, sexual distress, and the importance of sex 40

Figure 2. Gender x Partner status interaction on the importance of sex

0
1
2
3
Men Women
Importance of sex
Interaction between Gender and Partner Status
Have a partner No partner
Running head: Comorbid sexual problems and their risk factors 41

Comorbidity patterns and risk factors of sexual problems among midlife and older adults: a latent
class analysis

Christine Juang, M.A., Department of Psychology, University of Southern California,
Los Angeles, United States
Bob G. Knight, Ph.D., School of Psychology and Counseling, University of Southern
Queensland, Australia

Correspondence concerning this article should be addressed to Christine Juang,
Department of Psychology, University of Southern California, Los Angeles CA 90089. Email:
juangc@usc.edu

Comorbid sexual problems and their risk factors 42

Abstract
Objective: This study identified different patterns of comorbid sexual problems and their risk
factors in late-life to better understand the etiology of sexual problems. Principles of multifinality
and equifinality in the context of sexual problems were addressed. Methods: Participants (1431
men and 1687 women) were drawn from the Wave 2 dataset of the National, Social Life, Health,
and Aging Project (NSHAP). Latent class analysis was conducted using 7 dichotomous self-
report sexual problems to identify subgroups with similar patterns of co-occurring sexual
problems. Cross-sectional and longitudinal multinomial regression was conducted to identify
demographic, physical and mental health predictors of these subgroups. Results: Results
indicated four patterns of sexual problems for men (minimal sexual problems, moderately
affected, climaxing-erectile difficulties, and multiple sexual problems group) and three patterns
for women (minimal sexual problems, desire-climaxing problems, and multiple sexual problems
group). Men’s climaxing-erectile difficulties group was predicted by older age, poor physical
health, and depression, whereas men’s multiple sexual problems group was predicted
predominantly by mental health factors. For women, education played a significant role in the
membership of multiple sexual problems group. Metabolic risk factors were associated with
women’s desire-climaxing problems. Conclusions: Different patterns of sexual problems were
associated with different risk factors. Findings highlighted multifinality, such that mental health
factors contribute to the development of multiple sexual problems for men. Equifinality was
demonstrated by the identification of multiple risk factors. These findings offered a nuanced
view of the comorbidity patterns of sexual problems and possible explanations for the co-
occurrence.
Keywords: Sexual problems, comorbidity, risk factors, latent class analysis
Comorbid sexual problems and their risk factors 43

Introduction
Sex remains important across the lifespan (Lindau et al., 2007), but research on aging and
sexuality has received relatively little attention. It is critical to understand sexual problems in
late-life, as sexual problems pose threats for older adults to express their sexuality and maintain
intimacy with their partners. Previous studies on aging and sexuality focused primarily on
identifying risk factors of single sexual problems. Most studies have examined sexual problems
separately, but sexual problems rarely occur in isolation (Bancroft et al., 2001).
High rates of comorbidity, or the co-existence or overlapping of different sexual problems, are
commonly found in men and women across the lifespan (Nobre, Pinto-Gouveia, & Gomes,
2006). Among younger adults diagnosed with hypoactive sexual desire disorder, 47% of men
and 41% of women have at least one other sexual dysfunction (Segraves & Segraves, 1991).
Men across the lifespan with erectile difficulties also frequently report having lack of sexual
desire or premature ejaculation (Corona et al., 2015; Corona et al., 2013; Porst et al., 2007). In a
population-based sample of women across the lifespan, women frequently report concurrent lack
of sexual desire and sexual arousal difficulties as well as dyspareunia and vaginismus (Peixoto &
Nobre, 2015).
These high rates of co-existing sexual problems should not be overlooked. Examining
comorbidity patterns of sexual problems in late-life can clarify the etiology of sexual problems.
Identifying risk factors of these patterns can further address two useful but underutilized
principles from developmental psychopathology: multifinality and equifinality. Multifinality
indicates that a given cause can lead to a variety of outcomes, whereas equifinality suggests that
multiple causes can lead to the same outcome (Cicchetti & Rogosch, 1996).
Multifinality: Shared risk factors contribute to the comorbidity between sexual problems
Comorbid sexual problems and their risk factors 44

In the context of sexual problems, multifinality indicates that a risk factor increases the risk of
developing multiple sexual problems, suggesting that sexual problems co-occur because they
share the same risk factors. Shared risks are likely factors that influence all biopsychosocial
aspects of a satisfying sexual relationship, resulting in comorbidities between different sexual
problems. Mental health problems, such as depression and heavy drinking, are likely shared risk
factors because of their varied biopsychosocial consequences.
Depression has been shown to separately increase the risks of many sexual problems for men
and women across the lifespan, including lack of sexual desire, arousal difficulties, lubrication
difficulties, and erectile difficulties, in cross-sectional studies (Araujo, Durante, Feldman,
Goldstein, & McKinlay, 1998; Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, & Wang,
2005; Laumann, Paik, & Rosen, 1999; Moreira, Glasser, Gingell, & Group, 2005; Shifren et al.,
2008). This may be because depression is associated with biological dysregulations in systems
important for sexual functioning, such as the hypothalamic-pituitary-adrenal (HPA)- axis,
metabolic and immune-inflammatory systems (Penninx, Milaneschi, Lamers, & Vogelzangs,
2013). Further, symptoms and behavioral patterns of depression, such as anhedonia, fatigue, low
self-esteem, inability to experience pleasure, and social withdrawal, could interfere with forming
and maintaining intimate and sexual relationships. For example, heightened self-focus and
performance anxiety could lead to erectile difficulties and decreased desire, arousal, and pleasure
(Atlantis & Sullivan, 2012).
Similarly, a large proportion of younger adults with alcohol dependence had multiple
complaints of sexual dysfunctions, including erectile difficulties, low sexual desire, and
problems with ejaculation (Arackal & Benegal, 2007; Peugh & Belenko, 2001). Heavy drinking
is associated with biological dysregulations, such as vagal neuropathy, lower testosterone, and
Comorbid sexual problems and their risk factors 45

changes in hormonal response, as well as interpersonal conflicts that can undermine sexual
relationships (O'Farrell, Choquette, Cutter, & Birchler, 1997; Olusola, Helen, Abiodun, & Udo,
2014). Thus, given that depression and heavy drinking have been shown to separately increase
the risks of co-occurring sexual problems, they may function as shared risk factors, underlying
several sexual problems because of their multifaceted consequences that disrupt sexual
functioning.
Equifinality: sexual problems are multiply determined
Equifinality suggests that different risk factors increase the risk of developing the same
sexual problem. This view is consistent with current conceptualizations that sexual problems are
multiply determined (Wincze & Weisberg, 2015). For example, men’s erectile difficulties have
been consistently predicted by older age, poor self-rated physical health, cardiovascular disease
(CVD), diabetes and depression in cross-sectional studies (Araujo et al., 1998; Bacon et al.,
2003; Dunn et al., 1999; Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, & Wang, 2005;
Laumann et al., 1999; Lindau et al., 2007; Moreira et al., 2005). For lack of sexual desire, older
age, CVD, and depression have been identified as risk factors (Laumann, Nicolosi, Glasser, Paik,
Gingell, Moreira, & Wang, 2005; Laumann et al., 1999; Lindau et al., 2007; Moreira et al., 2005;
Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Shifren et al., 2008).
Can different risk factors predict different comorbidity patterns of sexual problems?
However, some risk factors do not appear to be consistently significant across studies. Men
and women’s lack of sexual desire is predicted by older age in some (Laumann, Nicolosi,
Glasser, Paik, Gingell, Moreira, & Wang, 2005; Ponholzer et al., 2005) but not in other studies
(Laumann et al., 1999; Lindau et al., 2007; Moreira et al., 2005). CVD also predicts lack of
sexual desire in some (Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, & Wang, 2005;
Moreira et al., 2005) but not in other studies (Ponholzer et al., 2005; Shifren et al., 2008). In
Comorbid sexual problems and their risk factors 46

addition to lack of sexual desire, these mixed patterns of older age and CVD are also found in
studies examining inability to climax, premature ejaculation, and lubrication problems (Dunn et
al., 1999; Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, & Wang, 2005; Laumann et al.,
1999; Lindau et al., 2007; Moreira et al., 2005; Ponholzer et al., 2005; Shifren et al., 2008).
These findings suggest that the predictability of the different risk factors may vary depending
on the types of sexual problems examined. While older age and CVD have been a consistent
predictors of erectile difficulties, they are less consistently associated with other sexual
problems. In contrast, depression is a consistent predictor for multiple sexual problems. This
raises the interesting question of whether different risk factors are associated with different
patterns of co-existing sexual problems. For example, depression may predict a pattern of
multiple sexual problems, whereas older age may predict a pattern with predominantly erectile
difficulties. Investigating patterns of co-existing sexual problems provides the opportunity to see
how multiple factors contribute to the same sexual problem but predict distinct patterns of sexual
problems.
The current study
Taken together, examining patterns of co-occurring sexual problems and their risk factors
provides a unique perspective on the etiology of sexual problems. A person-centered approach to
data analysis, which examines relationships among individuals, identifies common patterns of
co-occurring sexual problems. This approach differs from the traditional variable-centered
approaches, such as multiple regression or factor analysis, which focus on the relationships
among variables (Muthen & Muthen, 2000). An example of a person-centered approach is latent
class analysis, a method that identifies subgroups of individuals with similar patterns of co-
occurring sexual problems.
Comorbid sexual problems and their risk factors 47

This study uses latent class analyses to identify common comorbidity patterns of sexual
problems in late-life and examines a range of risk factors, including demographic variables,
physical health, and mental health factors previously found to be important risk factors. To
disentangle the complex associations between risk factors and sexual problems, this study
assesses cross-sectional and longitudinal associations between risk factors and these patterns of
sexual problems.
Methods
Participants
Participants in the study were drawn from the National, Social Life, Health, and Aging
Project (NSHAP) (Waite et al., 2014a). There are two waves in this study. The first wave was
conducted during July 2005 to March 2006 through face-to-face interviews, questionnaires, and
in home collection of biomeasures. The final sample of the Wave 1 dataset includes 3,005
community-dwelling respondents with ages ranging from 57 to 85. The second wave was
collected during August 2010 to May 2011. The sample from Wave 2 includes respondents from
Wave 1, Wave 1 non-respondents, and partners of the main respondents. This results in 3,377
total respondents.
The sample from Wave 2 was used to conduct latent class analyses to identify subgroups
of individuals with similar patterns of sexual problems. In these analyses, 107 men and 152
women were excluded due to missing data needed for latent class analysis (i.e., all indicators of
sexual problems). This resulted in 1431 men and 1687 women in the final sample. In this sample,
1014 men and 1074 women participated in both Wave 1 and Wave 2.
Demographic information is presented in Table 1. In this sample, 86% of older adults
were 65 years-old or above. Approximately 70% of the sample was white. Over half of the
Comorbid sexual problems and their risk factors 48

sample had an education of some college or above. Seventy-eight percent of men and 59% of
women were married. Forty-eight percent of men and 34% of women reported being sexually
active for the last 3 months.
Measure
Self-report of sexual problems. Self-reported sexual problems were used as indicators
to estimate the latent classes. All respondents, regardless of whether they were sexually active,
were asked, “sometimes people go through periods in which they are not interested in sex or are
having trouble with sexual gratification. We have just a few questions about whether during the
last 12 months there has ever been a period of several months or more when you…” experienced
the following sexual problems: lack of sexual interest, inability to climax, climax too quickly,
pain during intercourse, lack of sexual pleasure, anxiety about performance, erectile problems
(men only), and lubrication problems (women only). The frequencies of endorsing these sexual
problems were presented in Table 2. The most common sexual problems for men were erectile
problems, lack of sexual interest, and climaxing too quickly. For women, the most common were
lack of sexual interest, inability to climax, and lack of sexual pleasure. In general, there were
fewer than 5% of men endorsing pain during intercourse and women reporting climaxing too
quickly.
Demographic information. We included demographic variables reported at Wave 2. Age
at Wave 2 was included as a continuous predictor. Other variables were included as covariates.
Ethnicity included White (reference), Black, and other. Education was categorized into four
groups: no high school degree (reference), high school degree, some college, and college degree.
Partner status was coded as yes if participants reported being married, living with a romantic
Comorbid sexual problems and their risk factors 49

partner, having an intimate partner (not living together), and no if reported being divorced,
widowed, or never married and also not having an intimate partner.
Physical and mental health predictors of latent class membership. The cross-
sectional analyses included physical and mental health factors from Wave 2, whereas for the
longitudinal analyses, Wave 1 variables were used to see whether these factors predicted latent
classes over time. Participants were asked to identify the presence of cardiovascular disease
(CVD) event, cancer (yes/no), and diabetes (yes/no). CVD event from Wave 1 was coded as yes
if they report experiencing stroke, heart attack, heart failure or operation to unclog arteries in
legs. CVD from Wave 2 was coded as yes if they reported experiencing stroke, heart attack,
congestive heart failure or other heart problems. Cancer was coded as yes if they reported any
types of cancer. Heavy drinking was coded as yes if participants reported having 4 drinks/day for
at least one day over the past three months. Currently smoking (yes/no) were also included.
Depression was assessed using the 11-item Center for Epidemiological Studies Depression
(CESD) on a scale of 0 (rarely or none of time) to 2 (occasionally/ most of the time). The cut-off
point for clinically significant symptoms of depression was 9 (Payne, Hedberg, Kozloski, Dale,
& McClintock, 2014).
Analyses
Descriptive statistics were calculated using SPSS (Version 21). All other analyses were
conducted in Mplus (Version 7.31). Missing data were handled using the full information
maximum likelihood method. All analyses included non-response adjusted weights and further
adjusted for clustering and stratification of the complex sampling design. Latent class analyses
were conducted using maximum- likelihood estimation based on an expectation-maximization
algorithm. It is an iterative approach that begins with a set of start values to estimate parameters
Comorbid sexual problems and their risk factors 50

and continues to re-estimate the values until convergence is reached, or until the largest log
likelihood is achieved. To ensure that the global maximum of log likelihood was reached, the
models were run with different starting values. A series of models with increasing numbers of
classes were estimated, beginning with a 2-class model to a 5-class model.
To determine the optimal number of classes that best described the data, the following
model fit indices were evaluated (Hagenaars & McCutcheon, 2002): Akaike Information
Criterion (AIC), Bayesian Information Criterion (BIC), and sample size adjusted Bayesian
Information Criterion (SSABIC). The lower the values, the better the model fit. The Lo-Mendell-
Rubin adjusted likelihood ratio test was evaluated to compare the increase in fit between a model
with k number of classes and a k-1 class model. An insignificant p-value indicates that the k class
model does not provide significantly better fit than the k-1 class model, showing that the k-1
class model is more parsimonious. To allow for meaningful interpretation, we also considered
whether it was possible to assign labels to the classes in the final solution and whether the
sample size of each class was large enough to be meaningful.
We conducted both cross-sectional and longitudinal multinomial regression to identify
concurrent Wave 2 predictors as well as well as Wave 1 factors that predict class memberships
over time. To conduct the multinomial regression, we used the new three step approach in Mplus
(Version 7.31). This method examines the association between the latent class variable and
predictors, while taking into account misclassification, or measurement error of assigning the
most likely class membership (Asparouhov & Muthen, 2014). This method has advantages over
traditional methods of directly assigning individuals to the most likely membership class,
because class assignments are prone to misclassification errors, particularly when entropy is low.
Comorbid sexual problems and their risk factors 51

The three step approach also addresses limitations of the one step approach, such as problems
with model building.
Of note, the three step approach in Mplus did not support full information maximum
likelihood, so missing data was handled through listwise deletion. The final sample included in
the cross-sectional multinomial regression was 1385 men and 1647 women. The longitudinal
multinomial regression included 990 men and 1051 women who participated in both Wave 1 and
Wave 2. The results of multinomial regression were reported as odds ratios with their 95%
confidence intervals. The inclusion of 1 in the 95% confidence interval indicated that the odds
ratio was not significant.
Results
Latent class analysis
Fit indices for the latent class analysis were shown in Table 3. For men, a 4-class model
was identified as the most parsimonious description of the data. For women, a 3-class solution
provided the best fit. Results from the bivariate model fit information indicated that the
assumption of local independence was not violated for these two models. The proportions for the
latent classes were calculated based on categorizing individuals to their most likely latent class
membership. Item probabilities by class for men and women were presented in Figure 1. Item
probabilities above 70% were considered high, whereas below 30% were considered low
probabilities. Item probabilities between 30-70% were considered moderate probabilities.
For men, the largest group was labelled the minimal sexual problems group (45.2%), with
low probabilities of endorsing all of the sexual problems. The second largest group was
identified as the climaxing-erectile difficulties group (35.8%), with high probabilities of
reporting inability to climax and erectile difficulties and low probabilities of reporting climaxing
Comorbid sexual problems and their risk factors 52

too quickly, pain, and lack of sexual pleasure. Approximately 14.5% of men were categorized
into the moderately affected group, with moderate probabilities of reporting climaxing quickly,
anxiety about performance, and erectile difficulties with low probabilities of low sexual desire,
inability to climax, pain, and lack of sexual pleasure. Other men were categorized into the
multiple sexual problems group (4.5%) with high probabilities of reporting most sexual
problems.
For women, 58.1% the sample was categorized into the minimal sexual problems group,
with low probabilities of reporting most sexual problems. The second largest group was the
desire-climaxing problems group (31.0%), with high probabilities of reporting low sexual desire
and inability to climax. Approximately 10.9% of women were categorized into the multiple
sexual problems group, with high probabilities of reporting low sexual desire, sexual pain and
lubrication problems and moderate probabilities of other problems.
Cross-sectional multinomial regression
Multinomial regression was conducted to identify Wave 2 predictors of the latent classes,
with the minimal sexual problems groups treated as the reference groups for men and women
(see Table 4). Compared to men in the minimal sexual problems group, men in the multiple
sexual problems group were more likely to report heavy drinking (OR= 2.56, 95% CI [1.03,
6.33]) and depression (OR= 4.07, 95% CI [1.26, 13.20]). Men in the climaxing-erectile
difficulties group were more likely to be older (OR=1.04, 95% CI [1.01, 1.08]), have a partner
(OR= 2.00, 95% CI [1.14, 3.51]), more likely to report diabetes (OR= 2.06, 95% CI [1.27,
3.35]), CVD (OR= 1.72, 95% CI [1.11, 2.66]), cancer (OR= 1.60, 95% CI [1.04, 2.48]), and
depression (OR= 1.87, 95% CI [1.15, 3.03]). Men in the moderately affected group were more
Comorbid sexual problems and their risk factors 53

likely to have a partner (OR=4.00, 95% CI [1.06, 7.50], report diabetes (OR= 2.82, 95% CI
[1.06, 7.50]) and cancer (OR=2.66, 95% CI [1.29, 5.48]).
Compared to women in the minimal sexual problems group, women in the multiple
sexual problems group were more likely to have some college education (OR= 3.12, 95% CI
[1.58, 6.18]) and a college degree (OR= 2.76, 95% CI [1.38, 5.52]), and have a partner (OR=
19.57, 95% CI [3.62, 105.80]). Women in the desire-arousal problems group were more likely to
report diabetes (OR= 1.59, 95% CI [1.08, 2.34]) and less likely to report CVD (OR= .54, 95% CI
[.35, .84]), compared to the minimal sexual problems group.
Longitudinal multinomial regression
Multinomial regression was conducted to identify Wave 1 predictors of the Wave 2 latent
classes, after adjusting for the effects of Wave 2 demographic covariates, including age,
ethnicity, education, and partner status. Minimal sexual problems groups were treated as the
reference groups for men and women. Compared to men in the minimal sexual problems group,
men in the multiple sexual problems group were more likely to report heavy drinking (OR= 3.68,
95% CI [1.25, 10.79]) at Wave 1. Men in the climaxing-erectile difficulties were more likely to
have depression (OR= 3.00, 95% CI [1.08, 8.29]) at Wave 1. No Wave 1 predictors were
identified for the moderately affected group. Compared to women in the minimal sexual
problems group, women in the desire-climaxing problems group were more likely to report
smoking (OR=2.11, 95% CI [1.07, 4.17]) at Wave 1. No Wave 1 predictors were identified for
women’s multiple sexual problems group.
Discussion
To better understand patterns of comorbid sexual problems in late-life, this study
identified subgroups of individuals with similar comorbidity patterns in a nationally
Comorbid sexual problems and their risk factors 54

representative sample. Results showed four subgroups of older men with different patterns of
comorbidity: the minimal sexual problems group, moderately affected group, climaxing-erectile
difficulties group, and multiple sexual problems group. Three subgroups for older women were
identified: the minimal sexual problems group, desire-climaxing problems group, and multiple
sexual problems group. Of note, approximately half of the older adults were in the minimal
sexual problems groups, contrary to popular beliefs that sexual problems are part of normal
aging (Gott & Hinchliff, 2003). These subgroups with different patterns of comorbid sexual
problems were predicted by different sets of risk factors, demonstrating equifinality and
multifinality.
Equifinality is demonstrated through the identification of multiple risk factors, consistent
with the views that sexual problems are multiply determined. Men’s membership for the
moderately affected group were predicted by concurrent diabetes and cancer. Membership for
the climaxing- erectile difficulties group, compared to the minimal sexual problems group, was
predicted by older age, diabetes, CVD events, cancer, and depression concurrently. Our findings
are consistent with the literature showing that poor overall health and chronic medical conditions
increase the risks of erectile difficulties and inability to climax (Araujo et al., 1998; Bacon et al.,
2003; Laumann, Nicolosi, Glasser, Paik, Gingell, Moreira, & Wang, 2005; Lindau et al., 2007;
Moreira et al., 2005). Of note, depression emerged as the only significant predictor over time for
the climaxing- erectile difficulties group, further supporting the notion that erectile difficulties,
depression, and CVD have a common pathophysiological background (Gandaglia et al., 2014).
Our findings also showed multifinality, such that mental health problems played a
significant role in the co-occurrence of sexual problems for men. Compared to the minimal
sexual problems group, men’s membership in the multiple sexual problems group was predicted
Comorbid sexual problems and their risk factors 55

by concurrent depression and heavy drinking. Past heavy drinking also emerged as the main risk
factor for men’s multiple sexual problems over time. Physical health did not predict men’s
membership in the multiple sexual problems group. This is consistent with a meta-analysis
indicating that comorbid erectile difficulties and premature ejaculation were better predicted by
mental than physical health (Corona et al., 2015). This suggests that depression is an important
etiological factor for older men with multiple sexual problems, suggesting that treatment for
depression may be effective at treating sexual problems for this group of men.
Results for men showed some evidence that distinct risk factors predict different patterns
of comorbid sexual problems. The multiple sexual problems group was only predicted by mental
health factors, whereas the climaxing- erectile difficulties group was predicted by both physical
and mental health factors. This indicates that multifinality may be more commonly observed for
some risk factors (e.g., depression) than others (e.g., CVD), and so different risk factors predict
distinct patterns of sexual problems.
Equifinality was also observed for women. Women in the desire-climaxing problems
group were more likely to report concurrent diabetes, smoking at a previous time point, and less
likely to report concurrent cardiovascular disease. Although studies have shown that
cardiovascular and metabolic health are associated with women’s sexual function, findings have
been inconsistent, with the mechanisms of these associations unclear (Miner, Esposito, Guay,
Montorsi, & Goldstein, 2012). These findings highlight the complexity of the effects of physical
health, suggesting the need for more studies to disentangle the mechanisms between
cardiovascular and metabolic health and women’s sexual problems.
Evidence of multifinality for mental health factors was not supported for women’s
patterns of sexual problems. We note, however, unweighted analyses of both cross-sectional and
Comorbid sexual problems and their risk factors 56

longitudinal analyses resulted in a significant role of depression (results not presented but
available upon request). The NSHAP dataset oversampled Blacks, Hispanics, men, and older
adults ages 75 to 84, which may have driven the discrepant effects of depression on women’s
membership in the multiple sexual problems group in weighted and unweighted analyses.
Regardless, weighted analyses are preferred because they provide more accurate parameter
estimates, suggesting that the effects of depression were not robust and likely confounded by
other contextual factors, such as ethnicity.
Our findings further showed that higher educational level was associated with women’s
multiple sexual problems group. Previous findings showed that education was associated with
reduced risks of desire, arousal and climaxing problems (Laumann et al., 1999; Shifren et al.,
2008) but also increased risks for lubrication problems (Laumann et al., 2006). It is possible that
education protects women from life stressors that may affect sexual functioning but also
increases women’s awareness of sexual problems that are less apparent, such as lubrication
problems, a salient problem for women in the multiple sexual problems group. This is consistent
with prior research documenting that sociocultural factors are important to older women’s sexual
expressions (Baumeister, 2000).
For both men and women, our findings indicated that having a partner was generally
associated with patterns with elevated probabilities of sexual problems. Being married has
typically been associated with reduced risk of sexual problems (Laumann et al., 1999), although
some studies have also found that being married increased the risk (Abdo, Oliveira, Moreira, &
Fittipaldi, 2004; Lutfey, Link, Rosen, Wiegel, & McKinlay, 2009; Shifren et al., 2008). It is
possible that while being married indicates relationship stability that is protective of sexual
health, having a partner may also mean having more opportunities to notice sexual problems,
Comorbid sexual problems and their risk factors 57

particularly problems that are salient during intercourse. As our analyses included all individuals,
whether or not they were sexually active, it is possible that having a partner resulted in more
opportunities to become aware of the sexual problems.
Implications
The results support previous observations that sexual problems co-occur frequently. It is
important to explore reasons that contribute to comorbidities between different sexual problems.
Our findings show that shared risks are critical to the development of multiple co-existing sexual
problems. Our study also shows that latent class analysis is a powerful method for identifying
common comorbidity patterns of sexual problems in late-life and their risk factors. This approach
offers the opportunity to address multifinality and equifiniality, two important but underutilized
concepts that help inform the etiology and comorbidities of medical or psychiatric conditions.
Without recognizing these two principles, it is difficult to disentangle and integrate the complex
associations between sexual problems and their risk factors. Our findings highlight the utility of
describing sexual problems as constellations of sexual problems as opposed to separate, single
diagnoses.
Results suggest that assessing overall patterns of sexual problems may provide insight
into the etiology of a person’s sexual problems, as different patterns appear to be associated with
distinct risk factors. Accurate assessment of existing risk factors can better assist with treatment
planning and predict prognosis. For example, older men with multiple sexual problems may
respond better to treatment for depression compared to interventions promoting cardiovascular
and metabolic health. More studies are needed to explore how overall patterns of sexual
problems can inform researchers and clinicians’ conceptualizations of the development of sexual
problems.
Comorbid sexual problems and their risk factors 58

Limitations
There are some limitations in this study. There may be inaccuracy in the categorization of
the groups as the entropy level for the latent class analysis is not considered high. Although this
error is taken into account in the analyses, it suggests that there may be individuals whose
patterns of sexual problems do not fall into any group.
In this study, each sexual problem was assessed via self-report of one dichotomous item.
Future studies may improve accuracy and take into account severity of the sexual problems by
using reliable and valid measurements, structured interviews, physiological measures and/or
behavioral indices of sexual responses, such as vaginal photoplethysmography or intravaginal
ejaculation latency time. It is also important to note that personal distress about each of these
sexual problems is not measured, and because one’s subjective reactions, such as distress, are
part of the diagnostic criteria for sexual dysfunction, we cannot conclude that these problems
represented clinical sexual dysfunction. Thus, differences may be observed when including
sexual problems versus sexual dysfunctions as the latent class indicators.
Conclusions
Despite these limitations, our study utilized a novel approach to understanding patterns of
co-occurring sexual problems in late-life in a nationally representative sample. Nearly half of the
older men and women were in the minimal sexual problems group. A more typical pattern for
older men may be having erectile difficulties and inability to climax and not multiple sexual
problems, disconfirming popular beliefs that multiple sexual problems are inevitable in late-life.
Our findings highlight multifinality and equifinality. Shared risks likely contribute to the high
rates of co-occurrence between sexual problems. For men, endorsing multiple sexual problems
appeared to be associated more strongly with mental health than physical health factors. For
Comorbid sexual problems and their risk factors 59

women, education was an important predictor. Our findings offer a nuanced view of patterns of
co-existing sexual problems and provide insight to the etiology, assessment and treatment of
sexual problems for older men and women.

Comorbid sexual problems and their risk factors 60

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Comorbid sexual problems and their risk factors 65

Table 1. Unweighted descriptive statistics of sample characteristics
Frequency (%) or Mean (SD; Min-Max)
Men (n=1431) Women (n=1687)
Age 73.0 (7.5; 38-99) 71.7 (8.6; 36- 90)
<65 205 (14.3%) 362 (21.5%)
65-74 648 (45.3%) 711 (42.1%)
>=75 578 (40.4%) 614 (36.4%)
Ethnicity
White 1025 (71.8%) 1195 (71.1%)
Black 197 (13.8%) 273 (16.3%)
Hispanic 166 (11.6%) 176 (10.5%)
Other 39 (2.7%) 36 (2.1%)
Education
< High school 282 (19.7%) 306 (18.1%)
High school degree 316 (22.1%) 435 (25.8%)
Some college 405 (28.3%) 595 (35.3%)
College degree 428 (29.9%) 351 (20.8%)
Marital status
Married 1112 (77.7%) 994 (58.9%)
Living with a partner 37 (2.6%) 43 (2.5%)
Separated 17 (1.2%) 14 (1.0%)
Divorced 92 (6.4%) 149 (8.8%)
Widowed 144 (10.1%) 447 (26.5%)
Comorbid sexual problems and their risk factors 66

Never married 29 (2.0%) 40 (2.4%)
Have intimate partner
1
65 (23.0%) 48 (7.4%)
Sexually active last 3 months 684 (47.8%) 569 (33.7%)
1
Only participants reported being separated, divorced, widowed, or never married were asked
whether they have a romantic, intimate, or sexual partner. Percentage was calculated based on
those who responded to this question.
Comorbid sexual problems and their risk factors 67

Table 2. Unweighted frequency and percentages of self-reported sexual problems
Men (n=1431) Women (n=1687)
Sexual problems N
1
Frequency (%) N Frequency (%)
Lack of sexual interest 1407 495 (35.2%) 1654 955 (57.7%)
Inability to climax 1304 427 (32.7%) 1396 471 (33.7%)
Climaxing too quickly 1298 276 (21.3%) 1435 78 (5.4%)
Pain during intercourse 1351 28 (2.1%) 1488 166 (11.2%)
Lack of sexual pleasure 1296 127 (9.8%) 1414 253 (17.9%)
Anxiety about performance 1312 356 (27.1%) 1418 139 (9.5%)
Erectile problems 1324 555 (41.9%) NA NA
Lubrication problems NA NA 1409 358 (25.4%)
1
Total number of valid responses.

Comorbid sexual problems and their risk factors 68

Table 3. Fit indices for the latent classes analyses of self-reported sexual problems
Men
2 classes 3 classes 4 classes 5 classes
AIC
8509.09 8454.03 8420.91 8406.70
BIC
8588.08 8575.15 8584.16 8612.08
SSABIC
8540.43 8502.09 8485.68 8488.19
Entropy
0.66 0.67 0.70 0.61
LRT
1
p value
p < .01 p>.05 p>.05 p>.05
Women
AIC
8727.93 8549.61 8509.54 8498.90
BIC
8809.39 8674.52 8677.89 8710.70
SSABIC
8761.73 8601.45 8579.40 8586.80
Entropy
0.65 0.68 0.61 0.78
LRT
1
p value
p< .001 p< .05 p> .05 p> .05

1
LRT= Lo-Mendell-Rubin adjusted likelihood ratio test
Comorbid sexual problems and their risk factors 69

Table 4. Odds ratio (95% Confidence interval) of the cross-sectional multinomial regressions (all latent classes are compared to men
and women’s minimal sexual problems group).
Men
(n=1385)
Women
(n=1647)
Moderately
affected
Climaxing- erectile
difficulties
Multiple sexual
problems
Desire-climaxing
problems
Multiple sexual
problems
Age
1.00 (.95-1.05) 1.04 (1.01-1.08)** .99 (.93-1.07) 1.02 (.98-1.05) .99 (.95-1.02)
Ethnicity

Black
.72 (.12-4.32) 1.02 (.59-1.74) 2.14 (.71-6.48) .83 (.45-1.54) .59 (.32-1.07)
Other
.70 (.25-1.97) .48 (.17-1.33) 2.14 (.66-6.97) .79 (.29-2.15) 1.75 (.93-3.28)
Education

High school degree
1.08 (.31-3.80) .98 (.52-1.85) .66 (.18-2.41) 1.58 (.90-2.78) 1.53 (.64-3.69)
Some college
1.26 (.33-4.85) 1.03 (.60-1.77) .98 (.30-3.24) 1.28 (.74-2.19) 3.12 (1.58-6.18)**
College degree
1.27 (.39-4.13) .86 (.45-1.64) .47 (.13-1.73) 1.67 (.91-3.06) 2.76 (1.38-5.52)**
Partner status
4.00 (1.11-14.35)* 2.00 (1.14-3.51)* 6.07 (.88-42.04) 1.28 (.77-2.13) 19.57 (3.62-105.80)**
Diabetes
2.82 (1.06-7.50)* 2.06 (1.27-3.35)** 1.34 (.60-3.02) 1.59 (1.08-2.34)* 1.14 (.63-2.06)
Comorbid sexual problems and their risk factors 70

CVD
.59 (.25-1.39) 1.72 (1.11-2.66)* .49 (.16-1.49) .54 (.35-.84)** .73 (.46-1.15)
Cancer
2.66 (1.29-5.48)** 1.60 (1.04-2.48)* 2.24 (.75-6.69) .95 (.53-1.72) .80 (.48-1.36)
Smoking
.39 (.11-1.35) .75 (.44-1.26) .70 (.25-1.98) 1.31 (.68-2.49) .36 (.12-1.05)
Heavy drinking
1.33 (.50-3.52) 1.14 (.58-2.22) 2.56 (1.03-6.33)* .70 (.32-1.56) 1.03 (.50-2.10)
Depression
.26 (.01-5.04) 1.87 (1.15-3.03)* 4.07 (1.26-13.20)* 1.15 (.68-1.95) 1.30 (.73-2.31)
*p< .05; **p< .01; *** p< .001.

71

Figure 1. Item response probabilities of self-reported sexual problems by latent class
membership for men (upper figure) and women (lower figure).

Running head: Dyadic pathways linking sexual problems to sexual dissatisfaction

72

Pathways linking sexual problems to sexual dissatisfaction among older couples: the mediating
roles of physical pleasure and discontent with infrequent sex

Christine Juang
1
& Bob G. Knight
2

1
Department of Psychology, University of Southern California, Los Angeles
2
School of Psychology and Counseling, University of Southern Queensland, Australia

Correspondence concerning this article should be addressed to Christine Juang,
Department of Psychology, University of Southern California, Los Angeles CA 90089. Email:
juangc@usc.edu

Dyadic pathways linking sexual problems to sexual dissatisfaction 73
Abstract
Introduction: This study investigated the pathways through which sexual problems are
associated with sexual dissatisfaction within a couple’s context. The associations between sexual
problems and sexual dissatisfaction was hypothesized to be mediated by the discontent with
infrequent sex and low levels of physical pleasure.
Methods: Sample included 953 heterosexual couples from the Wave 2 dataset of the National
Social Life, Health, and Aging Project. Using structural equation models, the Actor-Partner
Interdependence Model was applied to test actor and partner effects of sexual problems on sexual
dissatisfaction and to investigate the mediating roles of discontent with infrequent sex and low
levels of physical pleasure.
Results: Men and women’s predicted higher sexual dissatisfaction for themselves and for their
partners. Sexual problems predicted higher sexual dissatisfaction indirectly via discontent with
infrequent sex for men and low levels of physical pleasure for women. Men’s sexual problems
predicted women’s sexual dissatisfaction indirectly via women’s discontent with infrequent sex.
Finally, men’s sexual dissatisfaction was closely linked with women’s discontent with infrequent
sex.
Conclusions: Both partners’ sexual problems played a crucial part in the couples’ sexual lives.
Our results advanced our understanding of the mechanisms of the effects of sexual problems on
sexual dissatisfaction for midlife and older couples. Reasons why sexual problems are
dissatisfying differed between men and women. These results provided clinical insights on ways
to promote sexual satisfaction in light of having sexual problems.
Keywords: Sexual problems, sexual dissatisfaction, mediating pathways, discontent with
infrequent sex, physical pleasure
Dyadic pathways linking sexual problems to sexual dissatisfaction 74
Introduction
Sexual satisfaction is an important domain of quality of life (WHO Group, 1998) and is
closely linked with relationship satisfaction (Byers, 2005). One barrier to sexual satisfaction is
sexual problem, often found to be linked with poor overall quality of sex (Connor et al., 2011;
Dennerstein, Koochaki, Barton, & Graziottin, 2006; Fisher et al., 2015; Heiman et al., 2011; Jern
et al., 2008; Rosen et al., 2016; Stephenson & Meston, 2015). Compared to younger adults, older
adults are more likely to encounter sexual problems, such as lack of sexual desire, inability to
climax, erectile difficulties for men and lubrication problems for women (Hillman, 2012).
Although research has shown that some older adults are not distressed by sexual problems, as
demonstrated by our findings in Manuscript 1, nevertheless, older adults’ sexual expression and
satisfaction can still be challenged by the presence of sexual problems (Heiman et al., 2011;
Rosen et al., 2016;).
Sexual problems also predict increased sexual dissatisfaction for the other partner (Burri,
Giuliano, McMahon, & Porst, 2014; Fisher et al., 2015; Fisher, Rosen, Eardley, Sand, &
Goldstein, 2005; Heiman et al., 2007; Rosen et al., 2016), suggesting that sexual problem is often
not an individual problem but a joint problem for the couple. However, most studies either focus
on individuals and individual-level processes or fail to consider both partners simultaneously in
the analyses (Mustanski et al., 2014). Partners within a dyad are closely related, and failure to
address the non-independence of the data can result in inaccurate estimates. Thus, it is critical for
both partners to be studied simultaneously in order to better understand how sexual problems
shape the sexual lives of midlife and older couples.
The link between sexual problems and sexual dissatisfaction is well established, but
rarely do researchers ask why, overlooking the fact that there are a variety of reasons for sexual
Dyadic pathways linking sexual problems to sexual dissatisfaction 75
dissatisfaction (Snyder & Berg, 1983; Stephenson & Meston, 2012; Træen, 2010). Sexual
problems could be associated with sexual dissatisfaction for different reasons. It is vital to study
the pathways explaining the association between sexual problems and sexual dissatisfaction as it
may provide insight on how psychological interventions can help couples cope with sexual
problems. Psychological interventions were found to have an average of medium effect size of
reducing symptom severity of sexual dysfunctions in a meta-analysis, but the evidence varied
across the type of problems (Frühauf et al., 2013). The variable treatment effects not only
highlight the continued need to optimize these treatments but also reflect the reality that some
sexual problems are difficult to treat. Thus, another important treatment goal, in addition to
altering sexual function directly, is to enhance sexual satisfaction in the presence of sexual
problems. Identifying dyadic pathways through which sexual problems shape sexual satisfaction
can provide insight on ways to promote sexual satisfaction when older adults have sexual
problems.
One pathway through which sexual problems are linked with sexual dissatisfaction is
being discontent with infrequent sex. Infrequent sex is commonly observed among individuals
with sexual problems (Dennerstein, Hayes, Sand, & Lehert, 2009; Dennerstein et al., 2006;
Koskimaki, Hakama, Huhtala, & Tammela, 2000; Stephenson & Meston, 2012). Infrequent sex
is a frequently cited reason for sexual dissatisfaction (Snyder & Berg, 1983; Træen, 2010), and it
is significantly associated with lower levels of sexual satisfaction (Fisher et al., 2015; Frederick,
Lever, Gillespie, & Garcia, 2017; Haavio-Mannila & Kontula, 1997; Heiman et al., 2011). In
addition, sexual frequency has been found to mediate the association between poor sexual
function and sexual distress (Stephenson & Meston, 2015).
Dyadic pathways linking sexual problems to sexual dissatisfaction 76
Another likely factor mediating the association between sexual problems and sexual
dissatisfaction is low level of physical pleasure. Having sexual problems is also associated with
lower levels of physical pleasure (Richters, Grulich, Visser, Smith, & Rissel, 2003), another
commonly cited consequence of sexual problems and reason for sexual dissatisfaction (Snyder &
Berg, 1983; Stephenson & Meston, 2012). As physical pleasure is one of the top reasons why
individuals engage in sex (Meston & Buss, 2007; Meston, Hamilton, & Harte, 2009), individuals
may be sexually dissatisfied when there are low levels of physical pleasure. In fact, physical
pleasure was found to mediate the association between poor sexual function and sexual distress
(Stephenson & Meston, 2015).
These findings together show two possible pathways through which sexual problems predict
sexual dissatisfaction: one via discontent with the infrequent sex and another via low level of
physical pleasure. It is unclear whether the proposed pathways are similar when facing partner’s
sexual problems. No studies, to our knowledge, have directly explored the mechanisms of how
one partner’s sexual problems predict the other partner’s sexual dissatisfaction. Some qualitative
studies documenting the frustrations of female partners of men with sexual dysfunctions,
including male partner’s withdrawal from sexual and intimate activities (Burri et al., 2014;
Carroll & Bagley, 1990; Conaglen & Conaglen, 2008; Conaglen, O'Connor, McCabe, &
Conaglen, 2010). These findings suggest that men’s sexual problems may be associated with
women’s sexual dissatisfaction because women are discontented with the infrequent sex and low
levels of physical pleasure. Yet male partners of women with sexual problems have rarely been
the focus, and so it is unclear how men react to their female partner’s sexual problems. Thus,
more studies are needed to investigate the perspectives from both partners on how their sexual
problems jointly shape the couple’s sexual experiences.
Dyadic pathways linking sexual problems to sexual dissatisfaction 77
As the relationship context is critical to the couples’ sexual experiences, the current study
recognizes relationship quality as an important factor to consider when understanding the effects
of sexual problems on sexual dissatisfaction. Relationship quality is associated with sexual
satisfaction, frequency of sex, as well as physical pleasure (Byers, 2005; Carpenter, Nathanson,
& Kim, 2009; McNulty, Wenner, & Fisher, 2014; Sprecher & Cate, 2004), highlighting that
relationship quality is intricately related to these different aspects of sexual experiences. Thus, it
is vital to adjust for the effects of relationship quality in order to parse out the effects of
discontent with the infrequent sex and physical pleasure that are beyond the effects of
relationship quality.
Of note, there may be gender differences within heterosexual relationships. The gendered
sexuality over the life course (GSLC) model (Carpenter & DeLamater, 2012) suggests that men
and women develop different patterns of sexual desires, attitudes, and behaviors over the life
course. For example, men were found to endorse higher levels of sexual desire and prefer more
frequent sex than women (Beutel, Stobel-Richter, & Brahler, 2008; Regan & Atkins, 2006; Juliet
Richters et al., 2003; Smith, Mulhall, Deveci, Monaghan, & Reid, 2007). These findings suggest
that men may be more upset when the frequency of sex is low, resulting in higher sexual
dissatisfaction. As sexual problems are related to lower frequency of sex, it is hypothesized that
the strength of the indirect effect via discontent with frequency of sex would be stronger for men
than women.
In contrast, we do not expect to see gender differences in the strength of the mediating role of
physical pleasure. Both men and women reported gaining physical pleasure is an important
reason why both men and women engage in sex (Leigh, 1989; Meston & Buss, 2007; Meston et
Dyadic pathways linking sexual problems to sexual dissatisfaction 78
al., 2009). This suggests that physical pleasure matters, and lack of physical pleasure associated
with sexual problems are likely problematic for both genders.
Current study
In summary, this study aims to investigate the pathways through which sexual problems
are associated with sexual dissatisfaction within a couple’s context. In this study, discontent with
infrequent sex and lower levels of physical pleasure are hypothesized to be important mediators.
Gender is hypothesized to be a moderator for the pathway via discontent with infrequent sex,
such that the strength of the indirect effects via discontent with infrequent sex is stronger for men
than women. The identification of the pathways is vital as it complements existing treatment
protocols of sexual problems. While improving sexual function directly remains important,
targeting and altering the consequences of sexual problems may be key at enhancing sexual
satisfaction for couples experiencing sexual problems.
Methods
Participants
Analytic sample included a subset of dyadic sample from the Wave 2 data of the National
Social Life, Health, and Aging Project (Waite et al., 2014), a study that investigates health,
social-life and well-being among older adults using a nationally-representative sample. Wave 2
included 3,377 respondents, including 955 couples. Two couples were same-sex couples. The
final sample included in the analyses consisted of 953 heterosexual couples.
Measures
Self-report of sexual problems. Participants were asked whether they experienced the
following sexual problems: lack of sexual interest, inability to climax, climaxed too quickly, pain
during intercourse, lack of sexual pleasure, anxiety about performance, erectile problems (men
Dyadic pathways linking sexual problems to sexual dissatisfaction 79
only), and lubrication problems (women only). The total number of sexual problems was
calculated by summing the number of endorsed sexual problems.
Sexual dissatisfaction. Sexual dissatisfaction was represented by one item, “is sex life
lacking in quality?” Participants responded on a 4-point scale: (0) not at all, (1) slightly, (2)
moderately, or (3) extremely lacking in quality.
Discontent with infrequent sex. Discontent with infrequent sex was assessed by one
item. Participants were asked, “during the past 12 months, would you say that you had sex” and
asked to select one of the following responses that best described their situation: (1) much less
often than you would like, (2) somewhat less often that you would like, (3) about as often as you
would like, (4) somewhat more often than you would like, (5) much more often than you would
like. Only 5.2% of women and 2.0% of men responded to (4) and (5), and so responses (4) and
(5) were combined with response (3) into a category of perception of enough sex. The current
study reverse coded the remaining three responses, such that a higher number indicated stronger
discontent with low frequency of sex.
Physical pleasure. Physical pleasure was measured via the following question, “how
physically pleasurable is the relationship?” Participants responded on a 5-point scale, (0) not at
all, (1) slightly, (2) moderately, (3) very, and (4) extremely.
Covariates. Age at Wave 2 was included as a continuous predictor. Ethnicity included
non-Hispanic White (reference), non-Hispanic Black, Hispanic and other. Education was
categorized into four groups: no high school degree (reference), high school degree, some
college, and college degree. Self-rated health examined individuals’ global perception of their
health. Participants were asked to rate their physical health on a 5-point scale of poor, fair, good,
very good, and excellent.
Dyadic pathways linking sexual problems to sexual dissatisfaction 80
Relationship quality was also included as a covariate. The construct was the sum of four
items on the scale of 1 (never, hardly ever or rarely) to 3 (often). These items are, “how often can
you open up to [current partner] if you need to talk about your worries?” “how often can you rely
on [current partner] for help if you have a problem?” how often does [current partner] make too
many demands on you?” and “how often does [current partner] criticize you?” The last two
questions were reverse coded, such that higher scores represent more positive relationship
quality. Cronbach’s alpha was .57.
Analyses
Descriptive statistics were calculated using SPSS (Version 21). Other analyses were
completed using Mplus (Version 7.31).
Actor-partner interdependence model. The Actor-Partner Interdependence Model (APIM),
a statistical approach to analyzing dyadic data, was used to estimate the effects of sexual
problems on one’s own and partner’s sexual dissatisfaction. The APIM model can estimate the
effect of an individual’s predictor score on their own outcome variable (actor effect) and the
effect of an individual’s predictor score on their partner’s outcome variable (partner effect)
simultaneously and independently (Kenny & Cook, 1999; Kenny & Ledermann, 2010).
Model testing. The APIM model was estimated via structural equation modeling (SEM).
Maximum likelihood with robust standard errors was used to accommodate non-normal data as
well as handle missing data. An unrestricted model with the following variables were estimated:
both partners’ predictor variables (number of sexual problems), mediating variables (satisfaction
with frequency of sex and physical pleasure), and outcome variables (sexual dissatisfaction).
Covariation between partner’s predictors, mediators, and outcome variables were estimated to
adjust for nonindependence between the same variables reported by both partners. Both partners’
Dyadic pathways linking sexual problems to sexual dissatisfaction 81
outcome variables and mediators were regressed on both partners’ covariates, including age,
education, ethnicity, relationship quality and self-rated health. The covariation between all
covariates were included in the model. This unrestricted model is saturated with no degrees of
freedom, resulting in a perfect model fit.
To test whether men and women were statistically distinguishable, a chi-square difference
test was used to compare model fit between the unrestricted model and a model constraining the
paths for men and women as equal. Significantly worse model fit for the constrained model
would indicate that the paths constrained are statistically distinguishable for men and women.
Indirect Effects. Indirect effects were tested using the bootstrapping method. This method
allowed for empirical, nonparametric approximations of the sampling distributions of the indirect
effects of interest by repeatedly sampling the dataset 1000 times. This produced point estimates
and 95% confidence interval of the indirect effects. Bias-corrected (BC) confidence intervals
were used as it performed well in terms of both power and Type I error rates. A pairwise contrast
for the indirect effects was conducted to test whether specific indirect effects differed for men
and women (Preacher & Hayes, 2008).
Results
Descriptive statistics. Descriptive statistics for the couples are presented in Table 1. The
correlation matrices within individuals and across partners are presented in Table 2 Our findings
indicated that all variables of interest as well as continuous covariates were significantly
correlated between men and women within dyad, suggesting non-independence in the data.
Pairwise t-test indicated that men were significantly older and that men reported higher
discontent with frequency of sex and higher physical pleasure than women (see Table 1).
Dyadic pathways linking sexual problems to sexual dissatisfaction 82
Actor-partner interdependence model. We estimated the unrestricted model as well as the
constrained model hypothesizing no gender differences. Results indicated that the model fit was
significantly worse for the constrained than the unrestricted model, suggesting that men and
women differed in the constrained paths. This finding suggested that there were gender
differences in the conceptual model presented, and so the unrestricted model was interpreted.
Findings for the unrestricted model was presented in Table 3 and Figure 1.
Actor effects. For men, higher numbers of sexual problems predicted higher levels of his own
sexual dissatisfaction (β= .10, p< .01), discontent with infrequent sex (β= .10, p< .01) and lower
physical pleasure (β= -.07, p< .05). Discontent with infrequent sex predicted higher levels of
sexual dissatisfaction (β= .38, p< .001). Men’s physical pleasure was not associated with his
sexual dissatisfaction.
For women, higher numbers of sexual problems predicted higher levels of her own sexual
dissatisfaction (β= .18, p< .001) and lower levels of physical pleasure (β= -.14, p< .001).
Interestingly, women’s sexual problems were associated with lower discontent with infrequent
sex (β= -.25, p< .001). In other words, the higher numbers of sexual problems, the less discontent
with frequency of sex women report. Women’s physical pleasure was negatively associated with
sexual dissatisfaction (β= -.29, p< .001). Women’s discontent with infrequent sex was associated
with increased sexual dissatisfaction (β= .41, p< .001).
Partner effects. No direct effects were observed between men’s sexual problems and
women’s sexual dissatisfaction. However, men’s sexual problems predicted women’s higher
discontent with low frequency of sex (β= .13, p< .001), which further predicted women’s sexual
dissatisfaction as reported earlier. Men’s sexual problems were not associated with women’s
physical pleasure.
Dyadic pathways linking sexual problems to sexual dissatisfaction 83
Women’s sexual problems predicted higher levels of sexual dissatisfaction for men (β= .08,
p< .05). Interestingly, women’s sexual problems predicted higher levels of men’s physical
pleasure (β= .07, p< .05). Women’s sexual problems and men’s discontent with infrequent sex
were not significantly associated.
Indirect effects. Findings of the indirect effects were presented in Table 4. Analyses of
indirect effects showed two significant indirect effects between men’s sexual problems and
sexual dissatisfaction. The one via their own discontent with low frequency of sex was found to
be significant, β = .04, 95% CI (.01, .06). The other via women’s discontent with low frequency
of sex was also found to be significant, β = .02, 95% CI (.01, .04).
There were also two significant indirect effects between women’s sexual problems and
sexual dissatisfaction. Women’s physical pleasure was found to be a significant mediator, β= .04,
95% CI (.02, .07), suggesting that the association between women’s sexual problems and sexual
dissatisfaction was partially explained by lower levels of physical pleasure. A significant indirect
effect via women’s discontent with low frequency of sex was found, β = -.10, 95% CI (-.15,
-.07). This indirect effect is in the opposite direction of that of the direct effect, suggesting that
women’s sexual problems could be associated with lower sexual dissatisfaction as they become
less discontent with frequency of sex.
Our results suggested that women’s discontent with infrequent sex completely mediated the
association between men’s sexual problems and women’s sexual dissatisfaction, β = .06, 95% CI
(.03, .09). Specifically, men’s sexual problems positively predicted women’s discontent with low
frequency of sex, which further predicted higher levels of women’s sexual dissatisfaction.
We did not find a mediation pathway that explained the association between women’s sexual
problems and men’s sexual dissatisfaction. On the contrary, we found an indirect effect that was
Dyadic pathways linking sexual problems to sexual dissatisfaction 84
in the opposite direction of a mediation pathway. Specifically, women’s sexual problems
predicted lower discontent with infrequent sex for women, which further lowered the sexual
dissatisfaction for men, β = -.02, 95% CI (-.04, -.01).
Discussion
This study examined the effects of sexual problems in a relationship context for midlife and
older couples. The simultaneous examination of both partners bolstered the argument that sexual
problem is a joint problem, as actor and partner effects were demonstrated after adjusting for
non-independence in the data. We further addressed dyadic pathways linking sexual problems
and sexual dissatisfaction, demonstrating that sexual problems are associated with sexual
dissatisfaction for different reasons.
Pathways linking sexual problems and sexual dissatisfaction
Men and women’s sexual problems predicted higher sexual dissatisfaction for both partners
directly and indirectly. Men with sexual problems were sexually dissatisfied in part because of
their discontent with infrequent sex. In contrast, women’s sexual problems were indirectly
associated with increased sexual dissatisfaction because of low levels of physical pleasure. The
results suggest that when faced with their own sexual problem, men are dissatisfied because of
infrequent sex, whereas women are dissatisfied because of low physical pleasure. This may be
because men generally endorsed higher sexual desire and preferred more frequent sex than
women (Beutel et al., 2008; Regan & Atkins, 2006; Juliet Richters et al., 2003; Smith et al.,
2007), such that they become more upset when sexual frequency is low. This is consistent with
previous studies demonstrating that men’s sexual satisfaction was more closely linked with
sexual frequency (McNulty et al., 2014), whereas women’s sexual satisfaction was more closely
linked with relationship attributes (Hurlbert, Apt, & Rabehl, 1993).
Dyadic pathways linking sexual problems to sexual dissatisfaction 85
It is important to note that discontent with infrequent sex remains an important source of
sexual dissatisfaction for women, but for women with sexual problems, discontent with
infrequent sex was not the primary reason for sexual dissatisfaction. We further found that the
more sexual problems women report, the lower women report their discontent with infrequent
sex, which in turn predicted lower sexual dissatisfaction for her. This suggests that women’s
discontent with infrequent sex likely ameliorated the effects of her sexual problems. Taken
together, even though women with sexual problems are sexually dissatisfied because of low
physical pleasure, the magnitude of the dissatisfaction was lessened because they were also
content with the frequency of sex.
With regards to indirect partner effects, men’s sexual problems were indirectly associated
with women’s sexual dissatisfaction via increased discontent with infrequent sex for women.
This is consistent with findings from qualitative studies of female partners of men with sexual
problems, which documented their frustration with men withdrawing from sexual activities
(Carroll & Bagley, 1990; Conaglen & Conaglen, 2008; Conaglen et al., 2010). It is also
consistent with the results from an international survey, showing less frequent intimate activities
among female partners of men with sexual problems (Rosen et al., 2016). These findings
together highlight that discontent with infrequent sex is a key source of sexual dissatisfaction for
women when their male partners have sexual problems.
We also found that men’s sexual dissatisfaction was closely linked with women’s discontent
with infrequent sex. Men’s sexual problems predicted higher sexual dissatisfaction for men, in
part because women were discontent with infrequent sex. This suggests that men with sexual
problems are likely sensitive to their female partners’ reactions, such that female’s negative
reactions may further increase men’s sexual dissatisfaction. Interestingly, women with sexual
Dyadic pathways linking sexual problems to sexual dissatisfaction 86
problems were more content with the sexual frequency, which resulted in lessened sexual
dissatisfaction. In other words, the magnitude of the effects of women’s sexual problems on
men’s sexual dissatisfaction was lessened because women with sexual problems were more
content with the sexual frequency. These findings highlight that men’s sexual satisfaction is
partially dependent upon their female partner’s sexual experiences. Previous studies have found
that men’ sexual satisfaction were closely linked with women’s experience of orgasms
(Klapilova, Brody, Krejcova, Husarova, & Binter, 2015; Træen, Martinussen, Öberg, & Kavli,
2007), suggesting that women’s positive experiences and appraisals of sex are likely important
sources of sexual satisfaction for men.
Gender differences in the effects of sexual problems within a relationship context
Our results showed the complexity of how women’s sexual problems manifest within a
relationship context. Women’s sexual problems were detrimental to the couple’s sexual
dissatisfaction overall, but it also had effects that mitigated the magnitude of the adverse effects.
For example, women’s sexual problems predicted higher physical pleasure for men and lower
discontent with infrequent sex for women. This is in contrast to men’s sexual problems, of which
the effects on both partners’ sexual lives were detrimental.
This may be reflective of the gender differences in the type of sexual problems that were
most commonly endorsed. Men’s most common sexual problem is erectile difficulties, which
often reduce the likelihood of penetration and pose greater barriers for sexual intercourse. This
may explain why men’s sexual problems were associated with discontent with infrequent sex for
both men and women. In contrast, women’s most common sexual problem is lack of sexual
desire, which is associated with disinterested in frequent sex. Hence, frequency of sex, albeit
low, may be enough for women with sexual problems.
Dyadic pathways linking sexual problems to sexual dissatisfaction 87
In addition, men and women may differ in their reactions to sexual problems. Men with
sexual problems often withdraw from intimate activities (Carroll & Bagley, 1990; Conaglen &
Conaglen, 2008; Conaglen et al., 2010; Rosen et al., 2016), and one of the major reason for men
to avoid sex is because fear of rejection (Leigh, 1989). This is in contrast to women with sexual
problems, who often continued to engage in sex in order to satisfy their partners, despite
disinterest and discomfort (Ayling & Ussher, 2008; Herbenick, Mullinax, & Mark, 2014; Traeen
& Skogerbo, 2009). Our results suggest that how couples react to sexual problems is a complex
issue that warrant further research that investigates the perspectives from both partners.
Clinical Implications
As partners mutually shape each other’s sexual experiences, couple-based interventions
are called for. Our study showed that men’s sexual satisfaction was closely tied with women’s
sexual experiences. For example, the higher discontent with infrequent sex women are, the
higher sexual dissatisfaction men report. Although our study only demonstrated partner effects
for men, we suspect that how partners communicate to each other matters for both men and
women. Thus, in light of sexual problems, clinicians can encourage couples to praise each other
sexually and communicate sexual needs in a non-derogatory manner in order to promote sexual
satisfaction.
The results on the pathways linking sexual problems and sexual dissatisfaction further
shed light on ways to enhance the sexual satisfaction of couples with sexual problems, without
necessarily focusing on the sexual problems per se. Acknowledging that there may be gender
differences in why sexual problems are dissatisfying may help normalize sexual disagreements
among heterosexual couples. The pathways further highlighted intermediate treatment targets,
such as enhancement of physical pleasure and content with frequency of sex. For example,
Dyadic pathways linking sexual problems to sexual dissatisfaction 88
guiding women to explore different ways of enhancing physical pleasure may be effective at
increasing sexual satisfaction, such as promoting kissing, cuddling, or touching. For men,
clinicians may help men be content with the frequency by expanding men’s definition of sex
beyond penile-vaginal intercourse. Furthermore, treatment could also focus on ways to facilitate
couples to engage in more frequent sex by scheduling intimacy rather than relying on
spontaneous sex which may be not provide sufficient time for Viagra to work successfully.
These findings showed that there are many ways to promote sexual satisfaction without
necessarily altering the sexual problems per se.
Limitations
There are some limitations in this study. We used cross-sectional data in the current
study, because partner data is only available at Wave 2 of NSHAP. The cross-sectional design
precludes us from determining the direction of causation between sexual problems, discontent
with frequency of sex, physical pleasure and sexual dissatisfaction. Longitudinal studies are
needed to better disentangle the temporal associations between these variables. Further, the
major constructs examined in this study were primarily assessed via single item, and future
studies would benefit from utilizing validated measures to reduce measurement error. Finally, we
only included heterosexual couples, and so our findings cannot be generalized to same-sex
couples.
Conclusions
Our results advanced our understanding of the mechanisms of the effects of sexual
problems on sexual dissatisfaction for midlife and older couples. We found that the reasons why
sexual problems are dissatisfying differed between men and women. When faced with their own
sexual problems, men are sexually dissatisfied because of discontent with infrequent sex,
Dyadic pathways linking sexual problems to sexual dissatisfaction 89
whereas women are dissatisfied because of low levels of physical pleasure. Both partners’ sexual
problems played a crucial part in both of their sexual lives, highlighting the need for a couple-
based intervention. The results provided clinical insights on ways to promote sexual satisfaction
in light of having sexual problems.

Dyadic pathways linking sexual problems to sexual dissatisfaction 90
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Dyadic pathways linking sexual problems to sexual dissatisfaction 97
Table 1. Descriptive statistics of Wave 2 heterosexual couples
Frequency (%) or Mean (SD; Min-Max) Paired
t-test

Men (n=953) Women (n=953) r
Age 72.36 (7.36) [38-99] 68.84 (8.07) [36-89] p <.001 .70***
Ethnicity
White 709 (74.4%) 704 (73.9%)
Black 107 (11.2%) 106 (11.1%)
Hispanic 113 (11.9%) 118 (12.4%)
Other 22 (2.3%) 23 (2.4%)
Education
< High school 176 (18.5%) 133 (14.0%)
High school degree 221 (23.2%) 236 (24.8%)
Some college 266 (27.9%) 352 (36.9%)
College degree 290 (30.4%) 232 (24.3%)
Marital status
Married 913 (95.8%) 910 (95.5%)
Living with a partner 33 (3.5%) 36 (3.8%)
Separated 1 (.1%) 2 (.2%)
Divorced 3 (.3%) 1 (.1%)
Widowed 3 (.3%) 2 (.2%)
Never married 0 2 (.2%)
Relationship quality 10.55 (1.48) [5-12] 10.63 (1.56) [4-12] ns .22***
Self-rated health 3.18 (1.06) [1-5] 3.26 (1.05) [1-5] ns .20***
Dyadic pathways linking sexual problems to sexual dissatisfaction 98
Sexual dissatisfaction 1.27 (1.16) [0-3] 1.20 (1.17) [0-3] ns .33***
Discontent with infrequent sex 2.01 (.85) [1-3] 1.76 (.89) [1-3] p <.001 .36***
Physical pleasure 3.10 (.99) [0-4] 2.72 (1.12) [0-4] p <.001 .33***
Total number of sexual problems 1.60 (1.49) [0-6] 1.69 (1.60) [0-7] ns .10**
*p <.05, **p <.01, ***p <.001.
Dyadic pathways linking sexual problems to sexual dissatisfaction 99
Table 2. Correlation matrix within individuals and across partners
Females (n=953) 1 2 3 4 5 6 7
1. Sexual dissatisfaction 1
2. Sexual problems .148
**
1
3. Physical pleasure -.422
**
-.134
**
1
4. Discontent with low
frequency of sex
.441
**
-.249
**
-.241
**
1
5. Age .061 -.076
*
-.084
*
.105
**
1
6. Self-rated physical health -.096
*
-.022 .177
**
-.155
**
-.099
**
1
7. Relationship quality -.279
**
.002 .354
**
-.243
**
-.005 .105
**
1
Males only (n=953) 8 9 10 11 12 13 14
8. Sexual dissatisfaction 1
9. Sexual problems .203
**
1
10. Physical pleasure -.223
**
-.080
*
1
11. Discontent with low
frequency of sex
.466
**
.143
**
-.200
**
1
Dyadic pathways linking sexual problems to sexual dissatisfaction 100
12. Age .026 .062 -.072
*
.115
**
1
13. Self-rated physical health -.185
**
-.149
**
.153
**
-.189
**
-.093
**
1
14. Relationship quality -.198
**
-.089
**
.270
**
-.119
**
-.010 .115
**
1
Across partners (F/M)
(couples n=953)
8. M 9. M 10. M 11. M 12. M 13. M 14. M
1. F Sexual dissatisfaction .329
**
.132
**
-.180
**
.221
**
.062 -.096
*
-.133
**

2. F Sexual problems .055 .101
**
.048 -.030 -.110
**
.078
*
.019
3. F Physical pleasure -.151
**
-.026 .329
**
-.099
**
-.087
**
.121
**
.140
**

4. F Discontent with low
frequency of sex
.277
**
.151
**
-.252
**
.362
**
.131
**
-.242
**
-.186
**

5. F Age .073
*
-.003 -.075
*
.094
**
.695
**
-.106
**
-.008
6. F self-rated physical
health
.013 .034 .194
**
-.053 -.109
**
.202
**
.072
*

7. F Relationship quality -.088
*
-.025 .240
**
-.141
**
-.064 .162
**
.217
**

*p <.05, **p <.01, ***p <.001.
Dyadic pathways linking sexual problems to sexual dissatisfaction 101
Table 3. Standardized coefficients (standard errors) of the unrestricted APIM model with discontent with infrequent sex and physical
pleasure as mediators

Sexual dissatisfaction Discontent with infrequent sex Physical pleasure
Men Women Men Women Men Women
M Sexual problems .10 (.04)*** .03 (.04) .11 (.04)** .15 (.04)*** -.07 (.04)* -.01 (.03)
W Sexual problems .08 (.04)* .18 (.03)*** -.03 (.04) -.25 (.03)*** .07 (.03)* -.14 (.03)***
M Discontent with infrequent sex .37 (.04)*** .04 (.04)
W Discontent with infrequent sex .13 (.05)** .41 (.05)***
M Physical pleasure -.08 (.04) 0 (.04)
W Physical pleasure -.07 (.04) -.29 (.04)***
M age -.09 (.05)* -.04 (.05) .04 (.05) .05 (.05) .01 (.04) -.03 (.04)
M education (ref= no high school)
High school .02 (.05) -.01 (.05) -.07 (.05) -.01 (.05) .07 (.05) .01 (.05)
Some college .06 (.05) .03 (.05) -.05 (.05) -.02 (.05) .07 (.05) .10 (.05)***
College .13 (.06)* -.02 (.06) -.04 (.06) .01 (.06) .01 (.06) .03 (.05)
M ethnicity (ref= white)
Dyadic pathways linking sexual problems to sexual dissatisfaction 102
Black -.11 (.11) .22 (.11)* -.2 (.12) -.42 (.08)*** .35 (.2) .16 (.07)*
Hispanic -.03 (.07) -.02 (.06) -.18 (.06)** -.03 (.05) -.07 (.05) -.03 (.05)
Other -.09 (.04)* 0 (.02) -.03 (.04) -.08 (.04)* 0 (.04) .01 (.03)
M relationship quality -.09 (.03)* .02 (.04) -.06 (.04) -.07 (.04) .21 (.04)*** .06 (.03)
M self-rated health -.08 (.04)* .03 (.04) -.14 (.04)*** -.15 (.04)*** .03 (.03) .03 (.03)
W age .08 (.05) .03 (.05) .05 (.05) .06 (.05) -.05 (.04) -.06 (.04)
W education (ref= no High school)
High school .08 (.06) .09 (.06) -.04 (.06) -.08 (.06) .11 (.06)* .10 (.05)*
Some college .03 (.07) .13 (.07) -.02 (.06) -.05 (.06) .15 (.06)* .07 (.05)
College .03 (.07) .11 (.06) -.01 (.06) -.01 (.06) .17 (.06)** .05 (.05)
W ethnicity (ref= white)
Black .08 (.11) -.23 (.11)* .16 (.12) .47 (.08)*** -.32 (.2) -.16 (.07)*
Hispanic .06 (.07) -.03 (.06) .04 (.06) .05 (.05) -.08 (.06) -.12 (.05)*
Other .02 (.03) -.03 (.03) .06 (.03) .09 (.04)* -.01 (.04) -.01 (.04)
W relationship quality .04 (.04) -.08 (.04)* -.10 (.04)** -.17 (.04)*** .17 (.04)*** .31 (.03)***
W self-rated health .06 (.04) 0 (.04) -.03 (.04) -.11 (.04)** .09 (.04)* .07 (.03)*
*p <.05, **p <.01, ***p <.001.
Dyadic pathways linking sexual problems to sexual dissatisfaction 103
Table 4. Unstandardized point estimates (95% confidence interval) of total, direct, and indirect
effects of the unrestricted APIM model with discontent with low frequency of sex and physical
pleasure as mediators

Effects B (95% CI)

M sexual problems → M sexual dissatisfaction
Total Effects .13 (.06, .19)***
Direct Effects .08 (.03, .14)**
Indirect effects
M discontent with infrequent sex .03 (.01, .06)**
M physical pleasure 0 (0, .01)
W discontent with infrequent sex .02 (.01, .03)*
W physical pleasure 0 (0, .01)
W sexual problems → M sexual dissatisfaction
Total Effects .02 (-.03, .08)
Direct Effects .05 (0, .11)
Indirect effects
M discontent with infrequent sex -.01 (-.03, .01)
M physical pleasure 0 (-.01, 0)
W discontent with infrequent sex -.02 (-.04, -.01)**
W physical pleasure .01 (0, .02)
W sexual problems → W sexual dissatisfaction
Total Effects 0.08 (0.03, 0.13)**
Dyadic pathways linking sexual problems to sexual dissatisfaction 104
Direct Effects 0.13 (0.08, 0.18)***
Indirect effects
M discontent with infrequent sex 0 (-.01, 0)
M physical pleasure 0 (-.01, 0)
W discontent with infrequent sex -.07 (-.10, -.05)***
W physical pleasure .03 (.02, .05)***
M sexual problems → W sexual dissatisfaction
Total Effects .08 (.02, .14)*
Direct Effects .02 (-.03, .08)
Indirect effects
M discontent with infrequent sex 0 (0, .01)
M physical pleasure 0 (-.01, .01)
W discontent with infrequent sex .05 (.02, .08)***
W physical pleasure 0 (-.01, .02)
*p <.05, **p <.01, ***p <.001.

Dyadic pathways linking sexual problems to sexual dissatisfaction 105

igure 1. The unrestricted APIM model of physical pleasure and discontent with low frequency of sex as mediators for the associations
between sexual problems and sexual dissatisfaction. *p <.05, **p <.01, ***p <.001.
106
Overall Discussion
This dissertation sought to provide a better understanding of the patterns and correlates of
sexual problems in late-life. In the first study, we found that women, older adults, and those
without partners reported lower levels of sexual distress. These differences were attributed to
differences in the ratings of the importance of sex, as they rated sex as less important than their
counterparts. The second study addressed issues of comorbidity, identifying four and three
patterns of co-occurring sexual problems for men and women respectively. Risk factors were
identified, demonstrating principles of multifinality and equifinality. In the third study, we
recognized sexual problems as a dyadic problem and identified pathways through which sexual
problems predict sexual dissatisfaction for older couples. Men with sexual problems predicted
sexual dissatisfaction indirectly via discontent with infrequent sex, whereas associations between
women’s sexual problems and sexual dissatisfaction were partially mediated by low levels of
physical pleasure. These studies provided a more accurate understanding of aging and sexuality
and important insights to clinical assessments and treatments for older adults’ sexual problems.
We review common themes that emerged across the three studies.
Challenging misconceptions about older adults’ sexual experiences
Common patterns of sexual problems: an optimistic view. The results addressed
popular beliefs about sexual problems in late-life, including the notion that aging and sexual
problems are “inexorably linked” (Weeks, 2002). We found that sexual problems are common in
late-life, such that 70% of older adults reported having at least one sexual problems. However,
when a wide range of sexual problems were assessed, we found that nearly half of the older
adults were categorized in the minimal sexual problems group with low probabilities of
endorsing most sexual problems. In the minimal sexual problems group, approximately 40% of
107
women and 20% of men reported lack of sexual desire as their only sexual problem, suggesting
that older adults who reported only lack of sexual desire were considered to be more similar with
those without any sexual problems. Thus, being in the minimal sexual problems group was more
likely the norm than the exception.
In contrast, endorsing multiple sexual problems was uncommon for older men and
women, as only 5% of men and 11% of men belonged to the group of multiple sexual problems.
This suggested that developing multiple sexual problems is not part of normal aging. A more
typical pattern for older men was having erectile difficulties and inability to climax. These
problems were more prevalent in older age groups and were more likely to cluster together
among older men. In fact, 36% of older men were categorized into this pattern, the second most
common pattern following the minimal sexual problems group. For women, lack of sexual
desire, in particular, was more prevalent among older age groups. A more typical pattern for
older women was the pattern of elevated probabilities of lack of sexual desire and inability to
climax, which constituted 31% of older women. These findings painted a more optimistic picture
of older adults’ experiences with sexual problems, as it appeared to be more common to report
minimal sexual problems in late-life, rather than developing multiple sexual problems.
The non-pathological experiences with sexual problems in late-life. Among older
adults with sexual problems, our data showed that a large proportion of them were not bothered
by the problems. Among older adults with at least one sexual problem, only 47% of older men
and 12% of women with at least one sexual problem were bothered by the problems. Being
distressed about their sexual problems were more prevalent among midlife than older age groups,
suggesting age differences in sexual distress. These findings suggested that sexual problems
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were often not perceived to be a problem for older adults, cautioning against the tendency to
view sexual problems as pathological in late-life.
Of note, compared to other sexual problems, lack of sexual desire was related to the
lowest proportions of older adults who were sexually distressed. Approximately 60% of older
women reported lack of sexual desire, but only 17% of these women were sexually distressed.
For men, 34% of older men reported lack of sexual desire, and among them, only 40% were
sexually distressed. Our data showed that lack of sexual desire, while common, is not distressing
for the majority of older adults, particularly for older women.
Some researchers have suggested that low levels of sexual desire can be normative and
even adaptive response to life circumstances related to low opportunity for sex (Frost &
Donovan, 2015). Results indicated that lack of sexual desire was more prevalent among older
adults without partners than those with partners, suggesting that lower sexual desire may be a
common in response to low opportunity of sex. Further, low sexual desire can be adaptive for
older couples when opportunities for sex are limited. We found that discontent with infrequent
sex was associated with higher sexual dissatisfaction, implying that unfulfilled sexual desire can
be a source of sexual dissatisfaction. Hence, it is possible that lower sexual desire can help older
adults adjust to circumstances linked with infrequent sex. Thus, it is important to recognize that
older adults’ sexual problems, most notably low sexual desire, can be non-pathological.
The hidden cost of the importance of sex. While it is vital to dispel ageist stereotypes,
we caution against adopting an overly positive tone on the importance of sex in late-life. Our
analyses showed that the more important older adults viewed sex to be, the more distressed they
were about their sexual problems. Thus, for older adults with sexual problems, viewing sex to be
important predicted higher sexual distress. This finding does not suggest that sex should be
109
viewed as unimportant. Rather, it highlights the complexity of perceiving sex to be important,
recognizing the hidden cost of overly emphasizing on the importance of sex in late-life.
This echoes recent concerns about society’s overly strong emphasis the importance of sex
in late-life. Societal narratives, such as “sex for life,” encourage a positive attitude towards older
adults’ sexuality and empower older adults to assert their sexual needs. However, these messages
also inadvertently imply that active sex life is necessary for successful aging (Marshall, 2012).
The overly strong emphasis on sexual vitality in late-life not only overlooks the heterogeneity of
older adults’ sexual experiences but also increases the pressure for older adults to fit the new
sexual norm (Marshall, 2012). Thus, rather than promoting a sexual attitude at either end of the
continuum, it is important to recognize and celebrate older adults’ heterogeneous sexual attitude
and interest.
Gender differences
Our results demonstrated notable gender differences in late-life, lending support for the
gendered sexuality over the life course model (GSLC model; Carpenter & DeLamater, 2012). In
general, men appeared to value and desire sex more than women. Specifically, we found that
men perceived sex to be more important than women. Positively linked with the importance of
sex (DeLamater & Sill, 2005), sexual desire followed a similar pattern. Previous research has
found stronger sexual desire for men than women (Beutel et al., 2008; Regan & Atkins, 2006;
Juliet Richters et al., 2003; Smith et al., 2007). Our results indirectly supported these findings as
lower rates of lack of sexual desire were found among men. In addition, men were more
discontent with infrequent sex, indicative of higher desired frequency of sex for men, suggesting
stronger sexual desire for men.
110
Gender differences in the strength of sexual desire may be biologically- rooted. For
example, gender differences in level of testosterone, which have been found to be linked with
sexual desire, could contribute to gender differences in sexual desire (Baumeister, Catanese, &
Vohs, 2001). On the other hand, sociocultural influences could also shape men and women’s
perception of and interest in sex differently. For example, sexual double standards are well
documented and even persist in the modern world, such that women’s sexual expressions are
often judged more negatively than men’s (Brodini & Sperb, 2013; Crawford & Popp, 2003).
Therefore, women may be less likely to acknowledge and report sexual desire for fear of
negative judgement. On the other hand, men may be socially indoctrinated to see sex as a key
part of their lives and identify. As individuals “do gender,” or actively construct their lives
consistent with gender-specific beliefs and expectations (West & Zimmerman, 1987), it is also
possible that these societal beliefs and expectations about men and women’s sexual expression
are internalized and enacted, resulting in men’s stronger and women’s weaker sexual desire.
Interestingly, we also found that gender moderated the effects of partner availability on
the importance of sex. Lack of partner predicted lower ratings of the importance of sex for
women than men. This is consistent with prior findings showing that lack of partner predicted
lower sexual desire for women but not for men (DeLamater & Sill, 2005). These findings
suggested that lack of partner appeared to be an important life transition affecting the sexual
trajectories of older adults, particularly for women, in line with GSLC’s predictions. As lack of
partner indicate fewer opportunities for sex, it is possible that women’s sexual desire and interest
are dependent upon opportunities for sex. One study found that women’s sexual desire was lower
with fewer opportunities of sex, suggesting that women’s sexual desire adapted to their
opportunities for sex, whereas men’s sexual desire remained high, regardless of their
111
opportunities for sex (Gebauer, Baumeister, Sedikides, & Neberich, 2014). These findings
suggested that women’s sexual attitude and interest may be context-dependent, such that fewer
opportunities for sex are related to weaker sexual desire and less importance placed on sex.
We further found that men perceived their sexual experiences to be more negative than
women, as demonstrated by higher sexual distress about their sexual problems and sexual
dissatisfaction about their quality of sex. Our results suggested men reported higher sexual
distress because they also rated sex as more important than women. Furthermore, we found that
men’s sexual dissatisfaction was related to men’s complaints about infrequent sex due to sexual
problems. These findings suggested that sexual problems were problematic for men in part
because men’s desired frequency of sex was higher than their actual sexual experience. Not
meeting the desired frequency may be frustrating for men because of unfulfilled needs as well as
threatening because of societal and individual expectations of men being “sexual” and
“masculine.”
It is important to note that sexual problems had negative effects on women’s sexual
experiences. However, pathways linking sexual problems and sexual dissatisfaction differed for
men and women. While frequency of sex mattered for men, physical pleasure mattered more for
women. This suggested that when faced with sexual problems, physical pleasure is the main
concern for women’s sexual dissatisfaction, rather than frequency of sex. Although the link
between sexual problems and sexual dissatisfaction is well established among men and women,
the pathway through which they are linked differed for men and women. This showed that men
and women may reach the same outcome through different pathways, highlighting that gender
differences exist in the mechanisms of a commonly observed phenomenon.
Clinical implications
112
Assessments. The results raised important considerations for clinical assessments for
sexual problems in late-life. Our results showed that sexual problems co-occur frequently,
suggesting a need for a comprehensive assessment in order to characterize the extent of co-
occurring sexual problems. As our findings showed that some comorbid patterns were more
linked with physical health and others were more linked with mental health, a comprehensive
assessment could also potentially inform the etiology of the sexual problems and subsequently,
choice of treatment.
As the majority of older adults did not find sexual problems to be distressing, clinicians
should assess older adults’ subjective reactions of sexual distress. It is important not to assume
distress and pathologize sexual problems when older adults themselves are not bothered by them,
as sometimes sexual problems, such as low sexual desire, may be a normative and even adaptive
response to life circumstances.
Interventions. Our results provided insights for clinicians to foster positive sexual
experiences, despite living with sexual problems. As perceiving sex to be important was
associated with higher sexual distress, clinicians can help older adults reframe the importance of
sex to reduce sexual distress. For example, clinicians can help older adults recognize that sexual
satisfaction and intimacy can be achieved without sexual intercourse.
Furthermore, assessing reasons of why sexual problems were sexually dissatisfying can
aid clinician’s case conceptualization and inform treatment directions. For example, if sexual
problems were dissatisfying because of low physical pleasure, clinicians can help foster coping
strategies and solutions to increase physical pleasure, without necessarily treating the sexual
problems directly.
113
As our results demonstrated that partners’ sexual satisfaction is closely linked, couple-
based interventions are called for. Results on gender differences suggested that clinicians
working with heterosexual couples may benefit from attending to potential gender differences in
sexual attitude and interest, such as the importance and desired frequency of sex. Prior studies
have shown that disagreement in sexual practices are sources of couple conflicts (Mark,
Milhausen, & Maitland, 2013; Willoughby, Farero, & Busby, 2014). In addition, we found that
men and women were sexually dissatisfied for different reasons, implying that they may benefit
from different solutions. Thus, it is critical for clinicians to pay attention to these nuanced
dynamics within a relationship when sexual problems arise.
Advances, limitations and future directions
This dissertation addressed limitations found in the aging and sexuality literature. To
increase generalizability of the results, findings of the three studies were based on a nationally-
represented sample. We also conducted analyses that would depict the nature of sexual problems
more accurately. For example, comorbid patterns of sexual problems were identified using latent
class analyses, and the dyadic nature of sexual problems were better captured with the use of
Actor-Partner Interdependence model. We further explored pathways and mechanisms of why
sexual problems are related to sexual distress and dissatisfaction, moving beyond studies of
descriptive statistics and direct correlations.
Although these limitations were accounted for, there are other limitations across the three
studies. One notable limitation is that all items are self-reported, which can lead to inaccurate
and biased reports, compared to objective measures. We argue, however, many important aspects
of sexuality, such as sexual attitudes, sexual satisfaction, and sexual activities, can only be
assessed through self-report. Yet another critical limitation is the use of single-item measures
114
that tend to increase the likelihood of measurement error. This limitation is, unfortunately, an
inevitable trade-off for using large national datasets, which typically cannot afford the use of
complex measures with multiple items. Regardless, future studies should strive to use measures
that are validated to characterize the constructs more accurately. While self-reported data is still
much needed in this area of research, we also believe that future studies can benefit from
assessing physiological aspects of sexual functions (e.g., vaginal photoplethysmography and
intravaginal ejaculation latency time), as these data can help disentangle the complex interactions
of biopsychosocial influences on sexual problems and its effects on older couple’s sexual
experiences.
Another notable limitation is that we cannot disentangle aging versus cohort effects, as
tests of temporal changes were limited. Two of the three studies were cross-sectional due to
methodological constraints. In study 1, longitudinal analyses were not possible due to
inconsistent instructions and coding of variables across the two waves. In study 3, partner data
was only available in Wave 2, precluding the possibility to examine partner data in both waves.
In study 2 that included longitudinal analyses, only two waves of data were utilized as only two
waves of data were available. To truly characterize temporal changes in sexuality across the
lifespan, ruling out cohort differences, future studies will benefit from utilizing three or more
waves of data.
Finally, the insufficient sample size of same-sex couples resulted in the predominant
focus on heterosexual couples in this dissertation. However, it is important to recognize that the
sexual experiences of LGBT older adults, who are faced with significantly more discrimination
and disadvantages, are different from those of heterosexual couples. Thus, the generalizability of
our findings are limited to heterosexual older adults.
115
Conclusion
An accurate understanding of older adults’ sexuality is vital for correcting ageist
narratives of older adults being asexual. On the other hand, our findings showed that
overemphasis on the importance of sex comes at a cost. Thus, it is important to allow for a
heterogeneous view of older adults’ sexuality, such that there are no “correct answers” regarding
how important sex should be. Finally, by advancing our understanding of the patterns and
correlates of sexual problems in late-life and disentangling the complex mechanisms, our results
have important implications on how to help older adults cope with sexual problems and lead a
satisfactory sex life, despite having sexual problems.

116
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doi:10.1007/s10508-013-0181-2

121
Appendix A: Sexuality-related variables
[Sexual problems] Sometimes people go through periods in which they are not interested in sex
or are having trouble with sexual gratification. We have just a few questions about whether
during the last 12 months there has ever been a period of several months or more when you
1) ...lacked interest in having sex?
2) ...were unable to climax (experience an orgasm)?
3) ...came to a climax (experienced orgasm) too quickly?
4) ...experienced physical pain during intercourse?
5) ...did not find sex pleasurable (even if it was not painful)?
6) ...felt anxious just before having sex about your ability to perform sexually?
7) ... had trouble getting or maintaining an erection (men only)?
8) ... had trouble lubricating (women only)? [If respondent does not know the meaning of
lubricating, use the following prompt: When the vagina felt dry during sexual activity or, in
other words, it did not become smooth or wet during sexual activity.]
[Sexual distress] How much did this/these problems bother you?
Skip if: respondents answered no on all sexual problems.
0) Not at all
1) Slightly
2) Moderately
3) Very
4) Extremely
[Sexual activity status] Had sex in the last 3 months?
0) No
122
1) Yes
[Sexual dissatisfaction] To what extent do you feel your sex life is lacking in quality?
0) Not at all lacking in quality
1) Slightly lacking in quality
2) Moderately lacking in quality
3) Extremely lacking in quality
[Importance of sex] For some people sex is a very important part of their lives and for others it
is not very important at all. How important a part of your life would you say that sex is?
1) Not at all important
2) Somewhat important
3) Moderately important
4) Very important
5) Extremely important
[Physical pleasure] How physically pleasurable did/do you find your relationship with
[CURRENT/RECENT PARTNER] to be: extremely pleasurable, very pleasurable, moderately
pleasurable, slightly pleasurable, or not at all pleasurable?
0) Not at all
1) Slightly
2) Moderately
3) Very
4) Extremely
[Discontent with infrequent sex] During the past 12 months, would you say that you had sex:
1) Much less often than you would like
123
2) Somewhat less often than you would like
3) About as often as you would like
4) Somewhat more often than you would like
5) Much more often than you would like

124
Appendix B: Chronic health conditions and health behaviors
Wave 1
[Chronic health conditions]
Has a medical doctor ever told you that you have had a heart attack?
Have you ever been treated for heart failure?
Have you ever had an operation to unclog or bypass the arteries in your legs?
Has a medical doctor ever told you that you have any of the following conditions: Stroke,
cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)?
Has a medical doctor ever told you that you have any of the following conditions:
… High blood pressure or hypertension?
… Diabetes or high blood sugar?
… Leukemia or polycythemia vera?
… Lymphoma?
… Skin cancer (including melanoma, basal cell carcinoma, squamous cell carcinoma)?
… Cancer, other than skin cancer, leukemia or lymphoma?
All conditions were prompted with: “Medical doctors include specialists such as dermatologists,
psychiatrists, ophthalmologists, as well as general practitioners and osteopaths. Do not include
chiropractors, dentists, nurses, or nurse practitioners.”
[Heavy drinking] In the last three months, on how many days have you had four or more drinks
in one occasion?
[Current smoking] Do you smoke cigarettes now? (Interviewer instruction: does not include
pipes, snuff, chewing tobacco or any other forms of tobacco besides cigarettes)

125
Wave 2
[Chronic health conditions] Has a doctor ever told you that you have
… high blood pressure or hypertension?
… a heart condition? if YES:
… a heart attack or myocardial infarction?
… congestive heart failure or "CHF"?
… Have you ever had a procedure to treat coronary artery disease, such as cardiac by-
pass surgery or placement of a coronary artery stent? (Interviewer instruction: if
respondent asks, this includes balloon angiplasty for treatment of coronary artery disease.
It does not include an angiogram, which is a diagnostic procedure)
… a stroke, a cerebrovascular accident (CVA, a blood clot or bleeding in the brain, or transient
ischemic attack (TIA)?
… skin cancer (including melanoma or other)?
… cancer (other than skin cancer)?
… diabetes or high blood sugar?
All conditions were prompted with: “Medical doctors include specialists such as dermatologists,
psychiatrists, ophthalmologists, as well as general practitioners and osteopaths. Do not include
chiropractors, dentists, nurses, or nurse practitioners.”
[Heavy drinking] In the last three months, on how many days have you had four or more drinks
in one occasion?
[Current smoking] Do you smoke cigarettes, cigars or a pipe now? (Interviewer instruction:
does not include snuff, chewing tobacco or any other forms of tobacco)

126
Appendix C: 11-item Center for Epidemiological Studies- Depression (CES-D) scale
Now let's talk about thoughts and feelings you may have had during the past week. I will read a
series of statements. Tell me how often during the past week you felt like this; (0) rarely or none
of the time, (1) some of the time, (2) occasionally, or (3) most of the time? Don't take too long
over your replies; your immediate reaction to each item will probably be more accurate than a
long thought out response. During the past week….
1) I did not feel like eating; my appetite was poor.
2) I felt depressed.
3) I felt that everything I did was an effort.
4) my sleep was restless.
5) I was happy.
6) I felt lonely.
7) people were unfriendly
8) I enjoyed life.
9) I felt sad.
10) I felt that people disliked me.
11) I could not get "going."

127
Appendix D: Relationship quality
How often can you open up to [CURRENT PARTNER] if you need to talk about your worries?
Would you say never, hardly ever or rarely, some of the time or often?

How often can you rely on [CURRENT PARTNER] for help if you have a problem? Would you
say never, hardly ever or rarely, some of the time or often?

How often does [CURRENT PARTNER] make too many demands on you? Would you say
never, hardly ever or rarely, some of the time or often?

How often does [CURRENT PARTNER] criticize you? Would you say never, hardly ever or
rarely, some of the time or often?

Abstract (if available)

Abstract This dissertation consists of three studies broadly focusing on sexual problems in late-life. The overarching aim is to provide an accurate understanding of the patterns and correlates of sexual problems in late-life, challenging popular myths of older adults’ sexuality and offering important insights for assessing and treating older adults’ sexual problems. In Manuscript 1, we investigate individual differences in the level of sexual distress as well as mediators that would explain such individual differences. In Manuscript 2, we explore an understudied phenomenon of the comorbidity between sexual problems by identifying patterns of comorbid sexual problems and their risk factors. In Manuscript 3, we investigate how sexual problems shape older couples’ sexual experiences by examining the dyadic pathways linking sexual problems to sexual dissatisfaction. Across these studies, gender differences will be addressed. These three studies are conducted using the sample or subsample from the National Social Life, Health, and Aging Project (NSHAP).

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Asset Metadata

Creator Juang, Christine (author)

Core Title Sexual problems among midlife and older adults: individual differences in sexual distress, comorbidity patterns and risk factors, and dyadic pathways linking to sexual dissatisfaction

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Psychology

Publication Date 04/04/2020

Defense Date 07/26/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag aging,comorbidity patterns,midlife and older couple,OAI-PMH Harvest,sexual dissatisfaction,sexual distress,sexual problems

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Knight, Bob G. (committee chair)

Creator Email christine.juang@gmail.com,juangc@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-489156

Unique identifier UC11266942

Identifier etd-JuangChris-6142.pdf (filename),usctheses-c40-489156 (legacy record id)

Legacy Identifier etd-JuangChris-6142.pdf

Dmrecord 489156

Document Type Dissertation

Rights Juang, Christine

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA