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Psychosexual adjustment among low-income Latinas with cervical cancer

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Psychosexual adjustment among low-income Latinas with cervical cancer

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Content Running head: PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER i Psychosexual Adjustment among Low-Income Latinas with Cervical Cancer By Lina Mercedes D’Orazio A Dissertation Presented to the FACULTY OF THE USC GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (PSYCHOLOGY) December 2013 Copyright 2013 Lina M. D’Orazio ii PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Dedication To my husband, Adam Baer, for your endless love and support, and to my family for always believing in me. iii PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Acknowledgments I gratefully acknowledge Dr. Beth Meyerowitz for her generous guidance and support, and valuable contributions to this project. In addition, I am grateful to Drs. Maria Aranda, Richard John, and Stanley Huey, Jr. for their helpful input. I will always appreciate the American Psychological Association Minority Fellowship Program for their unending encouragement and for funding my work (Grant# SM58567). I would also like to acknowledge Dr. Laila Muderspach and the USC+LAC Gynecologic Oncology Clinic nurses who made this project possible. Lastly, I would like to extend my gratitude to the Latina cervical cancer patients who graciously and courageously shared their experiences with me. I will always hold them in the highest esteem. iv PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Abstract Research on the psychosocial experiences of Latina cervical cancer patients remains limited, despite the fact that Latinas continue to have the highest incidence rates of cervical cancer. An understudied area of adjustment for Latinas with cervical cancer is sexual functioning after treatment. In this study, interviews were conducted with 100 Latina cervical cancer patients in an urban county hospital in order to describe their sexual functioning and related psychosocial experiences, to identify cancer-related (physical symptoms and body image concerns) and contextual predictors (life burden) of sexual functioning, and to examine hypothesized mediators and moderators of the relations between sexual functioning and emotional states, specifically depression and affect. Problems with sexual functioning were prevalent (84% of sexually active (n=56) women met criteria for sexual dysfunction) and reported levels of dissatisfaction with sexual functioning were high. Aspects of the cancer experience (body image concerns) and of the context of patients’ lives (life burden) accounted for significant variance in sexual functioning in regression analyses. Sexual functioning was negatively associated with depression and negative affect, and positively associated with positive affect. Relations between sexual functioning and depression and negative affect were mediated by patients’ intrusive thoughts about sexual dysfunction and avoidant coping strategies used to manage these intrusive thoughts. Sociosexual attitudes, hypothesized to distinguish patients at risk for sex-specific intrusive thoughts, failed to moderate the relation between sexual functioning and sex-specific intrusive thoughts. Partial Least Squares path modeling was used to test the conceptual model, which adequately fit the data. The findings from this study suggest that sexual functioning, predicted by cancer-related and contextual factors, is a relevant area of adjustment for this sample, and is associated with emotional states through patients’ sex-specific intrusive thoughts and coping strategies used to manage them. Clinical implications and directions for future research are discussed. v PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Table of Contents Dedication ii Acknowledgements iii Abstract iv Introduction 1 Part I: Sexual Functioning after Cervical Cancer Treatment 5 Part II: Sexual Functioning and Emotional States 9 Specific Aims 16 Method 19 Participants 19 Procedure 20 Statistical Analyses 31 Results 35 Part I: Descriptive Results 35 Part II: Examining the Relations between Sexual Functioning and Emotional States 45 Discussion 53 References 69 Tables 85 Figures 113 Appendix 116 Tables 117 Figure 120 Interview Questions 121 1 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Psychosexual Adjustment among Low-Income Latinas with Cervical Cancer For many cancer patients, the conclusion of treatment is met with a variety of functional challenges that result from the cancer itself, its treatments, side-effects, or a combination of the three (Harrington, Hansen, Moskowitz, Todd, & Feuerstein, 2010; Hewitt, Greenfield, & Stovall, 2006). One challenge many cancer patients report following treatment is sexual dysfunction (Sadovsky et al., 2010). Estimated rates of sexual dysfunction range from 40% to 100% across cancer types (National Cancer Institute, 2012). The extensive literature on sexual health and wellbeing after cancer shows that functional and psychological difficulties associated with sexuality can linger for years, if not indefinitely (Harrington et al., 2010; Krychman, Pereira, Carter, & Amsterdam, 2006; Verschuren, Enzlin, Dijkstra, Geertzen, & Dekker, 2010). A limitation of this literature, however, is its almost exclusive focus on non-Latino, White American and European cancer populations, despite the fact that some cancers especially associated with elevated risk for sexual dysfunction occur at higher rates among ethnic and racial minorities in the U.S., and in developing countries worldwide. Cervical cancer is one such cancer. Sexual dysfunction following cervical cancer is well documented, with rates of dysfunction ranging from 50% to 100% (Bergmark, Åvall-Lundqvist, Dickman, Henningsohn, & Steineck, 1999; Cull et al., 1993; Frumovitz et al., 2005; Greimel, Winter, Kapp, & Haas, 2009; Jensen et al., 2003, 2004; Klee, Thranov, & Machin Prof, 2000; Krychman et al., 2006). Among U.S. women, Latinas have had the highest incidence rates of cervical cancer of any ethnic group, with low-income Latinas at particularly high risk (American Cancer Society (ACS), 2012). Moreover, census data suggest that the number of Latinas at risk for cervical cancer in the U.S. will be increasing in the coming years as the population’s rapid growth continues (U.S. Census Bureau, 2012). Fortunately, improvements in cervical cancer detection and treatment approaches have resulted in approximately 75% of Latinas going on to 2 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER survive the disease for at least five years (ACS, 2012). Regardless of the high incidence of cervical cancer among Latinas—most of whom will survive—the literature on their experiences with the disease remains exceedingly limited. Conceptualizations of post-cancer sexuality have been shifting from the traditional biomedical model—focusing purely on disease-related dysfunction throughout the sexual response cycle—to the more comprehensive biopsychosocial model that also considers the role of the psychosocial and sociocultural contexts in which sexual dysfunction occurs (Brotto & Kingsberg, 2010; Syme, Mona, & Cameron, 2013). From this perspective, sexual functioning is determined by both physiological function and psychosocial factors that can include reactions to cancer, attitudes about sex, interpersonal dynamics of intimate relationships, sociocultural norms, and other contextual factors such as general life stress. Research on ethnic/racial disparities in cancer survivorship has indicated that the context of the middle-class White American or European patient, upon which the vast majority of the psycho-oncology sexuality literature is based, is not universally relevant (Aziz & Rowland, 2002; Janz et al., 2009; Luckett et al., 2011). For Latina cancer survivors in the U.S., issues related to immigration status (e.g., language, discrimination, and acculturative stress), socioeconomic status, and sociocultural norms and beliefs about cancer, sexuality, and gender role expectations, may all contribute to their experience of sexual dysfunction after treatment. Furthermore, these contextual factors have been shown to be associated with general psychosocial adjustment among Latino cancer populations, who regularly report poorer quality of life and elevated psychological morbidity as compared to non-Latinos, including other ethnic/racial minority groups (Aziz & Rowland, 2002; Janz et al., 2009; Luckett et al., 2011). Therefore, gathering information from patients and 3 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER survivors living in sociocultural contexts that are not currently represented in the sexuality psycho-oncology literature is particularly needed. Research on sexual functioning among healthy Latino populations is scarce (Meana, Oliver, & Jones, 2013), and information about sexual functioning among Latino cancer populations is similarly limited and often inconclusive (Yanez, Thompson, & Stanton, 2011). The small body of research that exists on Latinas' experiences with cervical cancer suggests that psychosocial adjustment to the disease can be challenging as indicated by reports of high rates of depression and negative affect, in addition to high levels of non-cancer related life stress associated with socioeconomic and immigration-related stressors (D’Orazio, Meyerowitz, Stone, Felix, & Muderspach, 2011; Meyerowitz, Formenti, Ell, & Leedham, 2000). In light of the potential detriments in quality of life experienced by Latinas with cervical cancer, information on their psychosexual wellbeing and adjustment can be a valuable addition to the literature. The purpose of this study was to address the gap in the current psycho-oncology literature by examining the psychosexual adjustment of low-income Latina cervical cancer survivors from a biopsychosocial perspective. The study tested various parts of the conceptual model below, as well as the model as a whole in exploratory analyses. Given that this is among the first studies to examine sexual functioning in Latina cervical cancer patients, the first part was designed to be descriptive, and focuses on identifying cancer-related and contextual factors associated with sexual functioning that would be most relevant to this population. The second part of this study delves deeper into several proposed relations between sexual functioning and emotional states, specifically depression, and positive and negative affect. The aims for this part of the study were to test potential mediators and moderators of the hypothesized association between sexual 4 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER functioning and emotional state, including sex-specific distress (intrusive thoughts), attitudes about sex and gender norms (sociosexual attitudes), as well as coping strategies for sex-related distress. Conceptual Model The design of this study was based on our previous research with low-income Latinas with cervical cancer (D’Orazio et al., 2011) and relevant psycho-oncology, cross-cultural psychology, and sexuality literatures detailed in the following review. It should be noted that although studies of sexual functioning often focus exclusively on sexually active or partnered individuals, this study did not exclude single or sexually inactive women in order to get the most accurate sense of the state of sexual functioning for the target population. Additionally, an overarching goal of this study was to provide information that will ultimately be used to inform psychosocial interventions for Latinas with cervical cancer, therefore the study was designed to provide data on the full range of sexual activity/ partnership statuses observed. (+) (+) (-‐) (-‐) (-‐) (+) Emotional States (-‐) (-‐) (-‐) (-‐) (+) (+) Life Burden Body Image Concerns Physical Symptoms Depression Positive Affect Sexual Functioning Intrusive Thoughts Sociosexual Attitudes Approach Coping Avoidant Coping Negative Affect Demographic Medical Covariates Relationship Quality 5 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Part I: Sexual Functioning after Cervical Cancer Treatment The first goal of this study was to provide a detailed description of sexual functioning for a sample of low-income Latinas who have completed cervical cancer treatment. Drawing from the biopsychosocial model of sexual functioning, factors considered for investigation included the physiological symptoms that are known to contribute to sexual dysfunction among cervical cancer patients, as well psychosocial contextual issues that would be most relevant to low- income Latina patients. In doing this, the aim is to provide a snapshot of sexual functioning for this understudied population as well as to learn what cancer-related and contextual factors are most strongly associated with sexual functioning for this sample. Cancer-related Biological Issues: Treatment-related Physiological Symptoms Sexual dysfunction often reported by cervical cancer patients and survivors may be partly caused by treatments’ subsequent side-effects (Abbott-Anderson & Kwekkeboom, 2012; Greimel et al., 2009). For example, surgical approaches are often invasive and can result in damage to delicate tissue and neurovascular functioning of genital pelvic organs and dysregulation of hormone levels, all of which play pivotal roles in the sexual response cycle (Abbott-Anderson & Kwekkeboom, 2012; Krychman et al., 2006). External beam and internal radiation implants, chemotherapy and hormone treatments have all been shown to result in decreased sexual desire, arousal, lubrication, and orgasms, as well as numbness, skin thickening, nausea, and fatigue. Additionally, vaginal discharge, odor, bleeding and incontinence have been known to occur after surgery and/or internal radiation implant treatments. One of the most common physical symptoms following cervical cancer treatment is vaginal stenosis—a shortening of the vaginal opening due to atrophy and damage to the surrounding structural and 6 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER muscular tissue that can interfere with sexual intercourse (Abbott-Anderson & Kwekkeboom, 2012; Bergmark et al., 1999; Juraskova et al., 2003; Krychman et al., 2006; Verschuren et al., 2010; Wolf, 2006). Not only do these physiological changes directly interfere with the sexual response cycle, they can make sexual activity difficult and painful, as well as cause self- consciousness or embarrassment that could contribute to avoidance of sexual intimacy (Verschuren et al., 2010). Some of these treatment-related physical side-effects can linger for years after treatment, even becoming permanent for many cervical cancer survivors (Abbott- Anderson & Kwekkeboom, 2012; Bergmark et al., 1999; Greimel et al., 2009; Wolf, 2006). Among the few studies of sexual functioning in Latina cancer patients and survivors, Latina breast cancer patients have been found to report more physical symptoms of sexual dysfunction, including dryness and pain, than non-Latina patients (Christie, Meyerowitz, & Maly, 2010; Fobair et al., 2006; Giedzinska, Meyerowitz, Ganz, & Rowland, 2004; Petronis, Carver, Antoni, & Weiss, 2003; Spencer et al., 1999). Additionally, a qualitative study of Latina cervical cancer survivors found self-consciousness and embarrassment about vaginal discharge, bleeding, and odor, and difficulty controlling urine were prevalent (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006). Cancer-related Psychological Issue: Body Image Concerns In addition to physical symptoms complicating sexual functioning, how a patient feels about the appearance of her body, as well as her sense of wholeness, femininity, and sexual attractiveness may be associated with interest in or ability to relax and enjoy sexual activity (Abbott-Anderson & Kwekkeboom, 2012; Gilbert, Ussher, & Perz, 2011; Pujols, Meston, & Seal, 2010). Negative body image has been shown to disrupt intimacy, sexual desire and performance among women with cancer (Abbott-Anderson & Kwekkeboom, 2012; Gilbert et al., 7 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER 2011; Krychman et al., 2006). Throughout the qualitative findings from Latina cervical cancer patients and quantitative evidence from the Latina breast cancer literature, body image concerns appear to be a particularly relevant adjustment challenge for Latinas (Ashing-Giwa, Padilla, Bohórquez, Tejero, & Garcia, 2006; Petronis et al., 2003; Spencer et al., 1999). It may seem that body image would not be as germane to cervical cancer patients as it might be with breast cancer patients as most physical changes among women with cervical cancer tend to be internal, and not often visible. However, there are some treatment-related changes to the body that can be visible and potentially upsetting. Among Latina cervical cancer survivors, qualitative findings indicated that self-consciousness regarding scars, hair loss, and weight gain were common (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006). Further, “invisible assaults to femininity,” as Butler et al., (1998) put it, including losing one’s sense of womanhood, femininity, or even wholeness due to removal of reproductive organs and feelings of sexual attractiveness due to having a disease of the sexual organs, may be particularly relevant for cervical cancer patients and survivors. Contextual Psychosocial Factors: Life Burden and Relationship Quality Life burden. In taking a contextual approach to examining psychosexual adjustment, a potentially relevant non-cancer-related factor to consider is the life burden patients regularly carry during adjustment. Stress has been shown to be associated with increased risk for sexual dysfunction, especially among women (Cain et al., 2003; Laumann, Paik, & Rosen, 1999). Non- cancer related life stress has been shown to be consistently associated with psychosocial outcomes among low-income Latina breast and cervical cancer patients (D’Orazio et al., 2011; Meyerowitz et al., 2000; Yanez et al., 2011). Low-income Latina cervical cancer patients and survivors have been shown to report moderate to high levels of non-cancer related life stress 8 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER associated with socioeconomic, minority, and immigration status, including financial hardship, limited work opportunities, acculturative stress, and family care-giving burdens (Ashing-Giwa & Lim, 2010; Ashing-Giwa et al., 2009; Ell et al., 2008; Meyerowitz et al., 2000). Findings from a study by D’Orazio et al. (2011) indicated that experiences specific to immigration and minority status (i.e., legal status, language barriers, and discrimination) were positively associated with depression and negative affect in low-income Latina cervical cancer patients. However, the relations between life stress and sexual functioning in Latina cervical cancer patients remains unknown. With an overwhelming amount of stress, sexual activity may lose priority to caring for family or working. Even if sex is considered a priority there may be limited time or energy available for patients to partake in it. Given the potential elevated levels of life burden low- income Latina cervical cancer patients might experience, considering its role in their sexual functioning is important. Relationship quality. Sex, for many, is an inherently interpersonal activity. Research shows that sexual activity among many women is motivated more by a need for intimacy than one of physiological sexual desire (Basson, 2000; Stephenson & Meston, 2010). The quality of the relationship with one’s sexual partner can shape motivation or desire for sexual intimacy for either partner (Hawkins et al., 2009). It can also influence a partner’s response to sexual dysfunction. Research has shown that difficulties in relationships with sexual partners, such as lack of emotional and physical satisfaction, can contribute to sexual dysfunction (Abbott- Anderson & Kwekkeboom, 2012; Ganz et al., 2004; Gilbert et al., 2011; Laumann et al., 1999; Stephenson & Meston, 2010). Therefore, relationship quality may be a relevant contextual factor in examining psychosexual adjustment to cervical cancer. However, it is should be noted that 9 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER women can still be sexually active without having a significant partner, therefore relevance of relationship quality is best assessed only with partnered women. Summary & Hypotheses Research suggests that in addition to physiological symptoms associated with cervical cancer treatments, sexual functioning among low-income Latina cervical cancer patients may be associated with cancer-related body image concerns, and contextual factors including life burden and relationship quality. In addition to demographic and medical variables that frequently co- vary with sexual functioning (e.g., age, years of education, cancer stage, treatments, etc.), physical symptoms, body image concerns, life burden and relationship quality were tested as predictors of sexual functioning. Specific physical symptoms included the most common symptoms reported by cervical cancer patients after completing treatment: vaginal stenosis, odor, and bleeding/discharge, as well as fatigue, nausea, abdominal pain, and difficulty controlling urine. It was expected that more physical symptoms, body image concerns, and life burden would be negatively associated with sexual functioning. In separate analyses including only partnered women, more physical symptoms, body image concerns, and life burden were expected to be negatively associated with sexual functioning, while better relationship quality was predicted to be positively associated with sexual functioning. Part II: Sexual Functioning and Emotional States The second part of this study was designed to take a closer look at how sexual functioning may be related to indicators of emotional states, specifically depression, and both positive and negative affect. Given that Latina cancer populations tend to encounter difficulties adjusting to the disease, evidenced by their higher levels of distress when compared to non- Latinas, it would be helpful to assess the extent to which sexual functioning may contribute to 10 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER levels of depression and affect, as well as to identify factors that may mediate and/or moderate these potential relations. As noted earlier, sexual dysfunction can be upsetting for cancer patients and healthy individuals alike (Abbott-Anderson & Kwekkeboom, 2012; Krychman et al., 2006; Laumann et al., 1999). For cervical cancer patients, after having endured possibly intense treatments and surviving a life-threatening disease, sexual dysfunction can be viewed as an added insult to injury. Intimate relationships, self-esteem, and general quality of life of cervical cancer patients can be disrupted by difficulties in sexual functioning (Abbott-Anderson & Kwekkeboom, 2012; Auchincloss, 1995; Bergmark et al., 1999; Frumovitz et al., 2005; Hawkins et al., 2009; Schultz & Van de Wiel, 2003). However, sexual functioning is not universally distressing—for some women it is a serious problem, while others perceive it as a manageable obstacle, and still others may not see any negative impact by sexual dysfunction on their lives at all (Stephenson & Meston, 2010). One way to assess the extent to which sexual dysfunction is problematic for patients is to consider their experience of intrusive thoughts related to this dysfunction. Intrusive thoughts are unwelcome, involuntary thoughts, memories, or images that have been considered to be indicators of cognitive processing of highly stressful events (Horowitz, 1986; Lepore, Ragan, & Jones, 2000). When confronted with an extremely stressful event, preexisting worldviews and beliefs about one’s place in the world can be challenged (Horowitz, 1986). Intrusive thoughts are a sign of the cognitive processing that takes place to help make sense of the stressful event and adjust to it. A relevant example for this study would be when sexual dysfunction challenges a woman’s view of her ability to fulfill certain expectations of her in intimate relationships. When this occurs, she may experience an increase in intrusive thoughts related to her sexual 11 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER dysfunction (e.g., “My relationship is doomed if I cannot have sex.”). For some women, sex may be essential enough in their lives that, in the face of dysfunction, sex-specific intrusive thoughts may be present and persistent. In the psychosocial oncology literature, intrusive thoughts about the diagnosis, treatment, or the general impact of the cancer experience on one’s life has been shown to be associated with psychological distress (Lepore, 2001). Therefore, it is possible that sexual functioning may be associated with emotional states indirectly through the experience of sex-specific intrusive thoughts, a mediator. Moderators and Mediators of the Relations between Sexual Functioning, Intrusive Thoughts and Emotional States The mediation model proposed above provides a basic explanation for how sexual functioning may be associated with emotional states through sex-specific intrusive thoughts, essentially a physical state is associated with unwanted thoughts that are linked to emotions. However, a few issues still remain unaddressed. First, for whom is the nexus between sexual dysfunction and intrusive thoughts significant or stronger? Second, does how one copes with sex-specific intrusive thoughts influence the emotional outcome? Here, a moderator of the association between sexual functioning and intrusive thoughts, and a mediator of the association between intrusive thoughts and emotional states are considered that may address these issues. Sociosexual attitudes. The extent to which sexual dysfunction is associated with sex- specific intrusive thoughts may vary by attitudes about sex. Women enter the cervical cancer experience with existing normative orientations and attitudes about sex, what it means to be a woman, and what is expected of women in intimate relationships. However, there is little to no information on what role, if any, these specific attitudes play in psychosexual adjustment to cancer beyond post-hoc speculation (Meana et al., 2013). Sociosexual attitudes may be 12 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER associated with psychosocial adjustment in that they make up the normative beliefs about sex that are subsequently challenged in the presence of sexual dysfunction. If, for example, a patient considers it a woman’s duty to keep her partner sexually satisfied, she may perceive sexual dysfunction as a serious threat, either to her ability to fulfill this role as a woman or to the stability of the relationship, or both. Attitudes that tap into traditional male 1 -dominant sex beliefs (i.e., it is inappropriate for a woman to initiate sex), general beliefs about sex being a taboo subject that should not be discussed, and beliefs regarding definitions of womanhood (e.g., a woman without her reproductive organs is no longer a woman) can be categorized along a continuum ranging from what will be termed conservative to liberal sexual attitudes, for a lack of more precise labels. Conservative attitudes reflect sexual norms that are more traditionally patriarchal, modest, and static, such as beliefs regarding subordinate female roles during intimacy. Liberal attitudes towards sex comprise more openness to sex-related topics and desires, egalitarian beliefs about power dynamics in sexual activity, and flexible gender-role expectations in intimate relationships. Although there is some evidence that the conservative attitudes presented here are not uncommon among Latinas in the U.S., the prevalence of these attitudes can vary as there is considerable diversity within the Latino-American population (Harvey, Beckman, Browner, & Sherman, 2002; Meana et al., 2013). In The National Survey of Latinos (The Pew Hispanic Center/Kaiser Family Foundation, 2002), Latinos were generally found to be somewhat more socially conservative than non-Latino whites. National studies of sexual functioning, practices and well-being report similar conservative trends among Latinos (Cain et al., 2003; Laumann et al., 1999). Cain et al. (2003) found that Latinas in their multi-ethnic sample were the least likely 1 It is important to note that although our discussion of sexual attitudes focuses on heterosexual relationships, these issues can exist for Latinas in intimate relationships with women. 13 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER to endorse having sex for pleasure and they were the most likely to cite getting pregnant as the main reason to engage in sex as compared to non-Latinas. This study also found the proportion of women reporting that they engaged in sex because their partner wanted them to was highest for Latina and Japanese women. Findings from qualitative research with Latina cervical cancer survivors showed that Latinas reported feeling pressured to have sex with their partners before feeling ready or when they did not want to for fear of damaging their relationship or abandonment—which was a reality for some women (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006). Other beliefs focused on definitions of womanhood, with survivors often voicing distress associated with feeling like they were no longer women without their reproductive organs (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006). Many of these beliefs and concerns were also expressed by patients in our previous study examining the psychosocial adjustment of low-income Latina cervical cancer patients (D’Orazio et al., 2011). Given these conservative attitude trends, it is possible that Latina cervical cancer patients may be at increased risk for intrusive thoughts about sex. In sum, conservative, male/partner-dominant and female-subordinate attitudes may be prevalent (to varying degrees) among Latina cervical cancer patients. Women with more conservative sociosexual attitudes may perceive the cost of sexual dysfunction to be great—they may lose their partner, sense of womanhood and/or their sense of worth. Women with more liberal sociosexual attitudes may also view sexual dysfunction as troublesome; however, they may perceive more flexibility in the role of sex in their lives, how it can be accomplished, and in their beliefs about womanhood. Not having sex or changes in the quality of their sexual activity may not come with as large a cost as it would for women with more conservative sociosexual 14 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER attitudes. Therefore women with more conservative sociosexual attitudes may experience more intrusive thoughts about sex than those who report more liberal sociosexual attitudes. Coping strategies for intrusive thoughts. Intrusive thoughts can reveal the extent to which sexual dysfunction really bothers patients, which is expected to be related to their emotional state. In examining psychosexual adjustment, it is important to consider how Latina cervical cancer patients cope with these specific intrusive thoughts, if they are occurring. Coping strategies have consistently been associated with psychosocial adjustment in cancer populations, including cognitive processing and intrusive thoughts (Culver, Arena, Antoni, & Carver, 2002; Roesch et al., 2005). In psychosocial oncology research, coping strategies usually refer to the ways individuals deal with challenges or stressors related to cancer (Scheier, Weintraub, & Carver, 1986). In this case, coping strategies that are considered are those patients use to deal with intrusive thoughts related to sexual functioning. Patients use various modes of coping to adjust to difficult situations, including approach and avoidant strategies. Approach coping strategies involve attending to issues related to the source of distress, for instance, accepting the fact that sexual dysfunction may be distressing at times, using cognitive reframing to see the situation in a positive light, or planning for future obstacles (Solberg Nes & Segerstrom, 2006). Avoidant coping strategies, in contrast, are used to divert attention away from the source of distress, such as patients refusing to accept that their sexual functioning may be compromised indefinitely or using self-distraction to avoid thinking about it (Solberg Nes & Segerstrom, 2006). In our previous study of psychosocial adjustment among low-income Latina cervical cancer patients (D’Orazio et al., 2011), approach and avoidant coping were found to be orthogonal constructs, rather than two opposing ends of a dimension, with different outcomes associated with each form of coping. For example, approach 15 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER coping strategies were significantly associated with positive affect but not negative affect, whereas avoidant coping was significantly associated with negative affect but not positive affect, yet both forms of coping were associated with levels of depression (D’Orazio et al., 2011). To our knowledge, how cancer patients cope specifically with distress associated with sexual dysfunction has not been considered in the psychosocial oncology literature. Throughout this literature, stressors encountered during and after the cancer experience have been shown to lead to coping behaviors, which in turn, lead to certain psychosocial outcomes, such as mood, affect, and/or quality of life (Carver et al., 1993; Roesch et al., 2005; Stanton, Danoff-burg, & Huggins, 2002). It was expected that intrusive thoughts would be indirectly associated with emotional states through the approach and avoidant coping strategies patients used to manage these thoughts. Therefore as intrusive thoughts increase coping will increase, with more approach coping being associated with less depression and negative affect and more positive affect, and the opposite when more avoidant coping is used. Exploring the Role of Relationship Quality Research has shown that there is a reciprocal association between sexual satisfaction and relationship quality, with sexual intimacy often contributing to the quality and stability of romantic relationships and vice versa (Birnbaum, Reis, Mikulincer, Gillath, & Orpaz, 2006; Laumann et al., 2006). Relationship distress, for example uncertainty about the future of a relationship, has not only been shown to interfere with sexual desire and feelings of intimacy, but it also has been associated with difficulties in other female sexual responses, especially with ability to become lubricated and/or reach orgasm (Laumann et al., 2006). Illness can challenge even the most stable of relationships, although how couples cope and adjust can vary by age, culture, and disease (Berg & Upchurch, 2007). Anecdotal and qualitative findings from studies 16 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER of Latina cervical cancer patients indicate that this disease can lead to relationship difficulties, even ruptures for some couples, and the fear of this fate is not uncommon (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006. Therefore, within the context of post-treatment sexual dysfunction, relationship distress may be associated with sexual functioning. To assess how relationship quality is relevant to adjustment of partnered women in this study, it was included in exploratory analyses. It should be noted that the relevance of relationship quality to the adjustment of unpartnered women is difficult to assess, even though their partner status may be the result of cancer-related challenges. Summary & Hypotheses Sexual functioning and emotional states may be related indirectly through intrusive thoughts, a mediation. It is expected that lower levels of sexual function will be associated with higher levels of intrusive thoughts, which will be associated with more depression and negative affect, and less positive affect. However, intrusive thoughts may also occur more for some women than others. Specifically, those who endorse conservative sociosexual attitudes may report more intrusive thoughts in the presence of dysfunction than women who endorse more liberal sociosexual attitudes. Therefore, the relationship between sexual functioning and intrusive thoughts may be moderated by sociosexual attitudes. Lastly, how patients cope with sex-specific intrusive thoughts may be associated with their emotional states. Intrusive thoughts may be indirectly associated with depression, negative affect, and positive affect, through approach and avoidant coping strategies, mediators of the relations. Specific Aims Specific Aim I. To provide a description of sexual functioning among Latina cervical cancer patients and to identify cancer-related and contextual factors associated with sexual functioning. 17 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Hypothesis 1a: Physical symptoms, body image concerns, and life burden will be negatively associated with sexual functioning after controlling for potential covariates. Hypothesis 1b: Physical symptoms, body image concerns, and life burden will be negatively associated with sexual functioning, while relationship quality will be positively associated with sexual functioning, after controlling for potential covariates for women with partners. Specific Aim II. To test the association between sexual functioning and emotional states and to test sex-specific intrusive thoughts as a mediator of these relations. Hypothesis 2a: After controlling for covariates, sexual functioning will be significantly associated with emotional states such that sexual functioning will be negatively associated with depression and negative affect, and positively associated with positive affect. Hypothesis 2b: When controlling for intrusive thoughts, the relations between sexual functioning and emotional states will no longer be significant or the relation will be significantly weakened. Specifically, sexual functioning will be negatively associated with intrusive thoughts, which will be associated positively with depression and negative affect, and negatively with positive affect. Exploratory Question: Do intrusive thoughts mediate the relation between sexual functioning and emotional states when controlling for relationship quality with partnered women? Specific Aim III. To assess sociosexual attitudes of Latina cervical cancer patients and to test sociosexual attitudes as a moderator of the relation between sexual functioning and intrusive thoughts. 18 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Hypothesis 3: The relationship between sexual functioning and intrusive thoughts will be moderated by sociosexual attitudes. Sexual functioning is expected to be significantly associated with intrusive thoughts; however this relationship will be significantly stronger for women with conservative sociosexual attitudes than for women with liberal attitudes. Exploratory Question: Do sociosexual attitudes moderate the relation between sexual functioning and emotional outcomes when controlling for relationship quality with partnered women? Specific Aim IV. To examine the relations between intrusive thoughts and coping strategies and to test coping strategies as mediators of the relations between intrusive thoughts and emotional states. Hypothesis 4a: When controlling for covariates, intrusive thoughts will be positively associated with both forms of coping. Hypothesis 4b: Coping strategies will mediate the relations between intrusive thoughts and emotional states, such that when controlling for coping strategies, the relations between intrusive thoughts and emotional states will no longer be significant or the relations will be significantly weakened. Specifically, intrusive thoughts will be positively associated with both forms of coping. Approach coping will be negatively associated with depression and negative affect, and positively associated with positive affect, whereas avoidant coping will be positively associated with depression and negative affect, and negatively associated with positive affect. Question: Do coping strategies mediate the relation between intrusive thoughts and emotional outcomes when controlling for relationship quality with partnered women? 19 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Exploratory Analyses. The hypothesized relations between variables proposed above will hold when testing the conceptual model as a whole. Method Participants Cervical cancer patients who completed treatment within three months to three years before being interviewed for this study, with no recurrence of cancer, who self-identified as Latina, Hispanic, or Chicana, and who spoke Spanish or English were eligible to participate. Any patient who demonstrated moderate cognitive or psychiatric impairment, as judged by the medical staff, was excluded from the study. Descriptive statistics for demographic and medical variables are provided in Tables 1 and 2, respectively, for the total sample as well as for sexually active and non-sexually active subgroups. A total of 100 low-income Latina cervical cancer patients was recruited over a 12- month period from the Los Angeles County Hospital + University of Southern California (LAC+USC) Gynecological Oncology Clinic. Mean age for the sample was approximately 48 years. The average number of years patients reported living in the U.S. was roughly 20. All but five of the patients were immigrants to the United States, with a majority of patients having immigrated from Mexico. Education levels for the sample were generally low. Although 14% of the sample completed high school and 9% received some undergraduate education, roughly 69% of patients reported receiving between 1 and 11 years of education, while 8% reported that they never received formal schooling. Over half of the patient sample (64%) was unemployed at the time of the interview, while 27% of patients were unemployed prior to their diagnosis. Based on 2013 federal poverty levels, all patients were from low-income households (U.S. Dept of Housing and Development, 2013). Seventy percent of the women in the sample were partnered. 20 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Of the partnered women, 66 (94%) lived with their partners. The median number of children was three, with 13% of patients having had five or more children. Just over a third (35%) of patients reported having sole fiscal responsibility for their households. Just under half (48%) of patients were caring for one or more children and 8% were caring for at least one older adult at the time of the interview. All patients were Spanish-speakers and 95% were monolingual. The five bi- lingual speakers chose to complete the interview in English. The majority of patients fell within a good prognostic category of having Stage I or II cervical cancers (84%). Treatment modality options for patients included surgery, chemotherapy, external beam radiation, and/or internal radiation implant. For this sample, 22% received all four treatments, 31% only had surgery, and 23% received only radiation plus chemotherapy. The remaining 24% received a combination of surgery, and either radiation or chemotherapy. The average time since treatment was 16.5 month, and average treatment duration was just under 8 months. Procedure Data were collected via in-person interviews by a bi-lingual female interviewer, the study investigator (L.D’O.). Patients were recruited before scheduled appointments with their gynecologic oncology medical providers at the clinic once they had checked in at the nurses’ station. The intake nurses, who take vital signs of all patients prior to their appointments, asked patients if they were interested in hearing about the present study. If the patient expressed an interest in learning more, the interviewer was introduced to the patient. The patient was escorted by the interviewer to a private location where the study was briefly explained. If the patient expressed interest in participating, written consent was obtained, including permission for access to medical records. The interview was conducted upon completion of the consent procedures. 21 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Patients were told at the outset of the interview that questions about sex and intercourse could be embarrassing or difficult to answer and they were encouraged to respond as best they could. They were also reminded that that they had the right to refuse to answer any question, although none of the patients did. Patients were given the choice of being interviewed in either Spanish or English. If the interview was interrupted because the patient was called in to see the doctor, the interview was continued after the appointment in most cases. Interviews generally took approximately one hour to complete. Participants were given a $10 gift card to a discount department store as a small compensation for their time. The interviewer was introduced to a total of 375 gynecologic oncology patients for recruitment. Of these, 271 patients were excluded from participating by the interviewer for not meeting eligibility criteria (e.g., not having a diagnosis of cervical cancer, not having completed treatment). A total of four patients declined to participate before signing consent due to not being interested in participating (n=2), not having time (n=1), and needing more time to read over the consent form (n=1). None of the study participants chose to discontinue participation after consent was obtained nor did any decide to stop the interview once it was started. An additional 11 patients were deemed ineligible by the intake nurses for reasons that included cognitive impairment (n=7) or moderate to severe psychiatric impairment (n=4), and, therefore, were not introduced to the interviewer. Measures. A questionnaire packet was created that included both standardized scales and some modified scales specifically adjusted for this study. The standardized scales have all demonstrated adequate reliability and validity. To the extent possible, validated Spanish translations of scales were used. Measures that did not have a validated Spanish translation were translated into Spanish by the study investigator and confirmatory back-translations were done 22 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER by two independent professional Spanish translators. The appendix includes the English versions of all of the instruments that were used in this study (Spanish versions can be provided upon request). An 8.5 x 11 inch card was made for instruments that used Likert-type response scales that listed the possible responses for each item. For example, one card had numbers from 0 to 4 and under the number 0 it read “Never”, under 1 it read “Almost never” and so on. Symbols (e.g., happy or sad faces), were included to aid participants with limited literacy. Descriptive statistics for measures are provided in Tables 3 and 4. Reliability statistics Z H U H F D O F XO D W H GI RU D O O V F D O H V Z L W K& U RQED F K¶ V Į V ! F RQV L GH U H GD F F H SW D EO H O H YH O V RI internal consistency D QGĮ V between .60 and .69 considered borderline acceptable (Nunnally & Bernstein, 1994). Demographic and medical information. Demographic information included age, years in the U.S., country of origin (U.S., Mexico, Central America, or South America), years of education, employment status (pre- and post-diagnosis), income, marital/partner status, number of patients’ children, who was fiscally responsible for housing (self or other), and number of people patients cared for (children and older adults). Level of acculturation was measured using the Acculturation Rating Scale for Mexican Americans-II (Brief Version) (ARSMA-II; Cuéllar, Arnold, & Maldonado, 1995; Dawson, Crano, & Burgoon, 1996). The brief version of the ARSMA-II is a 12-item scale that measures acculturation among three domains: language, ethnic identity, and ethnic interaction. Responses are based on a 5-point scale assessing frequency of engaging in various activities in Spanish or in English, ranging from 1 (Not at all) to 5 (Almost always/Extremely often). This scale is made up of two, 6-item subscales, a Mexican Orientation Subscale (MOS) and an Anglo Orientation Subscale (AOS). Given that this study includes non- Mexican Latinas, the MOS is referred to as the Latino Orientation Subscale (LOS) from this 23 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER point on. Items were revised replacing “Mexican” for “Latino.” Scores are based on the average of responses to items for each subscale and a total acculturation score is derived from subtracting the LOS mean from the AOS mean. Positive scores indicate more Anglo orientation and negative scores indicate more Latino orientation. This scale has been used with non-Mexican Latino samples (D’Orazio et al., 2011). , QW H U Q D O U H O L D EL O L W L H V RI W KH W RW D O V F D O H & U R QED F K¶ V Į = .93) and the two subscales were V W U RQJ / 2 6 & U RQED F K¶ V Į $ 2 6 & U RQED F K¶ V Į Medical information included cancer stage, treatment types (i.e., surgery, chemotherapy, external beam radiation, radiation implant), months since treatment completion, length of treatment course (in months), and current medications (including current or past antidepressant use and/or hormone replacement therapy). These data were collected from patients and confirmed via chart review and are provided in Table 2. Frequency of sexual activity and importance of sex. Participants were asked to report the number of times they were sexually active during the four weeks prior to the interview. Sexual activity was defined to participants as including caressing, foreplay, masturbation and vaginal intercourse. Participants were then asked three yes/no questions: (1) if sex was an important part of their lives, (2) if the patient would like to be more sexually active than she was at the time of the interview, and (3) if she wanted to be less sexually active. Sexual functioning. Sexual functioning during the previous four weeks was assessed using the Female Sexual Functioning Index (FSFI; Rosen, Brown, Heiman, & Leib, 2000). The FSFI is a 19-item measure of female sexual function across 6 domains, specifically frequency and level of difficulty experienced for each of the sexual response cycle phases (American Psychiatric Association, 2000): desire (2 items), arousal (4 items), lubrication (4 items), orgasm (3 items), satisfaction (3 items), and pain (3 items). Items are rated on 5-point Likert-type scales, 24 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER ranging from 1 to 5, with responses specifically catered to each domain. The FSFI has been validated for use with cancer survivors (Baser, Li, & Carter, 2012). A validated Spanish translation of the FSFI provided by the authors was used. Typically, total scores for the FSFI are calculated as a sum of weighted subscale score sums. However, given that sexually inactive women can only complete two of the six subscales (desire and satisfaction), a multistep analysis was conducted to assess the appropriateness of using the mean of subscale means to estimate an overall state of sexual functioning for the whole sample. First, correlations between items within each subscale were examined for sexually active and inactive women separately to determine the extent to which they were assessing a common construct. Items that did not significantly correlate with other items within a given subscale were dropped. This resulted in one of the three items from the satisfaction subscale (satisfaction with emotional closeness) being dropped for both sexually active and inactive women. Next, subscale means were correlated with one another to determine the extent to which a common construct was being assessed across subscales for sexually active and inactive women separately. For sexually active women, the pain subscale did not significantly correlate with any of the other five subscales, therefore it was not included in the total score. All correlations among the remaining subscales were significant (rs ranging from .34 to .79), which suggested that a common underlying construct was present across subscales. For sexually inactive women, the desire and satisfaction subscale means were significantly correlated with one another (r =.48, p =.001), suggesting that they, too, were measuring a similar construct. Total sexual functioning scores were calculated as the mean of subscale means, which could range from 1 (low functioning) to 5 (high functioning). For sexually active women, the total sexual functioning score was the mean of the desire, arousal, lubrication, orgasm, and 25 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER satisfaction subscale means. The Cronbach’s alpha for the five subscales for sexually active women was .86 (.94 for the 15 subscale items). For sexually inactive women, the total sexual functioning score was the mean of the desire and satisfaction subscales means. The Cronbach’s alpha for the two subscales means was .64 (.67 for the four subscale items). Although the alpha for the two subscale means for sexually inactive women is of borderline strength, this is likely an artifact of having fewer items in the analysis by including two subscales, versus four items. The Cronbach’s alpha for the four items from the desire and satisfaction subscales for the entire sample was .77 and for the two subscales was .71, suggesting that the underlying construct for these subscales is consistent for sexually active and inactive women. Given the generally strong inter-item/subscale correlations, the consistent directions of these associations for both groups, and the relatively strong internal reliabilities for subscales/items, these FSFI subscales appear to be assessing a common construct for both groups. Therefore, using a mean of subscale means (mean of means) would be a representative estimation of this common construct. Weighted sum scores, as recommended by the scale’s authors (Rosen et al., 2000), were only calculated for sexually active women for descriptive purposes in order to assess the proportion of the sample who met criteria for sexual dysfunction. The authors of the FSFI provide a scoring algorithm consisting of sum scores for each subscale that are then weighted by a factor score. The total score is the sum of these weighted subscale scores. A suggested cut-off score indicating a high risk for sexual dysfunction in sexually active women has been set at or below a score of 26 (Wiegel, Meston, & Rosen, 2005). Emotional states. Depressed mood. The Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) was used to measure cognitive and somatic depressive symptoms during the 26 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER previous four weeks. The CES-D is made up of 20 self-report items and scores range from 0 to 60. Responses are based on the frequency of each symptom rated on a 4-point scale ranging from 0 (Rarely/Never) to 3 (Most/All of the time). Scores of 16 or above indicate depressive symptoms comparable to patients with depressive disorders. & U RQED F K ¶ V Į I RU W KH V F D O H Z D V Affect. The Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1988) or the Spanish version of the Positive and Negative Affect Schedule (SPANAS; Joiner, Sandín, Chorot, Lostao, & Marquina, 1997) was used to measure affect. This scale is an adjective checklist in which mood states are assessed with 10 positive affect items (PA) and 10 negative affect items (NA). Participants were asked to rate the frequency with which they have experienced these emotions during the previous four weeks on 5-point scales, ranging from 1 (Very slightly/Not at all) to 5 (Extremely). Higher total scores indicate higher levels positive or negative affect. & U RQED F K¶ V Į V I RU W KH SRV L W L YH D Q GQH JD W L YH D I I H F W V F D O H V Z H U H D QG respectively. Cancer-related factors associated with sexual functioning. Physical symptoms. Levels of physical symptoms that could potentially interfere with sexual activity during the previous four weeks were assessed using items from the Functional Assessment of Cancer Treatment—Cervical Cancer (Version 4; FACT-Cx), and its validated Spanish version. The FACT-Cx is made up of the FACT-G scale (General; Cella et al., 1993, 1998) and a 15 item subscale (Cx; Monk, Huang, Cella, & Long, 2005) developed to tap specific cervical cancer experiences. Seven physical symptom items were selected from the physical wellbeing subscale and the cervical cancer-specific concerns supplemental scale. Items chosen assessed fatigue, nausea, body pain, vaginal discharge or bleeding, vaginal odor, vaginal stenosis, and problems controlling urination. Items are rated by the extent to which patients are 27 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER bothered by symptoms on a 5-point scale ranging from 0 (Not at all) to 4 (Very much). A sum score was calculated for the analyses. Given that this score reflects a checklist of physical V \ P SW RP V L W Z D V QRW XQH [ SH F W H GW KD W W KH V F D O H U H O L D EL O L W \ & U RQED F K¶ V Į .58) fell below what is W \ SL F D O O \ F RQV L GH U H G D F F H SW D EO H .70; Nunnally & Bernstein, 1994). Body image. Body image was assessed using the 6-item Body Image Scale (BIS; Hopwood, Fletcher, Lee, & Al Ghazal, 2001). This scale assesses the extent to which respondents feel self-conscious about their body’s appearance and sense of femininity, sexual attractiveness, and body wholeness as a result of their illness or treatments during the previous four weeks. Each item is rated by how much patients agree or disagree on a 4-point scale ranging from 0 (Not at all agree) to 3 (Very much agree). Scores are a sum of item responses, with higher scores indicating more negative body image. The BIS was developed with The European Organization on Research and Treatment of Cancer (EORTC) and has been incorporated into the EORTC Breast Cancer Module (EORTC QLQ-BR23; Sprangers et al., 1998), however it can be modified for use with any cancer population. This scale was translated into Spanish for this study. & U RQED F K¶ V Į I R U W KH % , 6 Z D V Contextual predictors of sexual functioning. Life burden. Life burden was a composite variable created by combining z-scores from measures of life stress and family responsibility. An abbreviated version of the Hispanic Stress Inventory (Cavazos-Rehg, Zayas, Walker, & Fisher, 2006; Cervantes, Padilla, & Salgado de Snyder, 1991) was used to measure life stress experienced during the past four weeks that was not specifically cancer-related. The 25-item abbreviated HSI immigrant version (HSI-I) has been validated; however, an abbreviated version of the non-immigrant HSI did not exist at the time of this study. Since many of the items from the abbreviated HSI-I are also included in the HSI non- 28 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER immigrant version, the abbreviated HSI-I was used for all participants in this study. Means between scores for immigrants and non-immigrants did not significantly differ. On both, participants first responded “yes” or “no” as to whether they had experienced the situation depicted in the item within the past four weeks. If the participant’s response was “no”, meaning the situation described did not occur during the prior four weeks, the response was zero. If the event occurred, they rated the level of distress the situation caused from 1 (Not at all worried/tense) to 5 (Extremely worried/tense). Domains of stress included occupational/economic, parental, marital, immigrant-specific stress, and family/cultural conflict. Scale scores are based on the mean of items, with higher scores indicating higher levels of stress. & U RQED F K¶ V Į for the abbreviated HSI-I was .87. Family responsibility was assessed using the Family Responsibility Scale (FRS; Abell, Ryan, Kamata, & Citrolo, 2006), a 10-item scale measuring the extent to which respondents felt burdened and pressured to meet family responsibilities during the past four weeks. Participants report the frequency with which each item occurred within the past four weeks on a 7-point scale ranging from 1 (Never) to 7 (All of the time). A validated Spanish translation of the FRS provided by the authors was used with Spanish speakers. Scale scores are based on the sum of items, with higher scores indicating higher levels of stress. & U RQED F K ¶ V Į I RU the FRS was .90. Relationship quality. Relationship quality was assessed using the Revised Dyadic Adjustment Scale (RDAS; Busby, Russell, Larson, & Christensen, 1995). The RDAS is a 14- item measure assessing perceived agreement on common life decisions couples face, perceived cohesion between partners, and satisfaction with various aspects of an intimate relationship. Sums of item responses make up total scores, which range from 0 to 69. Higher scores indicate better relationship quality. Scores 48 and higher indicate non-distressed relationships, and scores 29 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER 47 and below indicate distressed relationships (Crane, Middleton, & Bean, 2000). The scale was translated into Spanish for this study. & U RQED F K ¶ V Į I RU W KH 5 ' $ 6 Z D V Possible moderators and mediators. Intrusive thoughts. Intrusive thoughts were measured with the Impact of Events Scale – Revised Intrusion subscale (IES-R; Weiss & Marmar, 1997) and its validated Spanish translation, Escala Revisada De Impacto Del Estresor (EIE-R; Báguena et al., 2001). The IES-R measures participant’s reactions to a stressful event, in this case difficulties with sexual functioning. The IES-R Intrusion subscale contains eight items, each of which is rated as to how distressing the item has been during the past four weeks with respect to thoughts and concerns related to sexual dysfunction. For this study, seven of the eight items were used. One item was dropped because it assessed the extent to which reminders take the respondent back to the time of the “trauma,” which did not appear appropriate for assessing intrusive thoughts about current concerns. Each item is rated for the frequency of experiencing each intrusive thought on a 5- point Likert-type scale ranging from 0 (“Not at all”) to 4 (“Almost always”). The sum of the items was used as the scale score. & U RQE D F K¶ V Į I R U W KH , ( 6 -R was .83. Socio-sexual attitudes. A 12-item measure of socio-sexual attitudes was created for this study using items selected from The Brief Sexual Attitudes Scale (BSAS; Hendrick, Hendrick, & Reich, 2006) and The Revised Trueblood Sexual Attitudes Questionnaire (TSAQ; Hannon, Hall, Gonza, & Cacciapaglia, 1999), in addition to items created specifically for this study by the investigator. This socio-sexual attitudes scale was designed to measure outlooks within three domains: global attitudes about sex (global subscale; e.g., sex importance, appropriateness), gender role definition/expectations (gender subscale), and perceived pressure to have sex (power subscale). Each domain is rated by the extent to which patients agree or disagree with the items 30 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER rated on 5-point Likert-type scales ranging from 0 (Strongly disagree) to 4 (Strongly agree). Higher scores indicate more conservative/static attitudes towards sex and lower scores indicate more liberal/flexible attitudes towards sex. A principal components factor analysis was performed to assess the factor structure of the sociosexual attitudes scale and to confirm the existence of the subdomains proposed. A Varimax rotation was used to identify orthogonal factors as indicated by factor loadings greater than 0.4 with no higher loadings on more than one component. Both the Kaiser-Meyer-Olkin measure of sampling adequacy (0.69) and Bartlett’s test of sphericity (p < .001) were adequate, indicating that a factor analysis is appropriate for these data. Three factors were extracted that together explained 56.3% of the variance (factor loadings provided in Table A of appendix). The three I D F W RU V P D SS H GRQW RW KH W KU H H SU RSRV H GGRP D L QV & U RQED F K¶ V Į V F D O F XO D W H G I RU V XEV F D O H reliability analyses revealed excellent internal consistency for the predicted power subscale Į D QGERU G H U O L QH L Q W H U QD O F RQV L V W H QF \ I RU W KH SU H GL F W H G J O RED O V XEV F D O H SO XV RQH L W H P I U RP W KH SU H GL F W H G JH QGH U V XEV F D O H Į + RZ H Y H U W KH U H P D L QL Q J L W H P V I U RP W KH SU H GL F W H G JH QGH U subscale demonstrated weak internal conV L V W H QF \ Į ) RU W KH SX U SRV H V RI W KL V V W XG \ analyses were conducted using the total sociosexual attitudes scale ( & U RQE D F K¶ V Į , as well as the global and power subscales, but not the gender subscale. Means of item responses were used as scale/subscale scores. Coping strategies. Coping strategies of participants were measured using the Brief Coping Orientation to Problems Experienced Scale (Brief COPE; Carver, 1997). This 28-item scale assesses coping strategies that can be anchored to any event within 14 domains including active coping, denial, behavioral disengagement, positive reframing, acceptance, and self-blame, for example. For the purposes of this study, the scale was anchored to how patients cope with 31 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER unwelcome thoughts about sexual dysfunction that weigh on their minds (intrusive thoughts). Each item is based on a 4-point scale ranging from 1 (I haven’t been doing this at all) to 4 (I’ve been doing this a lot). For domain scales, the total score was calculated by averaging the two items. The scale’s authors recommend grouping subscales into categories of coping based on the hypotheses being tested. For this study, two categories were created based on theoretical grounds, analysis of reliability, and previous findings (D’Orazio et al., 2011): approach coping and avoidant coping. The approach coping scale score is the average of the following subscale scores: active coping, use of emotional and instrumental support, positive reframing, planning, and acceptance. The avoidant coping scale score is the average of the following subscale scores: self-distraction, self-blame, denial, substance use, behavioral disengagement, and venting. A validated Spanish translation of this scale provided by the measure’s authors was used with Spanish-speakers (Perczek, Carver, Price, & Pozo-Kaderman, 2000). For this study, however, a modified version of this Spanish translation was used due to the fact that the Spanish version of the Brief COPE does not include the self-blame or use of instrumental support subscales, which are included in the English version. Therefore self-blame and instrumental support items were translated into Spanish for this study. & U RQED F K ¶ V Į V I RU W KH D SSU RD F KD QGD YRL GD QW F RSL QJ V F D O H V was .88 and .78, respectively. Statistical Analyses Statistical analyses were performed using SPSS v19. Descriptive statistics included calculating sample means, ranges, and frequencies. Additionally, given that the purpose of the study is to examine sexual functioning, ANCOVA (controlling for relevant covariates) D QGȤ 2 tests were used to assess differences across variables between sexually active and inactive participant (defined by a dichotomous variable). Correlation analyses were conducted, including 32 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Pearson correlations (r) for continuous variables and Spearman’s rho (r s ) correlations for dichotomous variables. Prior to statistical analyses, screening was done to detect missing data, outliers, and to assess deviations from normality among variable distributions. Missing data. Data were missing from one scale, the FRS. The FRS was the last measure in the interview, and three participants did not have time to complete it. The three FRS scale scores were imputed using the linear trend for that point that predicts the value using regression analyses. There were no other missing data, a result of the in-person interview format. Outliers. Outliers were found for the following scales: RDAS, Latino Orientation Subscale, and the Anglo Orientation Subscale using the outlier labeling rule established by Hoaglin, Iglewicz, & Tukey (1987). In order to reduce the impact of the outliers, each outlying high score was modified to equal the next actual highest score for the sample plus one, and each outlying low score was changed to equal the next actual lowest score for the sample minus one (Tabachnick & Fidell, 2013). Transformations. In assessing the distributions for each variable for deviations from normality, several were found to be skewed. Distributions with moderate to substantial skewness were transformed using square root and log transformations (Tabachnick & Fidell, 2013). The transformation with skewness closest to zero was used in subsequent regression analyses. Skewness statistics for all transformed variables fell between -1 and 1. Covariate analysis. Age and sexual activity status were controlled for across all analyses on theoretical grounds. Sexuality literature has shown that age is a strong correlate of sexual functioning (Laumann et al., 1999; correlation from the present study: r = -.36, p < .01), with younger age being associated with better sexual functioning. Sexual activity status was expected to significantly covary with sexual functioning and was controlled for in order to assess relations 33 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER between sexual functioning and other key variables above and beyond what is accounted for by sexual activity status alone. Additional covariates were identified through correlation and regression analyses. Significant demographic and medical correlates of each outcome variable were entered into a regression equation with age and sexual activity status, and only significant independent predictors were used as covariates for each outcome variable. Descriptive correlation analyses. Correlates (demographic and medical variables, as well as relationship quality and sexual activity status) for each key variable are listed in Tables 5 (sexual activity status) and 6. As demographic and medical variables can covary with one another (e.g., partner status and income, cancer stage and treatment modality), for descriptive purposes, significant independent correlates for each key variable were identified using the same method to identify covariates of outcome variables. Therefore, all significant correlates of each key variable were entered into separate regressing equations and the correlates that remained significant independent predictors were reported in the descriptive results section for each key variable. Multicollinearity. Multicollinearity, which can cause problems in regression analyses, was assessed by generating variation inflation factors (VIFs). Using a standard rule of thumb, VIFs of less than 3 (tolerance levels < .33) were deemed indicative of multicollinearity (Brace, Kemp, & Snelgar, 2006). No instances of multicollinearity were detected among key predictor variables. Multiple regression. Hierarchical multiple regression analyses were used to identify variables associated with sexual functioning, and to test potential mediations and moderations among variables. For all regression analyses, covariates were entered into the first block, and key independent variables were entered into subsequent blocks. Mediations were tested according to 34 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER the steps defined by Baron and Kenny (1986), with covariates in the first block, the independent variable in the second block, and both the independent variable and mediator in the third block. In accordance with contemporary analytics, mediation analysis was conducted even in the case where the first step of the Baron and Kenny (1986) approach (initial variable being associated with the outcome) was not met as is the case with inconsistent mediations (MacKinnon, Fairchild, & Fritz, 2007). Mediations were confirmed using the Sobel Test (Sobel, 1982). Given that the Sobel Test has been found to be a highly conservative test of indirect effect, p-values between .05 and .10 were considered significant (MacKinnon, Warsi, & Dwyer, 1995). For all other analysis, p-values equal to or less than .05 were identified as significant and those between .05 and .10 were considered borderline or marginally significant. For testing moderation, predictor and moderator variables were centered to zero before calculating the cross-product (interaction) term to address the issue of multicolinearity between the independent and interaction terms (Aiken & West, 1991). After entering covariates into the first block, centered predictor and moderator variables were entered into the second block, and the interaction term into the third block. A moderator effect was identified if the interaction term significantly predicted the outcome variable when controlling for the main effects of its component variables. The high and low values of the moderator were plotted with simple regression lines (Aiken & West, 1991). Exploratory analyses. Two exploratory analyses were planned for this study. First, all analyses were re-run controlling for relationship quality, which only included partnered patients (n=70). Second, the proposed conceptual model was tested using partial least squares path analysis using the SmartpLS modeling program(Ringle, Wende, & Will, 2005). Partial least squares (PLS) path modeling is a structural equation modeling (SEM) approach that is based on 35 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER minimizing error in prediction, rather than reproducing a covariance matrix like the more popular forms of SEM (Haenlein & Kaplan, 2004; Wold, 1975). Further, PLS measurement models use principle components analysis rather than the usual factor analysis method. A strength of PLS is that it can handle large numbers of variables and non-normal distributions, particularly with modest sample sizes (Falk & Miller, 1992). PLS significant paths were identified using bootstrapping cross-validation indices (500 samples). Developers of SmartPLS, and other PLS programs, did not include a goodness of fit calculation due to limitations of such statistics with SEM, and especially with related statistical approaches that have different objective functions, like that of PLS (Chin, 1998). They instead recommend considering R 2 s to determine how well the model fits the data using several rules of thumb. Relevant rules of thumb for this study include: (1) R 2 V I RU H QGR J H QRXV Y D U L D EO H V V KRXO G EH 0 and (2) a predictor variable should account for at least 1.5 % of the variance in the predicted variable. Additional exploratory analyses were conducted to test relations within the proposed conceptual model that were not necessarily predicted. The choice of exploratory analyses was informed by the main findings from the proposed analyses. Justifications for each exploratory analysis are provided in the results section. RESULTS Part I. Descriptive Results Psychosexual Status Sexual activity. Over half (56%) of participants reported that they were sexually active in the four weeks before their interviews. Frequency of sexual activity ranged from 0 to 30 times during this four-week period: 39% of participants reported being active between 1 and 4 times, 8% reported activity between 5 and 8 times, and 9% reported 10 or more episodes of sexual 36 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER activity. The majority (70%) of sexually active participants endorsed that sex is an important part of their lives, while 37% of sexually inactive participants endorsed this statement. Over half (64%) of participants endorsed wishing they were more sexually active than they were at the time, with more sexually active women (68%) endorsing this more frequently than sexually inactive women (60%). Only one participant endorsed wishing to be less sexually active. Of the significant correlates of sexual activity status (Table 5), younger age and being partnered were independently associated with a higher likelihood of being sexually active. Sex was more likely to be endorsed as important by women who were younger and whose treatment completion was more recent. Women who rated sex as important were more likely than those who did not rate it as important to endorse that they wished that they were more sexually active (r s = .30, p < .01). Sexual functioning. Overall, sexual functioning among the women in this sample was low as indicated by means for both sexually active and inactive women falling within the lower half of the scale. Based on weighted sum scores, the vast majority of sexually active women in this sample (84%) reported scores at or below the validated clinical cut-off for sexual dysfunction ) 6 ) , V F RU H Wiegel et al., 2005; M = 19.17, SD = 5.27). As a point of comparison, 52% of women in a study validating the use of the FSFI with cancer patients, including gynecologic cancer patients, met the criteria for sexual dysfunction (N=181; Baser et al., 2012). Assessing levels of sexual dysfunction for sexually inactive women is challenging as the only domains that can be assessed are desire and satisfaction with one’s sexual life. Based on item responses for the women in this subsample, 82% reported being dissatisfied with their overall sexual life, with 54% endorsing feeling moderately to very dissatisfied. Meeting diagnostic criteria for hypoactive sexual desire disorder (Brotto, 2009) requires the absence/reduction of sexual desire and “significant” distress as a result. Although dissatisfaction 37 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER does not guarantee the existence of distress, in light of the fact that the majority of sexually inactive women who reported dissatisfaction reported moderate to high levels of it, an increased risk for sexual dysfunction appears likely. Further, 10 of the 15 sexually inactive partnered women reported wishing they were more sexually active, and all 16 single sexually inactive women wished they could be more active. Sexually active women had significantly higher means for desire and satisfaction as compared to sexually inactive women (Table 3). For sexually active women (n=56), the domain of sexual functioning that appeared to have the greatest level of dysfunction was desire, with 95% of this subsample endorsing having sexual desire “less than half of the time” to “almost never.” Intensity of desire, however, was rated “moderate” to “high” for approximately 36% of the subsample. For arousal, 73% of sexually active women endorsed having “moderate” to “very low” levels of both frequency and intensity of sexual arousal, and about half endorsed having low levels of confidence in becoming aroused during sexual activity. For lubrication, slightly over half (52%) of sexually active women endorsed that becoming lubricated and maintaining lubrication during sexual activity was “difficult” to “extremely difficult/impossible.” About a third (32%) endorsed being able to maintain lubrication until the end of sexual activity “a few times” to “almost never/never, and 41% found this to be “difficult” to “extremely difficult/impossible.” Around 64% of sexually active women reported that it was “difficult” to “extremely difficult/impossible” to reach orgasm, and about 57% reported reaching orgasm “a little” to “almost never/never” during the past four weeks. A majority (59%) of sexually active women endorsed feeling “moderately” to “very” dissatisfied with their ability to reach orgasm. Despite the difficulties in sexual functioning that most of the women who were sexually active may have encountered, levels of satisfaction with current sex life was almost equally split 38 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER across the subsample. About 43% of sexually active women reported feeling “dissatisfied” to “very dissatisfied” with their sexual relationship. With respect to overall satisfaction with one’s sexual life, 52% of sexually active women reported feeling “dissatisfied” to “very dissatisfied.” Sexual desire was also an area of difficulty for the majority of sexually inactive women. The proportion for those endorsing “almost never/never” having sexual desire was approximately 64%, while just over 11% reported “sometimes” feeling sexual desire and 25% reported feeling sexual desire “a few times.” Most (89%) sexually inactive women reported “low” levels of desire intensity. Approximately 18% of sexually inactive women reported being “moderately” to “very” satisfied with their overall sexual life, about 27% were “about equally satisfied and dissatisfied,” and 54% reported feeling “moderately” to “very” dissatisfied. Of the significant correlates of sexual functioning (Table 6), younger age, being employed, and being sexually active were independently associated with higher levels of sexual functioning. With respect to medical variables, sexual functioning was positively associated with having had surgery, and negatively associated with cervical cancer stage, having had chemotherapy, and having had external beam radiation. Treatment variables were highly correlated with cancer stages, such that women who reporting having had surgery were more likely to also have earlier stage cancer (r s = -.45, p < .001), whereas those who reported receiving chemotherapy (r s = .64, p < .001), external beam radiation (r s = .58, p < .001), and/or internal radiation implant (r s = .43, p < .001), were more likely to have more advanced stage cancers. However, when these medical variables were included in a regression equation with significant demographic correlates of sexual functioning, none was found to independently predict sexual functioning. Emotional States 39 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Depression. CES-D mean scores indicated that patients in this study reported high prevalence of depressive symptoms (Table 3). Just under half (48%) of all participants scored at or above the cut-off score of 16, which is typically used to identify individuals at risk for depressive disorders and suggests the presence of moderate depressive symptomology. When using the cut-off score suggested for Latino populations, which has also been used to demarcate KL J KU L V NI RU G H SU H V V L RQ Blacher, Lopez, Shapiro, & Fusco, 1997; Vega, Kolody, Valle, & Hough, 1986), 38% of the sample scored at or above this cut-off. There were no significant differences in depression scores and item responses between sexually active and inactive women (Table 3), as well as partnered (M = 17.64, SD = 12.04) and single women (M = 18.07, SD = 14.12). Further, proportions of women who scored at or above both CES-D cut-off scores did not differ significantly between sexually active and inactive women, or between partnered and single women (Table 7). Affect. Overall, levels of positive affect for the sample were low, as indicated by the majority (81%) of the sample scoring in the lower half of the scale, and by comparing means to those from normative data from 708 women in Northern Spain provided by the scale’s authors (zs = -1.7 and -1.9 for sexually active and inactive women, respectively; Joiner et al., 1997). Levels of negative affect also appeared low, with the 84% of scores falling within the lowest quarter of the scale (Table 3) and were comparable to those reported in the scale’s normative data (zs = 0.81 and 0.92 for sexually active and inactive women, respectively; Joiner et al., 1997). There were no significant differences for either affect score between sexually active and inactive women. Scores for positive and negative affect for this sample were similar to those found in other Latina cervical cancer samples (D’Orazio et al., 2011). More years of education and having fewer children were significantly and independently associated with higher levels of 40 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER positive affect. Current hormone therapy was the only significant independent covariate of negative affect, such that being on hormone therapy was significantly associated with higher levels of negative affect. Cancer-Related Factors Associated with Sexual Functioning Physical symptoms. The number and intensity of physical symptoms for this sample were generally low and did not differ significantly between sexually active and inactive women (Table 4). The most frequently endorsed physical symptom was fatigue (71%), followed by vaginal stenosis (63%), difficulty controlling urine (47%), pain (46%), nausea (27%), vaginal discharge/bleeding (15%), and vaginal odor (10%). Vaginal stenosis was the most severe symptom reported, as indicated by the item having the largest proportion of women endorsing the top third of the scale (sexually active: 34%, sexually inactive: 32%). Longer treatment duration and current hormone therapy use were significantly and independently associated with higher physical symptoms scores. Body image concerns. Ratings of body image concerns associated with cervical cancer and its treatment were low for the sample, with means for both sexually active and inactive women falling within the lower third of the scale. No significant differences were found in body image concerns scale means or item means, or in the frequency of item responses between sexually active and inactive women (Table 4). The most prevalent body image concern was feeling less sexually attractive as a result of the illness or treatment (63%) followed by feeling like one’s body is less whole (60%), less physically attractive (45%), less feminine (43%), being more dissatisfied with one’s body (42%), and feeling more self-conscious about one’s body (38%). Current hormone therapy use was significantly associated with greater body image concerns. 41 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Contextual Predictors of Sexual Functioning Life burden. The only significant independent covariate of life burden was caregiving for children, such that caregiving for more children was significantly associated with higher levels of life burden. Given that life burden was a composite variable made of the sum of z- scores for life stress and family responsibility, descriptive findings for life burden components are described below separately. Life stress. Generally, the women in this study reported low to moderate levels of life stress as indicated by total and subscale means falling within the lower third of the scale. Immigration stress was the most frequently endorsed category of life stress, followed by occupational stress, parental stress, cultural/family conflict stress, and marital stress. There were no significant differences on life stress scale or subscale scores between sexually active and inactive women, with the exception of marital stress that was higher for sexually active women (Table 4). However, when controlling for relationship quality, the difference in marital stress means was no longer significant. More life stress was associated with younger age (r = - .26, p = .01) and fewer years in the U.S. (r = - .20, p = .04). Higher levels of life stress were also associated with having had surgery (r s = .29, p < 0.01), not having had chemotherapy (r s = -0.25, p =.01) or internal radiation implant (r s = -0.25, p = .01). Women who endorsed that sex is important and those wishing they were more sexually active reported significantly higher levels of life stress than those who did not rate sex as important and those who did not wish to be more sexually active (r s =.24, p= .03; r s = .28, p < .01, respectively). Family responsibility. Reports of stress associated with family responsibility and caregiving were generally low and did not differ by sexual activity status (Table 4). Of the scale items, “having no energy for anything after caring for family” and feeling “completely worn out 42 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER by caring for family” were the two highest rated items and endorsed by 67% and 52% of the sample, respectively. Feeling that “caring for others is taking over [one’s] life” was the least endorsed item (8%). Levels of family responsibility stress were significantly associated with younger age (r = - .21, p = .04), having fiscal responsibility for the household (r s = -.23, p = .02), and number of children under one’s care (r = .29, p < .01). Relationship quality. The sample’s mean for relationship quality (Table 4) was above 48, the cutoff score indicative of non-distressed relationships. Relationship quality scores for approximately 23% of partnered women fell within the distressed relationship range. Higher relationship quality scores were significantly associated with U.S. country of origin (r s = .39, p =.001) and with rating sex as important (r s = -.25, p = .04). Partnered women who had received radiation implant treatment were significantly less likely to fall below the cutoff score for distressed relationships (r s = -.24, p = .04). Partnered women with histories of antidepressant use were significantly more likely to have relationship quality scores within the distressed range (r s = .32, p = .01). Relationship quality scores did not differ between sexually active (n= 55) and inactive partnered (n=15) women (Table 4). Possible Moderators and Mediators Intrusive thoughts. Percentages of sexually active and inactive women who endorsed IES-R items, as well as percentages of those who endorsed them from the moderate rating and above, are provided in Table 8. Overall, women in this study reported high levels of intrusive thoughts about sexual dysfunction, although the extent to which they were bothersome ranged from low to high. Intrusive thoughts scores, as well as item frequencies and averages, did not differ significantly between sexually active and inactive women (Table 4). The majority of both sexually active and inactive women endorsed that they thought about their sexual difficulties 43 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER when they did not want to and that other things kept making them think about their sexual dysfunction. Under half of sexually active women endorsed items related to emotional responses to thoughts, such as experiencing waves of strong feelings about their sexual dysfunction and that any reminder of sexual dysfunction brought back feelings about these difficulties. A minority of sexually active women endorsed experiencing images related to their sexual dysfunction coming into their minds, or that intrusive thoughts disturbed their sleep. The vast majority of sexually active women reported never having dreams about their sexual difficulties (91%). Similar patterns of IES item frequencies were found for sexually inactive women. Significant independent covariates of intrusive thoughts included age and having had surgery, such that younger age and having had surgery were significantly associated with higher levels of intrusive thoughts. Sociosexual attitudes. Sociosexual attitudes total scale and subscales means suggest that this sample’s responses tended to cluster around the center of the scale and slightly below this midpoint, toward the more liberal end of the scale. There were no significant differences between sexually active and inactive women on the total sociosexual attitudes scale or the global attitudes subscale. However, among partnered women, the power subscale mean was significantly higher for sexually active women than for sexually inactive women (Table 4). This suggests that sexually active women rated issues related to sexual power dynamics in a significantly more neutral manner than sexually inactive women who responded in a more liberal manner. When considering means for individual item responses (Table 9), means for sexually active women were significantly higher than those for sexually inactive women on items from the power subscale on feeling pressured to have sex when not feeling up to it and feeling uncomfortable denying one’s partner sex even after controlling for partner status. Fewer years of 44 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER education significantly, and independently, predicted more conservative (higher) levels of sociosexual attitudes and higher global subscale scores. Being sexual active was found to independently predict more conservative (higher) power subscale scores. Coping strategies. Response frequencies for approach and avoidant coping strategies specifically targeting intrusive thoughts related to sexual dysfunction suggest that women in this study infrequently used coping strategies to manage unwanted sex-specific thoughts. Sexually active women had a significantly higher mean score for approach coping than sexually inactive women, although after controlling for relationship status, the difference was no longer significant (Table 4). There were no significant differences between group means for avoidant coping (Table 4). When considering the approach coping subscales, after controlling for age, the mean scores for active coping, planning, and both emotional and instrumental support were significantly higher for sexually active women than for those who were not (Table 10). However, when controlling for partner status, the only approach coping subscale mean that differed significantly by sexual activity status was for positive reframing; the mean for sexually active women remained significantly higher than that for sexually inactive women. Among avoidant coping subscales, there were no significant differences for any of the subscales between sexually active and inactive women, with the exception of substance use, where the mean was significantly higher for sexually inactive women than sexually active women. Yet, when controlling for relationship quality, there were no differences by sexual activity status for any of the avoidant coping subscales (Table 10). Aside from age and sexual activity status, no additional independent covariates were identified for approach or avoidant coping. Younger age and being sexually active were significantly associated with higher levels of approach coping. 45 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Younger age was also significantly associated with greater avoidant coping, although sexual activity status was not significantly associated with avoidant coping. Part II. Examining Relations between Sexual Functioning and Emotional States Intercorrelations between key variables are provided in Table 11. Correlations for the covariate analyses referenced below are drawn from Table 6. Cancer-Related and Contextual Factors Associated with Sexual Functioning The first aim of this study was to identify cancer-related and contextual factors that could be used to identify patients at-risk for sexual dysfunction. Significant independent covariates of sexual functioning (age, employment status, and sexual activity status) were entered into the first block of a regression equation. The second block contained cancer-related and contextual variables hypothesized to be associated with sexual functioning: physical symptoms, body image, and life burden. The model accounted for 40% of the variance in sexual functioning, and there was a statistically significant R 2 change when adding physical symptoms, body image, and life burden (Table 12a). All of the variables entered into this equation were significant independent predictors of sexual functioning, with the exception of physical symptoms. Younger age, being sexually active, being currently employed, having fewer body image concerns, and reporting less life burden were all significantly associated with better sexual functioning. When relationship quality was included in the first block of the same equation, the new model accounted for 43% of the variance in sexual functioning (Table 12b). Significant independent predictors of sexual functioning included younger age, better relationship quality, fewer physical symptoms, and fewer body image concerns. When including relationship quality in the model, life burden was no longer a significant independent predictor (p = .07) of sexual functioning for partnered women. 46 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Sexual Functioning and Emotional States: Mediating Role of Intrusive Thoughts The second aim of this study was to examine the relations between sexual functioning and emotional states and to test intrusive thoughts as a mediator of these associations. In the covariate analysis, covariates were identified for each emotional state variable. In addition to age and sexual activity status, history of antidepressant use was identified as a possible covariate for depression. Given the aim of assessing factors accounting for variance in depression, history of antidepressant use was not included as a covariate in the main analyses as it would likely account for the majority of the variance in depression. 2 For positive affect, additional covariates identified included years of education and number of children. For negative affect, current hormone therapy was identified as an added covariate. Having had surgery was identified as an added covariate for intrusive thoughts. Predicting depression. Regression analysis was used to test intrusive thoughts as a mediator of the relationship between sexual functioning and depression. Table 13a contains the results of each step of the mediation analysis. The regression analysis was run including covariates in the first block, sexual functioning in the second block and intrusive thoughts in the third block. This model accounted for 12% of the variance in depression. When including intrusive thoughts in the model, sexual functioning remained a significant independent predictor of depression, although intrusive thoughts did not. Results of a Sobel test indicated that intrusive thoughts did not significantly mediate the relation between sexual functioning and depression (z = -0.31, p = .75), as hypothesized. 2 In light of research indicating negative sexual side-effects (Clayton & Montejo, 2006), history of antidepressant use was included as a covariate in exploratory analyses predicting depression. The pattern of results did not change when the variable was included (results provided in Appendix, Tables B and C). 47 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER When running the analysis controlling for relationship quality (Table 13b), the model accounted for 19% of the variance in depression. Intrusive thoughts did not mediate the relations between sexual functioning and depression (Sobel: z = -0.89, p = .37). Predicting positive affect. A similar approach was used to test intrusive thoughts as a mediator of the relation between sexual functioning and positive affect (Table 14a). The mediation model accounted for 24% of the variance in positive affect. When sexual functioning and intrusive thoughts were both included in a regression equation, only sexual functioning significantly predicted positive affect. Intrusive thoughts were not found to mediate this relation (Sobel: z = 0.45, p = .65). Similar results were found when the analysis was run controlling for relationship quality (Table 14b; Sobel z =0.49, p= .63). Predicting negative affect. The indirect effect of intrusive thoughts on the relation between sexual functioning and negative affect was tested using the same approach as was used for depression and positive affect (Table 15a). In testing the mediation, the model accounted for 26% of the variance in negative affect. When intrusive thoughts was included in the regression equation with sexual functioning, sexual functioning remained a significant independent predictor of negative affect. Results of a Sobel test confirmed that there was no significant mediation effect of intrusive thoughts on the relation between sexual functioning and negative affect (z = -1.35, p = 0.17). When running the analysis controlling for relationship quality (Table 15b), the model also accounted for 26% of the variance in negative affect. Again, intrusive thoughts did not significantly mediate the relation between sexual functioning and negative affect (Sobel: z = -.90, p = .37). Sexual Functioning and Intrusive Thoughts: Testing Sociosexual Attitudes as a Moderator 48 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER The third aim of this study was to test sociosexual attitudes as a moderator of the relation between sexual functioning and intrusive thoughts. It was hypothesized that the relation between sexual functioning and intrusive thoughts would be stronger for women with more conservative sociosexual attitudes than for women with more liberal sociosexual attitudes. A regression analysis was performed with covariates in the first block, centered variables for sexual functioning and sociosexual attitudes in the second block, and the cross product of sexual functioning and sociosexual attitudes in the third block. Contrary to the hypothesis, the cross product of sexual functioning and sociosexual attitudes was not found to be significantly associated with intrusive thoughts above and beyond the variance accounted for by the centered sexual functioning and sociosexual attitudes variables (Table 16a). There was a significant main effect for sexual functioning on intrusive thoughts. The same pattern of results was found when controlling for relationship quality. The same analysis was run using the sociosexual attitudes power and global subscales. The cross product of sexual functioning and sociosexual attitudes power subscale was not found to be significantly associated with intrusive thoughts above and beyond the variance accounted for by the centered sexual functioning and sociosexual attitudes power subscale variables (Table 16b). There were main effects for sexual functioning and sociosexual attitudes power subscale. The cross product of sexual functioning and sociosexual attitudes global subscale also failed to reach significance (Table 16c) in predicting intrusive thoughts when controlling for the centered sexual functioning and sociosexual attitudes global subscale variables. Main effects were also found for both sexual functioning and sociosexual attitudes global subscale. The same pattern of results was found when controlling for relationship quality. 49 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER The effect size (f 2 s) for these analyses ranged from .02 to .05, indicating small effect sizes. To achieve the desired power with this effect size, a sample of approximately 222 to 276 would have been needed. Intrusive Thoughts and Emotional States: Testing the Indirect Effect of Coping Strategies The fourth aim of this study was to test coping strategies for intrusive thoughts as a mediator of the relations between intrusive thoughts and emotional states. During these mediation analyses, it was found that intrusive thoughts was not significantly associated with approach coping; therefore, mediation analyses were only conducted testing avoidant coping as a mediator of the relations between intrusive thoughts and the emotional states. Additionally, avoidant coping was not significantly associated with positive affect, for that reason this mediation analysis was not conducted. In the covariate analysis, no additional covariates were identified for avoidant coping. Predicting depression. Regression analysis was used to test avoidant coping as a mediator of the relation between intrusive thoughts and depression. Results of each mediation analysis step are presented in Table 17a. The model, which included covariates (age and sexual activity status) in the first block, intrusive thoughts in the second block, and avoidant coping in the third block, accounted for 8% of the variance in depression and was significant. When avoidant coping was included in the equation, intrusive thoughts did not independently predict depression, suggesting a complete mediation. Results of a Sobel test confirmed that avoidant coping significantly mediated the relationship between intrusive thoughts and depression, (z = 2.38, p = .02). Therefore, more intrusive thoughts was significantly associated with higher levels of depression via higher levels of avoidant coping. When controlling for relationship quality (Table 17b), the mediation effect was no longer significant (Sobel: z = 1.32, p = .18). 50 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Predicting negative affect. Results of the regression analysis testing avoidant coping as a mediator of the relation between intrusive thoughts and negative affect are provided in Table 18a. The model, including covariates (age, sexual activity status, and hormone therapy) in the first block, intrusive thoughts in the second block, and avoidant coping in the third block, accounted for approximately 24% of the variance in negative affect and was found to be significant. When including avoidant coping in the equation, intrusive thoughts no longer significantly predicted negative affect, suggesting a complete mediation. Results of a Sobel test confirmed that this mediation effect was significant (z = 3.10, p = .002). Therefore, more intrusive thoughts was significantly associated with higher levels of negative affect via higher levels of avoidant coping. When controlling relationship quality, the mediation effect remains significant (z = 1.69, p = .09; Table 18b). Exploratory Analyses Sexual functioning and avoidant coping: testing the indirect effect of intrusive thoughts. In light of findings that avoidant coping significantly mediated the relations between intrusive thoughts and depression and negative affect, intrusive thoughts was tested as a mediator of the relation between sexual functioning and avoidant coping, which could provide some insight into why intrusive thoughts failed to mediate the relations between sexual functioning and emotional states. Results of the regression analysis are provided in Table 19a. The model, including covariates (age and sexual activity status) in the first block, sexual functioning in the second block, and intrusive thoughts in the third block, accounted for approximately 39% of the variance in avoidant coping and was found to be significant. When including intrusive thoughts in the equation, sexual functioning no longer was a significant independent predictor of avoidant coping, suggesting a complete mediation. Results of a Sobel test confirmed that this mediation 51 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER effect was significant (z = -4.43, p< .001). Therefore, lower levels of sexual functioning were significantly associated with higher levels of avoidant coping via higher levels of intrusive thoughts. When controlling relationship quality, the model accounted for 47% of the variance in avoidant effect remains significant (z = -4.0, p< .001; Table 19b). Sexual functioning and positive affect: testing the indirect effect of approach coping. In light of the fact that intrusive thoughts was only associated with avoidant coping, as well as depression and negative affect, relations between sexual functioning, approach coping, and positive affect were explored. Specifically, approach coping was tested as a mediator of the relation between sexual functioning and positive affect. However, sexual functioning did not significantly predict approach coping when controlling for age and sexual activity status (p=.13). Therefore, the mediation was not tested using regression analysis. Exploring the relations between sociosexual attitudes and coping strategies. Significant correlations were found between sociosexual attitudes, particularly global sociosexual attitudes, and approach coping, where more conservative attitudes regarding sexual openness (thinking about or discussion sex-related topics is less acceptable) were significantly associated with lower levels of approach coping (see Table 11). Conversely, more conservative sociosexual attitudes, as well as conservative attitudes about sexual power dynamics, were significantly associated with greater avoidant coping. Given these significant correlations, sociosexual attitudes were tested as moderators of the relations between intrusive thoughts and coping strategies. However, none of the interactions between sociosexual attitudes, including its subscales, and intrusive thoughts was found to significantly predict either approach or avoidant coping. Sociosexual attitudes were also tested as moderators of the relations between sexual functioning and both forms of coping, still the interaction terms were not found to significantly 52 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER predict either coping strategy. Effect sizes for these moderations were small (f 2 s ranging from .01 to .02). To achieve the desired power with these effect sizes, a sample size upwards of 500 would have been needed. Testing the conceptual model. Results of the PLS path modeling analyses (Ringle et al., 2005) testing the fit of the conceptual model to the data are provided in Figure 1 and Table 20. Overall, the model appears to fit the data adequately. The reflexive outer model loadings for the emotional states latent variable were all significant at the p < .01 level, loading for depression, positive affect, and negative affect equaling .88, -.72, and .88, respectively. The majority of model paths tested were significant. All R 2 s for the internal model were above .10, and the mean variance accounted for by the model was 32% (Table 20). Again, the interaction between sexual functioning and sociosexual attitudes in predicting intrusive thoughts failed to meet significance. It should be noted that because the emotional states latent variable includes both depression and negative affect, with positive affect, the latent variable is weighted in a way to reflect more of a negative emotional state. Another technical issue with the model is that in including the interaction effect, the measure of sexual functioning that was included had to be the centered variable for sexual functioning. This resulted in paths involving sexual functioning to have the opposite sign than what was expected. When the model was re-run without the interaction effect and with the observed sexual functioning variable the R 2 s and path coefficients remained the same and the sign issue was resolved. Figure 1 includes the corrected signs. When examining the total effects of the model, which includes indirect effects in addition to direct effects, a significant indirect effect was found for the path from sexual functioning to avoidant coping via intrusive thoughts (p < .001). Also of note, when removing the direct path from 53 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER sexual functioning to emotional states, the indirect path from sexual functioning to emotional states via intrusive thoughts and avoidant coping remains significant (p < .01). A post-hoc model (Figure 2) was run incorporating the findings from the series of regression analyses. This model does not include the sociosexual attitudes interaction, but a path between sexual functioning and approach coping was added for exploratory purposes. The path from sexual functioning to approach coping was significant in this model. All other significant paths from the original model remained significant in the post-hoc model. The average R 2 for the post-hoc model was .33(Table 20). Both the original conceptual model and the post-hoc model were run including relationship quality, however, none of the paths involving this variable was found to be significant. Discussion The experiences of Latina cervical cancer patients have been understudied in both the psycho-oncology and sexuality literatures, despite the fact that they are at highest risk for this cancer that has been shown to negatively impact sexual wellbeing. The purpose of this study was to examine the post-treatment sexual functioning and related psychosocial experiences of low- income Latina cervical cancer patients. In addition to providing a general description of sexual functioning for this sample, this study identified cancer-related and contextual factors associated with sexual functioning, and examined hypothesized mediators and moderators of the relations between sexual functioning and emotional states, specifically depression and affect. Results of this study reveal that sexual functioning is a remarkably impaired area of post- treatment life for these Latina cervical cancer patients, and that it is a relevant and meaningful domain of psychosocial adjustment. The majority of sexually active women in this study reported dysfunction across the various sexual response cycle phases, and both sexually active 54 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER and inactive women reported moderate to high levels of dissatisfaction with their sexual functioning. Although the literature suggests that sexual difficulties encountered after completing cancer treatment can be attributed to treatment side-effects (Krychman et al., 2006), the results from this study support a broader biopsychosocial conceptualization of sexual functioning. As expected, medical variables were significantly correlated with sexual functioning. Women with advanced stage cervical cancer and who received chemotherapy and/or external beam radiation were more likely to report lower sexual functioning. Women who had surgery were more likely to report higher functioning. This may have been due to the fact that women who received surgery were more likely to have earlier stage disease and probably avoided some of the more sexually disruptive physiological changes that accompany chemotherapy and pelvic radiation treatment. However, medical variables were not found to be significantly associated with sexual functioning when included in regression analyses with cancer-related and contextual psychosocial variables. Further, physical symptoms, which often result from side-effects of treatment, failed to independently account for the variance in sexual functioning when included with cancer-related body image concerns and contextual life burden. Strongly associated with levels of sexual functioning were reactions to the perceived impact of cervical cancer and/or its treatments on one’s physical appearance, sense of attractiveness, including sexual attractiveness, and one’s sense of physical wholeness, as well as reported levels of general and Latino-specific life stressors. Notably, when controlling for relationship quality with partnered patients, physical symptoms and body image concerns were found to independently predict sexual functioning. In this case, relationship quality also independently predicted sexual functioning, such that higher levels of relationship quality were associated with better sexual functioning. These findings 55 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER suggest that in order to comprehensively assess risk for post-treatment sexual dysfunction among low-income Latina cervical cancer patients, assessing body image concerns and non-cancer related life stressors, as well as relationship quality with partnered patients, is as essential as evaluating medical variables. Along with low levels of sexual functioning, patients reported elevated levels of depression. Just under half of the sample reported clinically significant levels of depression symptoms. Although this proportion is smaller than the one found for a similar sample of low- income Latina cervical cancer patients (67%) in D’Orazio et al. (2011), which included patients at various post-diagnostic treatment stages, levels of depressive symptomology reported in this sample are notably elevated especially given that it only included patients who completed treatment. For example, the proportion of patients at risk for depression in this sample is higher than what is typically reported for White, middle-class cancer populations (< 30%; Simon, Palmer, & Coyne, 2006). Without baseline data, it is difficult to discern whether or not levels of depression reported in this study reflect a preexisting depressive state. However, given that physical symptoms were correlated with depression, it is unlikely that the levels of depression reported here were solely attributable to pre-cancer depressive conditions. Patients in this study reported relatively low levels of both positive and negative affect. It may appear peculiar to find high rates of depression and low levels of negative affect. However, this is not uncommon as the measure of negative affect used in this study taps into feelings of anger, disgust, guilt, fear, and nervousness (Watson et al., 1988), which can overlap with symptoms of depression, although not completely. Still, it is difficult to determine the relative severity of affect scores due to a lack of representative norms for the Spanish language version of this scale. Although levels of negative affect reported for women in this study were comparable 56 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER to those reported by women in Northern Spain who participated in the scale’s validation study, this may not be an equivalent comparison as there is wide-ranging diversity within the Latino population (Marín & Marín, 1991). The affect scores were comparable to those reported by low- income Latina cervical cancer patients in D’Orazio et al. (2011). Regardless, the low levels of positive affect were consistent with levels of depression. The remaining aims of this study were designed to examine the role of sexual functioning in psychosocial adjustment, specifically how it was related to emotional states and what variables might mediate or moderate these relations. The hypothesis that intrusive thoughts about sexual dysfunction would mediate the relations between sexual functioning and the emotional states was not supported by the findings of the regression analyses. According to stress and coping theory, the hypothesized mediation only captures part of the psychological processes that are thought to occur when one is faced with a stressor. Stress and coping theory, as described by Lazarus and Folkman (1984), proposes that in the presence of a stressor, a cognitive appraisal process occurs that leads to some form of coping. Intrusive thoughts are thought to indicate cognitive processing which can involve appraisals of the stressor, but they are not necessarily the same processes. Further, the hypothesized mediation did not include coping. Results indicated that coping strategies directed at sex-specific intrusive thoughts mediated the relation between these intrusive thoughts and depression, as well as between intrusive thoughts and negative affect. As expected, avoidant coping was found to completely mediate the relations between intrusive thoughts and depression, as well as between intrusive thoughts and negative affect, such that intrusive thoughts about sexual dysfunction were associated with higher rates of depression and negative affect through higher levels of avoidant coping. Therefore, the indirect effect of intrusive thoughts on the relations between sexual functioning and emotional states may not have 57 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER been significant due in part to the indirect effect of avoidant coping on the relations between intrusive thoughts and both depression and negative affect. Support for this was found in the path model findings where the path from sexual functioning to emotional states via intrusive thoughts and avoidant coping was strongly significant. Future research should examine how appraisals of sexual dysfunction may be associated with sex-specific intrusive thoughts and coping to evaluate how closely the psychosexual adjustment process supported by the findings from this study compares to established theories of stress and coping. Intrusive thoughts was only associated with avoidant coping strategies, as opposed to approach coping strategies. Typically, in the psycho-oncology literature, approach coping has been found to be associated with positive psychosocial adjustment outcomes (Solberg Nes & Segerstrom, 2006). However, coping in these studies is aimed at dealing with cancer more generally, rather than sexual functioning. When comparing levels of coping strategies directed at sex-specific intrusive thoughts in this study to those reported by low-income Latina cervical cancer patients who were coping with cancer in general (D’Orazio et al., 2011), levels of approach and avoidant coping with sex-specific intrusive thoughts were consistently lower across the subscales, suggesting fewer overall coping efforts targeted toward sex-specific intrusive thoughts. One explanation for this finding might be that patients use different coping strategies for different cancer-related issues. For example, for dealing with challenges faced by cancer more generally, proactive forms of coping may be encouraged and observed in others, and resources may be more easily available for patients. However, when focusing specifically on sex-related thoughts, there may be less guidance on how one addresses these issues, and even some beliefs that it is not socially appropriate to seek out assistance with sex-related GL I I L F XO W L H V í V RP H W KL QJ W K D W KD V EH H Q H F KRH GL Q I L QGL QJ V I U RP TX D O L W D W L YH Z RU NZ L W K / D W L QD EU H D V W 58 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER and cervical cancer patients (Ashing-Giwa, Padilla, Bohórquez, Tejero, & Garcia, 2006; Ashing- Giwa, Padilla, Bohórquez, Tejero, Garcia, et al., 2006). Yet, sexual functioning was found to be significantly, and positively, associated with approach coping in the post-hoc path model analysis despite the association’s almost borderline level of significance in the exploratory regression analysis. It is possible that with better sexual functioning, there is more hope for improvement, therefore approach coping may not seem as futile as it might in the case of more severe dysfunction. A related noteworthy finding was the pattern of relations between both coping strategies and affect. Approach coping was significantly correlated with positive affect but not negative affect, while avoidant coping was significantly associated with negative affect but not positive affect. This pattern of findings replicates the pattern found in the D’Orazio et al. (2011) study, which suggests that approach and avoidant forms of coping are truly distinct, or orthogonal (correlation between approach and avoidant coping for this study: r = .02, p = .82), constructs, rather than two opposing ends of a coping spectrum. Therefore, interventions aimed at increasing positive affect and reducing negative affect may need to address both approach and avoidant forms of coping targeting sex-specific intrusive thoughts. In addition to examining mediators of the relations between sexual functioning and emotional states, sociosexual attitudes were tested as moderators of the relation between sexual functioning and intrusive thoughts with the intent of identifying a marker for women at risk for increased sex-specific intrusive thoughts following treatment. Women in this study generally endorsed neutral to liberal attitudes about sex, including attitudes towards thinking about and/or discussing sex-related topics, and about sexual power dynamics between intimate partners. However, results of both the regression analyses and the path model failed to support an 59 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER interaction between sexual functioning and sociosexual attitudes. Moderation analyses typically require large sample sizes, and the small effect sizes estimated for the analyses in the present study indicate they were largely underpowered. Still, there were direct effects for the sociosexual power and global attitudes in predicting intrusive thoughts. More conservative power attitudes were significantly correlated with more intrusive thoughts, while more conservative global attitudes were significantly associated with lower levels of intrusive thoughts. The relation between conservative power attitudes and more intrusive thoughts is consistent with the hypothesis that women with these attitudes may feel more responsibility to keep their partners sexually satisfied regardless of their own sexual interest; therefore they may experience more intrusive thoughts about sexual dysfunction. However, the fact that more conservative global attitudes about sex were associated with lower levels of intrusive thoughts contradicts what was expected. It is possible that for women with more liberal leaning global attitudes, sex is seen as a valuable part of life and sexual dysfunction could be felt as a notable loss, thus increasing the likelihood of experiencing intrusive thoughts about sexual dysfunction. Sociosexual attitudes were also found to be significantly correlated with both approach and avoidant coping, with more conservative attitudes being significantly correlated with lower levels of approach coping and higher levels of avoidant coping. Although these significant associations suggest that the choice of coping strategies could be shaped by sex-related sociocultural norms, sociosexual attitudes were not found to moderate the relations between intrusive thoughts and approach or avoidant coping, nor relations between sexual functioning and either form of coping. However, these analyses were severely underpowered. More research is needed to further examine the role of sociosexual attitudes in psychosexual adjustment among 60 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER Latina cervical cancer patients, as well as to validate the sociosexual attitudes scale that was developed for this study. Throughout the analyses in this study, sexual activity status, meaning active or inactive at the time of the interview, was included as a covariate. This may appear peculiar, given that the study’s research questions focus on how variables are associated with sexual functioning, and controlling for sexual activity status could account for the majority of variance in most regression analyses. The purpose in including sexual activity status was to be able to identify significant relations between variables that were not just distinguishing between sexually active and inactive participants. Even when controlling for this variable, significant findings emerged. This may be related to the fact that there were very few significant differences between women who were sexually active and those who were not. Although women who were sexually active were generally younger, and more likely to be partnered, there were no differences between these two groups on other demographic variables. With respect to medical variables, the only significant difference found was that a significantly greater proportion of sexually active women received surgery, while more sexually inactive women received chemotherapy. With respect to sexual functioning variables, sexually inactive women had significantly lower levels of sexual desire and satisfaction than sexually active women. Sexually inactive women also reported significantly lower levels of approach coping, but significantly higher levels of conservative global sociosexual attitudes than sexually active women. Another factor that was considered to co-vary with sexual functioning was relationship quality. For this study, hypotheses were tested for the entire sample and then retested with only partnered women (n=70) in order to include relationship quality and assess its potential association with sexual functioning. Relationship quality was found to predict sexual functioning 61 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER when controlling for age and sexual activity and when included in a regression equation with physical symptoms, body image concerns, and life burden. However, the pattern of results for the remaining analyses rarely changed when relationship quality was included. It is possible that there was not enough range in response for this variable, in that women tended to report high relationship quality on the whole. Research examining the sexual functioning and depressive symptoms in metastatic breast cancer patients and their partners found that dyad communication styles moderated the relation between sexual difficulties and depression for patients, such that the association was only significant for those who reported low levels of constructive communication (Milbury & Badr, 2013). Further study of partner communication and other subcomponents of relationship quality may reveal underlying factors associated with sexual functioning and emotional wellbeing after treatment for Latinas with cervical cancer. Future research including both partners of intimate relationships could examine the potential effects of individual psychosocial factors on the dyad that may not be captured by the construct of relationship quality, especially as rated by one partner. Nonetheless, it does appear that relationship quality is a relevant factor in sexual functioning for partnered patients. The results of this study indicate that problems with sexual functioning were prevalent throughout this sample, and that both cancer-related and contextual factors were associated with sexual functioning. Further, sex-specific intrusive thoughts were found to be indirectly associated with depression and negative affect through avoidant coping strategies targeting sex- specific intrusive thoughts. In light of the fact that these findings came from a series of regression analyses, the conceptual model that was used to guide the design of this study was tested as a whole so as not to capitalize on Type I error when conducting numerous analyses. Results from path modeling indicated that the conceptual model adequately fit the data, as 62 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER indicated by the majority of paths being significant and the relatively high R 2 s for endogenous variables, although the proposed interaction was not a significant component of the model. The path model analyses also revealed a significant indirect effect of intrusive thoughts and avoidant coping on the relation between sexual functioning and emotional states, as well as a significant relation between sexual functioning and approach coping. Limitations and Strengths This study had several limitations that should be noted and can be used to inform future research. First, as mentioned previously, the cross-sectional and non-experimental study design does not allow for causal or temporal conclusions about the data. Although the relations were presumed to go from sexual functioning to emotional states, it is entirely possible that the relations can go in the reverse direction, or mostly likely, in a causal loop. How the frequency and intensity of medical and psychosocial factors, as well as the relations between them, change over time remains unknown. Further, the absence of baseline data on sexual functioning makes it impossible to discern whether or not sexual dysfunction assessed in this study was preexisting or the result of cervical cancer. However, given the significant correlations found between medical variables and sexual functioning, it is unlikely that sexual dysfunction after treatment would be purely a continuation of premorbid levels of functioning. Second, the generalizability of these findings is restricted due to the sample size, and constricted focus on disadvantaged Latina cervical cancer patients who received medical care in Los Angeles. However, this is a representative sample of the population at highest risk for cervical cancer (ACS, 2012); therefore findings are likely relevant to the majority of women with cervical cancer. Nevertheless, how the findings from this study specifically relate to the experiences of other F H U Y L F D O F D Q F H U S D W L H QW JU RXS V í I RU H [ D P SO H patients in same-sex 63 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER U H O D W L RQV KL SV D QG RU / D W L QD V RXW V L GH 6 RXW KH U Q& D O L I RU QL D í L V XQNQRZ Q It should be noted that patients in this study were not asked about their sexual orientation. An additional factor that can influence sexual functioning and vary across populations may be religiosity (Wyatt & Riederle, 1994), however information on religious affiliation was not collected. A third limitation is the modest sample size of 100, with 56 sexually active and 44 sexually inactive women. However, significant relations were found among variables. The effect sizes for analyses ranged from medium to large (f 2 s ranged from .15–.61; Cohen, 1992), with the exception of the moderation effects, which were small. Additionally, many of the relations between variables were replicated in the path modeling analysis, which works well with modest sample sizes. A fourth limitation is the in-person interview design, which is vulnerable to both participant response and observer biases. Responses biases, like over/under and socially desirable responding, may be particularly an issue when inquiring about sexuality. Observer bias may have also been an issue as the interviewer was not blind to the study hypotheses. Still, the in-person interview format fosters participant engagement in study procedures and offers occasions for clarifying interview items. The bilingual/cultural interviewer may have aided the interview process by gaining patients’ trust, which could minimize socially desirable responding. Additionally, to minimize observer bias, standardized and validated instruments were used to the extent possible during interviews with patients. Nonetheless, this study was based almost entirely on self-report data, with the exception of medical variables that were confirmed by chart review. Therefore, the findings here could be inflated due to common method variance. Fifth, there were some limitations in the measures used in this study. To begin with, the measure of sexual functioning, FSFI, may not be appropriate for use with sexually inactive 64 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER women. Given the design of the questionnaire, women who reported that they were not engaging in sexual activity during the four weeks before the interview could only respond to items pertaining to sexual desire and satisfaction. However, using means of subscale means as the measure of sexual functioning and controlling for sexual activity status in all analyses, this bias was minimized. Nonetheless, the use of means of means rather than weighted sums was not intended by the scale’s authors and has not been validated. Further, it is unclear whether or not women in this study chose to include solitary sexual activity, such as masturbation, in their considerations of sexual activity. Although instructions for sex-related questions defined sexual activity to include masturbation, specific sexual activities that women engaged in were not identified and may have inadvertently excluded individual sexual activities. Therefore, some of the women in the sexually inactive group may have actually been sexually active. Lastly, the sociosexual attitudes scale was developed for this study, and as previously mentioned, it was not validated. Moreover, the scale items tended towards negative valence, and may have been artificially associated with the negative emotional states by tapping into hopelessness or demoralization. A sixth limitation is the lack of data on participants’ potential sexual trauma history. History of childhood sexual abuse or sexual assault as an adult has been shown to be associated with increased risk for sexual dysfunction in healthy adult women (Meston, Rellini, & Heiman, 2006), as well as in cervical cancer survivors (Bergmark, Åvall-Lundqvist, Dickman, Henningsohn, & Steineck, 2005). A 2010 national study of 2,000 Latinas living in high-density Latino neighborhoods found that the lifetime prevalence for sexual assault was approximately 17% (Cuevas & Sabina, 2010). Victims of sexual trauma may be particularly vulnerable to distress throughout their experience being diagnosed with and treated for cervical cancer; both 65 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER medical exams and treatments can feel like recurrent re-violations of the body (Bergmark et al., 2005). Moreover, rates of cervical cancer screening have been shown to be significantly lower for sexual trauma victims than women without a sexual trauma history (Farley, Golding, & Minkoff, 2002), suggesting that victims of sexual trauma may be at increased risk for cervical cancer. Therefore, future research on sexual functioning among cervical cancer patients, particularly Latinas, should assess the role of sexual trauma history in psychosexual adjustment following cancer treatment. Despite these limitations, this study had several strengths. First, the study included women at highest risk for cervical cancer who are frequently excluded by research studies due to language and access barriers. Further, this study had a high response rate (96%). This study also included both cancer-related and contextual factors specific to the experiences of Latinos in the U.S., providing information that fits the biopsychosocial direction of sexuality and psycho- oncology research and clinical practice. Additionally, despite the few differences between sexually active and inactive women on key variables, all analyses controlled for age and sexual activity status, meaning that the findings presented here may be relevant to patients regardless of their sexual activity status. There were also no differences between English and Spanish speakers across the study variables. Lastly, robust modeling analyses were used to test the conceptual model, which provides added statistical support for the series of regression findings. Conclusions & Future Directions This study is among the first to provide a description of post-treatment sexual functioning for Latina cervical cancer patients and to highlight relevant cancer-related and contextual factors in psychosexual adjustment. The extent of sexual dysfunction reported by women in this sample was so pronounced that assessing psychosocial adjustment to cervical cancer without considering 66 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER the domain of sexual functioning clearly overlooks an important area of need for an already underserved population. The findings from this study support the biopsychosocial approach to conceptualizing post-treatment sexual functioning in Latina cervical cancer patients. Results highlighted how both physical symptoms, as well as psychological reactions to body changes, and contextual life stress, contribute to sexual functioning. The findings also highlight the significant role of coping strategies targeting sex-specific intrusive thoughts in psychosexual adjustment. A goal of this study was for its findings to be used to inform integrated healthcare of Latina cervical cancer patient populations, as well as to help develop culturally salient psychosocial interventions for these patients. Often, the lack of research in the areas of sexual functioning and cancer adjustment with Latinas is attributed to a perceived reluctance of Latinas to discuss such issues, particularly with strangers (Julliard et al., 2008). This study demonstrated that research in both of these areas is not only possible, but appreciated and necessary. The vast majority of eligible Latinas approached about the study agreed to participate. The women who participated in this study were quite candid about their experiences with both cervical cancer and sexual functioning. Furthermore, they often voiced an appreciation for our interest in their experiences and were hopeful that their participation could help other Latinas. Perhaps these findings can help shift the current medical culture surrounding the perceived priority of sexual functioning among Latina cervical cancer patients, where there can be more open, nonjudgmental communication about sexual concerns and services developed to support patients’ needs regarding sexual dysfunction. Given the findings from this study, cognitive-behavioral based interventions may prove beneficial to Latinas with cervical cancer who are experiencing sexual dysfunction. Patient- 67 PSYCHOSEXUAL ADJUSTMENT AFTER CERVICAL CANCER focused interventions can start with psychoeducation about the course of sexual functioning after treatment, and help patients learn about how their thoughts about sex, their role in their sexual relationship, and their coping strategies in dealing with sexual dysfunction relate to how they feel emotionally. Interventions should also be designed to help patients develop approach coping skills to help manage sex-specific cognitive intrusions, as well as to develop strategies to minimize avoidant coping behaviors. Furthermore, culturally informed dyadic interventions could be helpful to patients and their partners as they both adjust to the changes in sexual functioning that can follow treatment. Research indicates that Latino/a men and women differ in the sources of stress and support associated with distress (Aranda, Castenada, Lee, & Sobel, 2001). Sexual couples counseling can provide psychoeducation highlighting the physical and psychological components to sexual dysfunction, provide instrumental support in overcoming sexual obstacles, as well as facilitate the couple’s communication about each partner’s needs and challenges (Southern, 2006). Interventions can also target healthcare providers and medical staff, teaching those who interact with patients how to foster an environment of openness and nonjudgmental aid with regards to sexual difficulties. This can include assisting medical teams in developing effective, culturally salient communication strategies for discussing sex-related issues with patients. Furthermore, the results of this study highlight several signs to watch for in post-treatment adjustment among Latinas with cervical cancer that may suggest increased risk for sexual dysfunction and distress, such as rumination on changes in sexual functioning, increased body image concerns and avoidance surrounding discussions of sexual functioning. Future research should include longitudinal studies, as well as those that include patients’ sexual partners. 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Journal of Cancer Survivorship, 5(2), 191–207. doi:10.1007/s11764-011-0171-0 85 Table 1 Patient Demographic Variables Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) Test Statistic (df) a Mean (SD) Range Mean (SD) Range Mean (SD) Range Age 47.99 (10.43) 28 - 76 44.07 (9.05) 28 - 67 52.98 (9.94) 31 - 76 t(88)= - 4.62*** Years in the United States 19.58 (11.88) 2 - 60 17.87 (11.16) 2 - 60 21.75 (12.52) 2 - 54 t(87)= - 1.61 Country of Origin (n) (n) (n) US 5 4 1 Mexico 58 31 27 Central America 35 19 16 South America 2 2 0 Education 7.14 (4.19) 7.54 (3.72) 0 - 15 6.64 (4.71) 0 - 16 t(80)= - 1.61 (years) (n) (n) (n) No schooling 0 8 3 5 <High school 1 – 8 50 27 23 Some high school 9 – 11 19 15 4 High school graduate 12 14 7 7 Some college 13 – 14 8 4 4 Bachelor degree 16 1 0 1 Current Occupational Status (n) (n) (n) Ȥ 2 (1)= 9.16 Not in labor force 64 33 31 Working 36 23 13 Pre-Diagnosis Occupational Status Ȥ 2 (1)= 6.58 Not in labor force 27 19 8 Working 73 37 36 Income (monthly) $933.45 (726.52) $0 - 3,200 $1,109.29 (666.86) $0 - 3,200 $709.66 (744.92) $0 - 2,800 F(1,98)= 0.55 b Current Relationship status (n) (n) (n) Not Partnered Never married 13 1 12 Widowed 1 0 1 Divorced/Separated 16 2 14 Married/Partnered 70 55 15 (table continues) 86 Table 1 (cont.) Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) Test Statistic (df) a Mean (SD) Range Mean (SD) Range Mean (SD) Range Number of Children 3. 51 (2.24) 0 - 13 3.11 (1.64) 0 - 9 4.02 (2.77) 0 - 13 F(1,98)= 0.003 b Fiscal Responsibility (n) (n) (n) Ȥ 2 (1)= 1.64 Other 65 39 26 Self 35 17 18 Caregiving Charges (n) (n) (n) Children 0 52 25 27 Ȥ 2 (1)= 3.97 1+ 48 31 17 Older Adults 0 92 51 41 1+ 8 5 3 a Test statistic and significance levels for mean differences between sexually active and not sexually active groups. b Controlling for partner status. * p p p 87 Table 2 Patient Medical Variables Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) Test Statistic (df) a n Mean (SD) Range n Mean (SD) Range n Mean (SD) Range Cancer Stage Good Prognosis Stage 1A 15 10 5 Stage 1B 44 28 16 Stage 2A 7 4 3 Stage 2B 18 9 9 Stage 3A 0 0 0 Stage 3B 11 4 7 Stage 4A 5 1 4 Stage 4B 0 0 0 Cytology Adenocarcinoma 14 7 7 Squamous-cell Carcinoma 85 48 37 Small-cell Neuroendocrine 1 1 0 Treatment Surgery (S) only 31 22 9 Chemotherapy (C) only 0 0 0 Whole Pelvis Radiation (R) only 0 0 0 Implant Radiation (IR) only 0 0 0 S/C 1 0 1 S/R 4 2 2 S/IR 1 1 0 S/C/R 11 7 4 C/R 7 2 5 C/R/IR 23 7 16 S/C/R/IR 22 15 7 Time since treatment completion (in months) 100 16.50 (11.54) 3 - 36 56 14.59 (10.57) 3 - 36 44 18.93 (12.36) 3 - 36 t(98)= - 1.85 Treatment duration (in months) 100 7.70 (6.65) 1 - 43 56 6.52 (5.55) 1 - 27 44 9.20 (7.56) 1 - 43 t(98)= - 1.97 (table continues) 88 Table 2 (cont.) Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) Test Statistic (df) a n Mean (SD) Range n Mean (SD) Range n Mean (SD) Range History of Antidepressant Use Yes 8 3 5 No 92 53 39 Current Hormone Therapy Yes 5 2 3 No 95 54 41 a Test statistics and significance levels differences between sexually active and not sexually active groups. * p p p 89 Table 3 Descriptive Statistics for Sexual Functioning and Emotional States Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) F (df) a Scale Range Mean (SD) Range Mean (SD) Range Mean (SD) Possible Actual Possible Actual Possible Actual Sexual Functioning (FSFI) 1 - 5 1 - 4.25 2.18 (0.80) 1 - 5 1.20 - 4.25 2.69 (0.93) 1 - 5 1 - 3.5 1.67 (0.69) 6.80 (1,98)** b Desire 1 - 5 1 - 4.5 1.79 (0.77) 1 - 5 1 - 4.5 2.08 (0.90) 1 - 5 1 - 3 1.50 (0.63) 6.23 (1,98)* b Arousal - - - 1 - 5 1 - 4.67 2.55 (1.05) - - - - Lubrication - - - 1 - 5 1 - 5 3.17 (1.03) - - - - Orgasm - - - 1 - 5 1 - 5 2.73 (1.23) - - - - Satisfaction 1 - 5 1 - 5 2.38 (1.09) 1 - 5 1 - 5 2.92 (1.35) 1 - 5 1 - 4 1.84 (0.77) 13.34 (1,98)*** b Depression (CES- D) 0 - 60 0 - 48 17.8 (12.6) 0 - 64 0 - 44 17.2 (11.74) 0 - 64 0 - 48 18.5 (13.78) 0.35 (1,98) Affect (SPANAS) Positive Affect 10 - 50 10 -50 23.3 (8.37) 10 - 50 12 - 39 23.7 (7.34) 10 - 50 10 - 50 22.8 (9.59) 0.07 (1,98) Negative Affect 10 - 50 10 - 44 16.6 (6.90) 10 - 50 10 - 44 17.1 (7.48) 10 - 50 10 - 38 15.9 (6.11) 0.56 (1,98) Key: FSFI = Female Sexual Functioning Index, CES-D =Center for Epidemiologic Studies Depression Scale, SPANAS = Spanish Positive and Negative Affect Schedule a Mean differences controlling for age and covariates identified in preliminary analyses (depression: history of antidepressant use, positive affect: years of education, number of children, negative affect: hormone therapy). b Mean differences controlling for age, covariates identified in preliminary analyses, and partner status. * p p p .001 90 Table 4 Descriptive Statistics for Cancer-related and Contextual Psychosocial Variables Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) F(df) a Scale Range Mean (SD) Range Mean (SD) Range Mean (SD) Possible Actual Possible Actual Possible Actual Acculturation (ARSMA-II) -5 - 5 -4 - 3.83 -3.04 (0.15) -5 - 5 -4 - 3.83 -2.92 (0.24) -5 - 5 -4 - 1.33 -3.19 (0.16) 0.21 (1,99) Latino Orientation 1 - 5 1 - 5 4.60 (0.76) 1 - 5 3 - 5 4.67 (0.62) 1 - 5 3.3 - 5 4.63 (0.46) 0.61 (1,99) Anglo Orientation 1 - 5 1 - 4.83 1.56 (0.89) 1 - 5 1 - 4 1.62 (0.86) 1 - 5 1 - 4 1.42 (0.69) 0.61 (1,99) Physical Symptoms 0 - 28 0 - 15 5.37 (3.85) 0 - 28 0 - 15 5.05 (3.75) 0 - 28 0 - 15 5.77 (3.98) 0.45 (1,99) Body Image (BIS) 0 - 18 0 - 18 4.96 (4.56) 0 - 18 0 - 18 5.02 (4.83) 0 - 18 0 - 15 4.89 (4.23) 0.55 (1,99) Life Burden b n/a -2.3 - 3.6 0.00 (1.70) n/a -2.16 - 3.1 --- n/a -2.3 - 3.6 --- 1.43 (1,99) Life Stress (HSI-I) 0 - 5 0 - 3 1.10 (0.68) 0 - 5 0 - 3 1.23 (0.95) 0 - 5 0 - 3 0.95 (0.60) 1.44 (1,99) Occupational 0 - 5 0 - 5 1.62 (1.37) 0 - 5 0 - 5 1.71 (1.36) 0 - 5 0 - 5 1.50 (1.38) 0.03 (1,99) Parental 0 - 5 0 - 5 1.00 (1.00) 0 - 5 0 - 5 1.08 (1.04) 0 - 5 0 - 4 0.91 (0.95) 1.15 (1,99) Marital c 0 - 5 0 - 4 0.47 (0.76) 0 - 5 0 - 4 0.64 (0.88) 0 - 5 0 - 2 0.25 (0.49) 4.47 (1,69)* Immigration 0 - 5 0 - 5 1.66 (1.28) 0 - 5 0 - 5 1.81 (1.31) 0 - 5 0 - 5 1.45 (1.22) 0.29 (1,99) Culture/Family Conflict 0 - 5 0 - 4 0.83 (0.81) 0 - 5 0 - 4 0.88 (0.88) 0 - 5 0 - 2 0.77 (0.72) 0.08 (1,99) Family Responsibility (FRS) 10 - 70 10-58 17.2 (9.70) 10 - 70 10 - 58 18.15 (9.99) 10 - 70 10 - 49 16.0 (9.28) 0.67 (1,99) Relationship Quality (RDAS) c 0 - 69 21 - 64 51.1 (9.44) 0 - 69 34 - 64 52.5 (7.65) 0 - 69 34 - 62 48.27 (9.35) 1.86 (1,99) Sociosexual Attitudes 0 - 4 0 - 3.6 1.42 (0.89) 0 - 4 0 - 3.44 1.41 (0.11) 0 - 4 0 - 3.6 1.44 (1.45) 1.95 (1,99) Global 0 - 4 0 - 3.6 1.68 (0.95) 0 - 4 0 - 3.2 0.94 (0.10) 0 - 4 0 - 3.4 1.39 (0.31) 5.22 (1,99)* Power c 0 - 4 0 - 4 1.86 (1.47) 0 - 4 0 - 4 2.04 (0.19) 0 - 4 0 - 3.75 1.18 (0.37) 0.51 (1,69) Intrusive Thoughts (IES-R) 0 - 28 0 - 19 4.43 (4.26) 0 - 28 0 - 19 4.91 (4.46) 0 - 28 0 - 14 3.82 (3.94) 1.99 (1,99) (table continues) 91 Table 4 (cont.) Total Sample (N=100) Sexually Active (n=56) Not Sexually Active (n=44) F(df) a Scale Range Mean (SD) Range Mean (SD) Range Mean (SD) Possible Actual Possible Actual Possible Actual Coping Strategy (Brief COPE) Approach Coping 1 - 4 1 - 4 1.85 (0.06) 1 - 4 1.08 - 4 2.02 (0.66) 1 - 4 1 - 2.58 1.63 (0.44) 5.93 (1,99)* Avoidant Coping 1 - 4 1 - 4 1.45 (0.04) 1 - 4 1 - 3.5 1.49 (1.42) 1 - 4 1 - 2.33 1.41 (0.33) 0.20 (1,99) Note: ARSMA-II= Acculturation Rating Scale for Mexican Americans Version II, FACT-Cx= Functional Assessment of Cancer Therapy-Cervical Cancer (selected items), BIS= Body Image Scale, HSI-I= Hispanic StUH V V ,Q Y H Q WR U \ í, P P L J UD Q W 9HUV LR Q abbreviated), FRS= Family Responsibility Scale, IES- R=Intrusive Thoughts Scale-Revised, RDAS= Revised Dyadic Adjustment Scale, Brief COPE=Brief COPE scale of Coping Strategies a Mean differences controlling for age and covariates identified in preliminary analyses (Table 6). b Composite z-score. c Only for partnered women (n=70, sexually active n=55, not sexually active n=15). * p p 92 Table 5 Significant & Borderline Significant (.06 p .1) Correlations (r s ) for Variables Associated with Sexual Activity, Importance of Sex, and Wishing to be More/Less Sexually Active (N=100) Sexually Active Sex is Important Wishes to be More Sexually Active Wishes to be Less Sexually Active Age - .48*** - .45*** Education (years) .23* Currently partnered a .64*** .21* Income .34** Currently employed a .35*** .18 Caregiving: Number of children .20 - .17 Cervical Cancer Stage - .25* Treatment duration (months) - .27** Months since treatment completion - .24* Surgery a - .36** Chemotherapy a External Beam Radiation a - .32** Internal Radiation Implant a .18 Vaginal Discharge/Bleeding .21* .27** Vaginal Odor .32** Note. Variables in columns are dichotomous. a Dichotomous variables * p p p 93 Table 6 Significant & Borderline Significant (.06 p .1) Correlations between Key Variables and Demographic and Medical Variables for Covariate Analysis (N=100) Sexual Functioning Depression Positive Affect Negative Affect Physical Symptoms Body Image Concerns Life Burden Age (years) - .36 ** - .27 ** U.S. a Mexico a Central America a South America a Years in the U.S. Education (years) .22 * .35 ** Monthly Income (dollars) Currently Employed a .30 ** Currently Partnered a .31 ** Fiscally Responsible for Household a Number Children - .22 * - .34 ** Caregiving: Number of Children - .18 .26 ** Caregiving: Number of Older Adults Acculturation Cervical Cancer Stage - .21 * .19 - .23 * Treatment Duration (months) - .19 .32 ** Months Since Treatment Completion - .18 Surgery a .20 * .28 ** Chemotherapy a - .21 * .35 ** - .24 * External Beam Radiation a - .20 * .37 ** - .21 * Internal Radiation Implant a .28 ** - .26 ** Currently on Hormone Therapy a .22 * .19 .23 * .20 * History of Antidepressant Use a .25 * .19 .17 .19 Sexually Active a .45 ** .20 * Relationship Quality b .31 ** .27 * (table continues) 94 Table 6 (cont.) Intrusive Thoughts Sociosexual Attitudes Sociosexual Attitudes: Power Sociosexual Attitudes: Global Approach Coping Avoidant Coping Age (years) - .24 * .28 ** .34 ** - .27 ** - .21 * U.S. a - .20 * Mexico a - .25 * Central America a .28 ** South America a Years in the U.S. - .18 Education (years) - .45 ** - .42 ** .18 Monthly Income (dollars) - .19 .27 ** Currently Employed a Currently Partnered a - .21 * .18 Fiscally Responsible for household a .18 Number Children .26 ** .27 ** - .30 ** - .20 Caregiving: Number of Children Caregiving: Number of Older Adults - .20 Acculturation Cervical Cancer Stage Treatment Duration (months) .21 * Months Since Treatment Completion .19 Surgery a .22 * - .17 .21 * Chemotherapy a .19 - .19 External Beam Radiation a .24 * - .26 ** Internal Radiation Implant a Currently on Hormone Therapy a History of Antidepressant Use a .20 * Sexually Active a .26 * - .26 ** .32 ** Relationship Quality b - .32 ** - .21 - .27 ** .32 ** - .26 * a Spearman’s rho correlation statistic reported for dichotomous variables (1 = Yes, 0 = No). b Only completed by partnered patients (n=70). * p p 95 Table 7 Proportions of Women Clinically Significant CES-D Cut-Off Scores Standard CES-D Cut- RI I Suggested CES-D Cut-off for Latino 3 RSXO D W L RQV Sexually Active (n=56) 48% 45% Not Sexually Active (n=44) 48% 29% Partnered (n=70) 43% 43% Single (n=30) 50% 43% Note: Percentages are rounded. Table 8 Proportions of Women Endorsing Sex-Specific Intrusive Thoughts Sexually Active (n=56) Not Sexually Active (n=44) IES-R Item “A little” to “Extremely” “Moderately” to “Extremely” “A little” to “Extremely” “Moderately” to “Extremely” Any reminder brought back feelings about it. 41% 14% 37% 11% I had trouble staying asleep. 21% 10% 14% 14% Other things kept making me think about it. 66% 39% 59% 23% I thought about it when I didn’t mean to. 71% 49% 61% 32% Pictures about it popped into my mind. 30% 16% 36% 13% I had waves of strong feelings about it. 41% 27% 32% 16% I had dreams about it. 9% 2% 14% 14% Note: Percentages are rounded. 96 Table 9 Proportions of Sexually Active and Inactive Women’s Responses to Sociosexual Attitudes Items Sexually Active (n=56) Not Sexually Active (n=44) Subscale Item Disagree Neutral Agree Mean (SD) Disagree Neutral Agree Mean (SD) F, df Global Sex is a very important part of life. a 9% 11% 80% 3.30 (1.09) 20% 21% 59% 2.75 (1.33) 1.79 (1,99) The main purpose of sex is to enjoy oneself. a 11% 0% 89% 3.48 (1.06) 16% 9% 75% 3.16 (1.31) 1.57 (1,99) It is acceptable for me to think or daydream about sexual activity. a 30% 13% 57% 2.41 (1.60) 59% 7% 34% 1.45 (1.76) 0.08 (1,99) Sex is not something one should talk about. 89% 5% 6% 0.30 (0.87) 67% 13% 20% 1.07 (1.42) 3.48 (1,99) It is not appropriate for a woman to initiate sex. 54% 14% 32% 1.54 (1.68) 59% 0% 41% 1.66 (1.83) 0.11 (1,99) Power b Sometimes I feel pressured to have sex with my partner. 51% 0% 49% 1.64 (1.75) 60% 7% 33% 1.20 (1.57) 1.59 (1,69) Sometimes I have sex with my partner when I don’t feel like it. 46% 2% 53% 1.98 (1.84) 80% 0% 20% 0.67 (1.40) 6.32 (1,69)* I don’t feel comfortable denying my partner sex. 31% 4% 65% 2.45 (1.73) 53% 7% 40% 1.47 (1.70) 7.17 (1,69)** I worry about what will happen to my relationship if I don’t have sex with my partner. 38% 7% 55% 2.09 (1.75) 60% 0% 40% 1.40 (1.81) 1.32 (1,69) a Reverse-coded items. b Only given to women with sexual partners (sexually active n=55; sexually inactive n=15). * p p 97 Table 10 Means for Coping Strategies and Subscale Scores Sexually Active (n=56) Not Sexually Active (n=44) F (1,99) a Partnered only b Scale Subscale Mean (SD) Mean (SD) F (1,69) Approach Coping Active Coping 1.98 (0.88) 1.35 (0.54) 8.76** 0.22 Positive Reframing 1.74 (0.96) 1.84 (0.94) 0.09 9.66** Planning 1.60 (0.84) 1.07 (0.28) 9.91** 0.45 Acceptance 2.28 (0.75) 2.43 (0.85) 0.04 1.05 Instrumental Support 2.05 (0.86) 1.60 (0.70) 5.81* 0.50 Emotional Support 2.38 (0.90) 1.56 (0.78) 11.34*** 2.90 Avoidant Coping Distraction 1.76 (0.82) 1.84 (0.87) 1.22 1.26 Denial 1.20 (0.53) 1.23 (0.51) 0.03 2.49 Substance Use 1.00 (0.00) 1.01 (0.07) 4.31* 1.17 Self-blame 2.02 (0.87) 1.68 (0.28) 1.01 0.39 Behavioral Disengagement 1.63 (0.66) 1.52 (0.57) 0.60 1.14 Venting 1.32 (0.65) 1.16 (0.40) 1.40 0.73 a Controlling for age. b Controlling for age and partner status. * p p p 98 Table 11 Correlations for Key Variables (N=100) a Only completed by partnered patients (n=70). * p p 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1. Sexual Functioning - 2. Physical Symptoms - .29 ** - 3. Body Image - .35 ** .38 ** - 4. Life Burden - .23 * .30 ** .39 ** - 5. Relationship Quality a .31 ** .10 - .13 - .14 - 6. Intrusive Thoughts - .37 ** .29 ** .33 ** .44 ** - .12 - 7. Sociosexual Attitudes - .37 ** .12 .36 ** .21 * - .32 ** .1 - 8. Sociosexual Attitude: Power a - .36 ** .13 .44 ** .38 ** - .21 .43 ** .81 ** - 9. Sociosexual Attitude: Global - .30 ** .08 .14 - .03 - .27 * - .18 .71 ** .09 - 10. Approach Coping .33 ** - .17 - .26 ** - .03 .32 ** .01 - .41 ** - .21 - .43 ** - 11. Avoidant Coping - .31 ** .23 * .38 ** .26 ** - .26 * .65 ** .24 * .47 ** .04 .02 - 12. Depression - .35 ** .58 ** .57 ** .48 ** - .15 .25 * .36 ** .33 ** .24 * - .21 * .33 ** - 13. Positive Affect .40 ** - .37 ** - .34 ** - .37 ** .27 * - .19 - .41 ** - .23 - .40 ** .35 ** - .11 - .53 ** - 14. Negative Affect - .39 ** .44 ** .58 ** .48 ** - .16 .36 ** .38 ** .32 * .14 - .17 .46 ** .72 ** - .53 ** - 99 Table 12a Regression Analysis to Identify Cancer-Related and Contextual Factors Associated with Sexual Functioning (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Block 1: Covariates 0.28 0.26 12.36 (3,96)*** Age - .23* Sexually Active .25* Currently Employed .26** Block 2: Cancer-related & Contextual Variables 0.44 0.40 .16*** 8.72 (3,93)*** Physical Symptoms - .13 Body Image Concerns - .19* Life Burden - .25** * p p p Table 12b Regression Analysis to Identify Cancer-Related and Contextual Factors associated with Sexual Functioning Including Relationship Quality (n=70). Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Block 1: Covariates 0.28 0.23 6.20 (4,65)*** Age - .30* Sexually Active .07 Currently Employed .24* Relationship Quality .24* Block 2: Cancer-related & Contextual Variables 0.49 0.43 .21*** 8.41 (3,62)*** Physical Symptoms - .20* Body Image Concerns - .25* Life Burden - .19 * p p p 100 Table 13a Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Depression (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Depression Block 1: Covariates 0.00 -0.02 0.02 (2,97) Age - .02 Sexually Active - .02 Block 2: 0.16 0.13 0.16*** 17.75 (1,96)*** Sexual Functioning - .45*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active - .04 Surgery .16 Block 2: 0.36 0.33 0.28*** 41.43 (1,95)*** Sexual Functioning - .60*** Step 3: Intrusive Thoughts Æ Depression Block 1: Covariates 0.00 -0.02 0.02 (2,97) Age - .02 Sexually Active - .02 Block 2: 0.06 0.03 0.06* 5.68 (1,96)* Intrusive Thoughts .24* MEDIATION Block 1: Covariates 0.00 -0.02 0.02 (2,97) Age - .02 Sexually Active - .02 Block 2: 0.16 0.13 0.16*** 17.75 (1,96)*** Sexual Functioning - .45*** Block 3: 0.16 0.12 0.001 0.01 (1,95) Sexual Functioning - .43** Intrusive Thoughts .04 * p * p * p 101 Table 13b Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Depression Controlling for Relationship Quality (n=70). Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Depression Block 1: Covariates 0.03 -0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.24 0.19 0.21*** 17.57 (1,65)*** Sexual Functioning - .51*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.09 0.03 1.60 (4,65) Age - .16 Sexually Active .06 Relationship Quality .12 Surgery - .21 Block 2: 0.40 0.36 0.31*** 33.61 (1,64)*** Sexual Functioning - .65*** Step 3: Intrusive Thoughts Æ Depression Block 1: Covariates 0.03 -0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.14 0.10 0.11** 8.34 (1,65)** Intrusive Thoughts .35** MEDIATION Block 1: Covariates 0.03 - 0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.24 0.19 0.21*** 17.57 (1,65)*** Sexual Functioning - .51*** Block 3: 0.25 0.19 0.01 0.82 (1,64) Sexual Functioning - .44** Intrusive Thoughts .12 * p p .01, *** p 102 Table 14a Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation Between Sexual Functioning and Positive Affect (N=100). Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Positive Affect Block 1: Covariates 0.16 0.12 4.54 (4,95)** Age .10 Sexually Active .05 Number of Children - .14 Years of Education .34** Block 2: 0.29 0.25 0.13*** 16.36 (1,94)*** Sexual Functioning .40*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active .01 Surgery .16 Block 2: 0.36 0.33 0.28*** 41.43 (1,95)*** Sexual Functioning - .60*** Step 3: Intrusive Thoughts Æ Positive Affect Block 1: Covariates 0.16 0.12 4.54 (4,95)** Age .10 Sexually Active .05 Number of Children - .14 Years of Education .34** Block 2: 0.21 0.17 0.05* 5.87 (1,94)* Intrusive Thoughts - .23* MEDIATION Block 1: Covariates 0.16 0.12 4.54 (4,95)** Age .10 Sexually Active .05 Number of Children - .14 Years of Education .34** Block 2: 0.29 0.25 0.13*** 16.36 (1,94)*** Sexual Functioning .40*** Block 3: 0.29 0.24 0.002 0.21 (1,93) Sexual Functioning .37** Intrusive Thoughts - .05 * p p p 103 Table 14b Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation Between Sexual Functioning and Positive Affect Controlling for Relationship Quality (n=70). Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Positive Affect Block 1: Covariates 0.17 0.11 2.68 (5,64)* Age .03 Sexually Active .06 Years of Education .08 Number of Children - .26 Relationship Quality .26* Block 2: 0.30 0.23 0.13*** 11.29 (1,63)*** Sexual Functioning .40*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.09 0.03 1.60 (4,65) Age - .16 Sexually Active .06 Surgery .12 Relationship Quality - .21 Block 2: 0.40 0.36 0.31*** 33.61 (1,65)*** Sexual Functioning - .65*** Step 3: Intrusive Thoughts Æ Positive Affect Block 1: Covariates 0.17 0.11 2.68 (5,64)* Age .03 Sexually Active .06 Years of Education .08 Number of Children - .26 Relationship Quality .26* Block 2: 0.23 0.16 0.06* 4.73 (1,63)* Intrusive Thoughts - .25* MEDIATION Block 1: Covariates 0.17 0.11 2.68 (5,64)* Age .03 Sexually Active .06 Years of Education .08 Number of Children - .26 Relationship Quality .26* Block 2: 0.30 0.23 0.13*** 11.29 (1,63)*** Sexual Functioning .40*** Block 3: 0.30 0.22 0.01 0.24 (1,62) Sexual Functioning .36* Intrusive Thoughts - .07 * p p p 104 Table 15a Regression Analysis Testing Sex-Specific Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Negative Affect (N=100) Variable ȕ R 2 Adjuste d R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Negative Affect Block 1: Covariates 0.06 0.03 1.99 (3,96) Age - .08 Sexually Active .06 Hormone Therapy .21* Block 2: 0.29 0.26 0.23*** 29.38 (1,95) *** Sexual Functioning - .54*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active .01 Surgery .16 Block 2: 0.36 0.33 0.28*** 41.43 (1,95)*** Sexual Functioning - .60*** Step 3: Intrusive Thoughts Æ Negative Affect Block 1: Covariates 0.06 0.03 1.99 (3,96) Age - .08 Sexually Active .06 Hormone Therapy .21* Block 2: 0.19 0.16 0.13*** 15.68 (1,95)*** Intrusive Thoughts .38*** MEDIATION Block 1: Covariates 0.06 0.03 1.99 (3,96) Age - .08 Sexually Active .06 Hormone Therapy .21* Block 2: 0.29 0.26 0.23*** 29.38 (1,95) *** Sexual Functioning - .54*** Block 3: 0.30 0.26 0.01 1.92 (1,94) Sexual Functioning - .46** Intrusive Thoughts .15 * p p p 105 Table 15b Regression Analysis Testing Sex-Specific Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Negative Affect Controlling for Relationship Quality (n=70) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Negative Affect Block 1: Covariates 0.09 0.04 1.64 (4,65) Age - .05 Sexually Active .11 Hormone Therapy .21 Relationship Quality - .18 Block 2: 0.31 0.26 0.22*** 16.81 (1,64)*** Sexual Functioning - .50*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.09 0.03 1.60 (4,65) Age - .16 Sexually Active .06 Surgery .12 Relationship Quality - .21 Block 2: 0.40 0.36 0.31*** 33.61 (1,64)*** Sexual Functioning - .65** Step 3: Intrusive Thoughts Æ Negative Affect Block 1: Covariates 0.09 0.04 1.64 (4,65) Age - .05 Sexually Active .11 Hormone Therapy .21 Relationship Quality - .18 Block 2: 0.23 0.17 0.14*** 11.65 (1,64)*** Intrusive Thoughts .40*** MEDIATION Block 1: Covariates 0.09 0.04 1.64 (4,65) Age - .05 Sexually Active .11 Hormone Therapy .21 Relationship Quality - .18 Block 2: 0.31 0.26 0.22*** 16.81 (1,64)*** Sexual Functioning - .50*** Block 3: 0.32 0.26 0.01 0.83 (1,63) Sexual Functioning - .43** Intrusive Thoughts .12 * p p p 106 Table 16a Regression Analysis Testing Interaction between Sexual Functioning and Sociosexual Attitudes in Predicting Sex-specific Intrusive Thoughts (N=100) Variable ȕ R 2 Adjusted R 2 ¨ 5 2 F (df) Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active -.01 Surgery .16 Block 2: Main Effects 0.36 0.32 0.28*** 20.51 (2,94)*** Sexual Functioning (centered) - .60*** Sociosexual Attitudes (centered) .01 Block 3: Interaction 0.36 0.32 0.00 0.03 (1,93) Sexual Functioning X Sociosexual Attitudes - .02 * p p p Table 16b Regression Analysis Testing Interaction between Sexual Functioning and Sociosexual Attitudes Power Subscale in Predicting Sex-specific Intrusive Thoughts (n=70) Variable ȕ R 2 Adjusted R 2 ¨ 5 2 F (df) Block 1: Covariates 0.05 0.01 1.26 (3,71) Age - .14 Sexually Active - .02 Surgery .17 Block 2: Main Effects 0.46 0.42 0.41*** 26.19 (2,69)*** Sexual Functioning (centered) - .53*** Power Attitudes (centered) .30* Block 3: Interaction 0.46 0.41 0.01 0.13 (1,68) Sexual Functioning X Power Attitudes .04 * p p p Table 16c Regression Analysis Testing Interaction between Sexual Functioning and Sociosexual Attitudes Global Subscale in Predicting Sex-specific Intrusive Thoughts (N=100) Variable ȕ R 2 Adjusted R 2 ¨ 5 2 F (df) Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active - .01 Surgery .16 Block 2: Main Effects 0.39 0.36 0.31*** 24.17 (2,94)*** Sexual Functioning (centered) - .63*** Global Attitudes (centered) - .21* Block 3: Interaction 0.39 0.35 0.01 0.02 (1,93) Sexual Functioning X Global Attitudes - .01 * p p p 107 Table 17a Regression Analyses Testing Avoidant Coping as a Mediator of the Relation between Sex-Specific Intrusive Thoughts and Depression (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Intrusive Thoughts Æ Depression Block 1: Covariates 0.01 -0.02 0.02 (2,97) Age - .02 Sexual Activity - .01 Block 2: 0.06 0.03 0.06* 5.68 (1,96)* Intrusive Thoughts .24* Step 2: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.03 0.01 1.59 (2,97) Age - .16 Sexual Activity .03 Block 2: 0.41 0.39 0.37*** 60.35 (1,96)*** Intrusive Thoughts .63*** Step 3: Avoidant Coping Æ Depression Block 1: Covariates 0.01 -0.02 0.02 (2,97) Age - .02 Sexual Activity - .01 Block 2: 0.11 0.09 0.11*** 12.27 (1,96)*** Avoidant Coping .34*** MEDIATION Block 1: Covariates 0.01 -0.02 0.02 (2,97) Age - .02 Sexual Activity - .01 Block 2: 0.06 0.03 0.06* 5.68 (1,96)* Intrusive Thoughts .24* Block 3: 0.12 0.08 0.06* 6.29 (1,95)* Intrusive Thoughts .05 Avoidant Coping .31* * p p p 108 Table 17b Regression Analyses Testing Avoidant Coping as a Mediator of the Relation Between Sex-Specific Intrusive Thoughts and Depression Controlling for Relationship Quality (n=70) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Intrusive Thoughts Æ Depression Block 1: Covariates 0.03 -0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.14 0.09 0.11** 8.34 (1,65)** Intrusive Thoughts .35** Step 2: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.12 0.08 2.86 (3,66)* Age - .12 Sexually Active .01 Relationship Quality - .34** Block 2: 0.50 0.47 0.38*** 49.63 (1,65)*** Intrusive Thoughts .64*** Step 3: Avoidant Coping Æ Depression Block 1: Covariates 0.03 -0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.15 0.09** 0.12** 8.50 (1,65)** Avoidant Coping .35** MEDIATION Block 1: Covariates 0.03 -0.01 0.78 (3,66) Age - .01 Sexually Active - .02 Relationship Quality - .18 Block 2: 0.14 0.09 0.11** 8.34 (1,65)** Intrusive Thoughts .35** Block 3: 0.17 0.10 0.02 1.83 (1,64) Intrusive Thoughts .21 Avoidant Coping .22 * p p p 109 Table 18a Regression Analyses Testing Avoidant Coping as a Mediator of the Relation between Sex-Specific Intrusive Thoughts and Negative Affect (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Intrusive Thoughts Æ Negative Affect Block 1: Covariates 0.06 0.03 1.99 (3, 96) Age - .08 Sexual Activity .06 Hormone Treatment .21* Block 2: 0.19 0.16 0.13*** 15.68 (1,95)*** Intrusive Thoughts .38*** Step 2: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.03 0.01 1.59 (2,97) Age - .16 Sexual Activity .03 Block 2: 0.41 0.39 .37*** 60.34 (1,96)*** Intrusive Thoughts .63*** Step 3: Avoidant Coping Æ Negative Affect Block 1: Covariates 0.06 0.03 1.99 (3, 96) Age - .08 Sexual Activity .06 Hormone Treatment .21* Block 2: 0.27 0.24 0.21*** 27.32 (1,95)*** Avoidant Coping .47*** MEDIATION Block 1: Covariates 0.06 0.03 1.99 (3, 96) Age - .08 Sexual Activity .06 Hormone Treatment .21* Block 2: 0.19 0.16 0.13*** 15.68 (1,95)*** Intrusive Thoughts .38*** Block 3: 0.28 0.24 0.09*** 11.49 (1,94)*** Intrusive Thoughts .14 Avoidant Coping .39*** * p p p 110 Table 18b Regression Analyses Testing Avoidant Coping as a Mediator of the Relation between Sex-Specific Intrusive Thoughts and Negative Affect Controlling for Relationship Quality (n=70) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Intrusive Thoughts Æ Negative Affect Block 1: Covariates 0.05 0.01 1.13 (4,65) Age - .04 Sexually Active .14 Hormone Treatment .22 Relationship Quality - .20 Block 2: 0.22 0.17 0.17*** 13.93 (1,64)*** Intrusive Thoughts .43*** Step 2: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.12 0.08 2.86 (3,66)* Age - .16 Sexually Active .09 Relationship Quality - .34** Block 2: 0.50 0.47 0.38*** 49.63 (1,65)*** Intrusive Thoughts .64*** Step 3: Avoidant Coping Æ Negative Affect Block 1: Covariates 0.05 0.01 1.13 (4,65) Age - .04 Sexually Active .14 Hormone Treatment .22 Relationship Quality - .20 Block 2: 0.23 0.18 0.18*** 14.80 (1,64)*** Avoidant Coping .45*** MEDIATION Block 1: Covariates 0.05 0.01 1.13 (4,65) Age - .04 Sexually Active .14 Hormone Treatment .22 Relationship Quality - .20 Block 2: 0.22 0.17 0.17*** 13.93 (1,64)*** Intrusive Thoughts .43*** Block 3: 0.26 0.20 0.04 3.44 (1,63) Intrusive Thoughts .25 Avoidant Coping .28 * p p p 111 Table 19a Regression Analyses Testing Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Avoidant Coping (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Avoidant Coping Block 1: Covariates 0.03 0.01 1.59 (2, 97) Age - .16 Sexually Active .03 Block 2: 0.18 0.16 0.15*** 17.82 (1,96)*** Sexual Functioning - .45*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .20 Sexually Active - .04 Surgery .16 Block 2: 0.36 0.33 0.28*** 41.43 (1,95)*** Sexual Functioning -.60*** Step 3: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.03 0.01 1.59 (2,97) Age - .16 Sexual Activity .03 Block 2: 0.41 0.39 .37*** 60.34 (1,96)*** Intrusive Thoughts .63*** MEDIATION Block 1: Covariates 0.03 0.01 1.59 (2, 97) Age - .16 Sexually Active .03 Block 2: 0.18 0.16 0.15*** 17.82 (1,96)*** Sexual Functioning - .45*** Block 3: 0.41 0.39 0.23*** 37.45 (1,95)*** Sexual Functioning - .12 Intrusive Thoughts .57*** * p p p 112 Table 19b Regression Analyses Testing Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Avoidant Coping controlling for Relationship Quality (N=70) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Avoidant Coping Block 1: Covariates 0.12 0.07 2.86 (3, 66) Age - .12 Sexually Active .09 Relationship Quality - .34* Block 2: 0.27 0.22 0.15*** 13.64 (1,65)*** Sexual Functioning - .45*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.09 0.03 1.60 (4,65) Age - .16 Sexually Active .06 Relationship Quality .12 Surgery - .21 Block 2: 0.40 0.36 0.31*** 33.61 (1,64)*** Sexual Functioning - .65*** Step 3: Intrusive Thoughts Æ Avoidant Coping Block 1: Covariates 0.12 0.08 2.86 (3,66)* Age - .16 Sexually Active .09 Relationship Quality - .34** Block 2: 0.50 0.47 0.38*** 49.63 (1,65)*** Intrusive Thoughts .64*** MEDIATION Block 1: Covariates 0.12 0.07 2.86 (3, 66) Age - .12 Sexually Active .09 Relationship Quality - .34* Block 2: 0.27 0.22 0.15*** 13.64 (1,65)*** Sexual Functioning - .45*** Block 3: 0.51 0.47 0.34*** 30.90 (1,64)*** Sexual Functioning - .12 Intrusive Thoughts .59*** * p p p 113 Figure 1 Path Coefficients for the Partial Least Squares Modeling of the Conceptual Model (N=100) Note. Numbers within shapes represent R 2 s and numbers above arrows are path coefficients. Solid lines indicate statistically significant paths (p<.05). Dashed lines indicate non-significant paths. Paths from age and sexually active to approach and avoidant coping (not shown) were not significant. .24 -.60 .19 Sexual Functioning 0.39 .35 - .25 - .26 - .15 - .30 .64 - .40 - .30 .24 - .72 .88 .88 Negative Emotional States 0.38 Depression Negative Affect Positive Affect Approach Coping 0.12 Avoidant Coping 0.41 Intrusive Thoughts 0.29 Sociosexual Attitudes Centered Sexual Functioning X Sociosexual Attitudes Body Image Concerns Physical Symptoms Life Burden Sexually Active Age 114 Figure 2 Path Coefficients for the Partial Least Squares Modeling of the Post-hoc Model (N=100) Note. Numbers within shapes represent R 2 s and numbers above arrows are path coefficients. Solid lines indicate statistically significant paths (p<.05). Dashed lines indicate non-significant paths. Paths from age and sexually active to approach and avoidant coping (not shown) were not significant. .29 .23 - .55 .19 .35 - .25 - .26 - .15 - .30 .64 - .40 - .30 .24 - .72 .88 .88 Sexual Functioning 0.39 Depression Negative Affect Positive Affect Approach Coping 0.17 Avoidant Coping 0.41 Intrusive Thoughts 0.28 Body Image Concerns Physical Symptoms Life Burden Sexually Active Age Negative Emotional States 0.38 115 Table 20 R 2 s for PLS Path Models R 2 Predicted Variable Original Post-hoc Approach Coping 0.12 0.17 Avoidant Coping 0.41 0.41 Body Image Concerns - - Emotional States 0.38 0.38 Intrusive Thoughts 0.29 0.28 Life Burden - - Sexual Functioning 0.39 0.39 Average R 2 0.32 0.33 116 APPENDIX Table A. Factor Analysis Results for Sociosexual Attitudes Scale Table B. Testing Intrusive Thoughts as Mediator of the Relation between Sexual Functioning and Depression Controlling for History of Antidepressant Use Table C. Testing Intrusive Thoughts as Mediator of the Relation between Sexual Functioning and Depression Controlling for History of Antidepressant Use and Relationship Quality Figure A. Comparing Coping Strategies Used for Sex-Specific Intrusive Thoughts from Present Sample with Coping Strategies for Cervical Cancer from D’Orazio et al. (2011) Sample. Interview Questions 117 Table A Factor Loadings for Principle Components Sociosexual Attitudes with Varimax Rotation of Sociosexual Attitudes Scale Items Note. Factor loadings > .40 are in boldface. a Reverse-coded items. Item Power Global Gender Sex is a very important part of life. a .10 .76 -.25 Main purpose of sex is to enjoy oneself. a -.24 .59 -.02 Acceptable for me to think/daydream about sexual activity. a .08 .79 -.04 Sex is not something one should talk about. -.04 .62 .25 A woman without her womb is not really a woman. .00 .39 .60 It is a woman’s duty as a partner/wife to keep her partner sexually satisfied. .23 .00 .71 It is not appropriate for a woman to initiate sex. .09 .42 .24 If a woman cannot have sex, she is worthless. .08 -.09 .70 Sometimes I feel pressured to have sex with my partner. .83 .05 -.06 Sometimes I have sex with my partner when I don’t feel like it. .84 .02 .05 I don’t feel comfortable denying my partner sex. .80 -.03 .18 I worry about what will happen to my relationship if I don’t have sex with my partner. .82 -.03 .29 118 Table B Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation between Sexual Functioning and Depression Controlling for History of Antidepressant Use (N=100) Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Depression Block 1: Covariates 0.06 0.03 1.94 (3,96) Age - .27 Sexually Active .01 History of Antidepressant Use .24* Block 2: 0.19 0.15 0.13*** 14.99 (1,95)*** Sexual Functioning - .41*** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.08 0.05 2.65 (3,96) Age - .19 Sexually Active - .01 Surgery .16 Block 2: 0.36 0.33 0.28*** 41.22 (1,95)*** Sexual Functioning -1.21*** Step 3: Intrusive Thoughts Æ Depression Block 1: Covariates 0.06 0.03 1.94 (3,96) Age - .27 Sexually Active .01 History of Antidepressant Use .24* Block 2: 0.10 0.06 0.04* 4.54 (1,95)* Intrusive Thoughts .22* MEDIATION Block 1: Covariates 0.06 0.03 1.94 (3,96) Age - .27 Sexually Active .01 History of Antidepressant Use .24* Block 2: 0.19 0.15 0.13*** 14.99 (1,95)*** Sexual Functioning - .41*** Block 3: 0.19 0.14 0.001 0.10 (1,94) Sexual Functioning - .39** Intrusive Thoughts .05 * p p p 119 Table C Regression Analysis Testing Intrusive Thoughts as a Mediator of the Relation Between Sexual Functioning and Depression Controlling for History of Antidepressant Use and Relationship Quality (n=70). Variable ȕ R 2 Adjusted R 2 ¨ R 2 F (df) Step 1: Sexual Functioning Æ Depression Block 1: Covariates 0.08 0.02 1.34 (4,65) Age - .03 Sexually Active .01 Relationship Quality - .13 History of Antidepressant Use .22 Block 2: 0.24 0.18 0.16** 13.30 (1,64)** Sexual Functioning - .45** Step 2: Sexual Functioning Æ Intrusive Thoughts Block 1: Covariates 0.09 0.03 1.60 (4,65) Age - .16 Sexually Active .06 Relationship Quality - .21 Surgery .12 Block 2: 0.36 0.31 0.27*** 27.23(1,64)*** Sexual Functioning - .61*** Step 3: Intrusive Thoughts Æ Depression Block 1: Covariates 0.08 0.02 1.34 (4,65) Age - .03 Sexually Active .01 Relationship Quality - .13 History of Antidepressant Use .22 Block 2: 0.17 0.10 0.09** 7.04 (1,64)** Intrusive Thoughts .32** MEDIATION Block 1: Covariates 0.08 0.02 1.34 (4,65) Age - .03 Sexually Active .01 Relationship Quality - .13 History of Antidepressant Use .22 Block 2: 0.24 0.18 0.16** 13.30 (1,64)** Sexual Functioning - .45** Block 3: 0.25 0.18 0.01 1.13 (1,63) Sexual Functioning - .38** Intrusive Thoughts .14 * p p p 120 Figure A. Comparing Coping Strategies Used for Sex-Specific Intrusive Thoughts from Present Sample with Coping Strategies for Cervical Cancer from D’Orazio et al. (2011) Sample. 0 0.5 1 1.5 2 2.5 3 3.5 4 Sexually Active Not Sexually Active D'Orazio et al. (2011) 121 Interview Questions 122 Demographic & Medical Information 1. DOB:______/______/_______ 2. Where were you born?_______________________________________________ 3. Where were did grow up?______________________________________________ 4. How many years have you spent in the US?________________________________ 5. Number of years of education completed:__________________________________ 6. Marital Status/History:_________________________________________________ 7. Who do you live with?_________________________________________________ 8. What is your annual income?____________________________________________ 9. Who is financially responsible for your home?______________________________ 10. Number of people currently in household?______________________ 11. Number of children: biological____________ other_______________ 12. For how many people are you the primary caregiver?______________ # children______ #elderly________ #other__________ 13. Pre-cancer occupation:____________________________________ 14. Post-cancer occupation:____________________________________ 15. What is your diagnosis?_____________________________________________ 16. When were you diagnosed?__________________________________________ 17. Where are you with treatment? Not yet started In tx Completed tx 18. How long has it been since you completed treatment?__________________________ 19. What kind of treatments have you received and when did you receive them? _____Surgery _____Radiation ______Chemo ____Hormones Specifics:_________________________________________________________________ _________________________________________________________________________ 20. What medications are you currently taking? (ask about antidepressants) _________________________________________________________________________ _________________________________________________________________________ 123 Brief ARSMA-II Please tell me to what extent you do each of these items. Not at all Very little/Not very much Moderately Much/ Very often Almost always/ Extremely often 1. I speak Spanish 1 2 3 4 5 2. I speak English 1 2 3 4 5 3. I enjoy speaking Spanish 1 2 3 4 5 4. I associate with Anglos 1 2 3 4 5 5. I enjoy listening to English language music 1 2 3 4 5 6. I enjoy Spanish language TV 1 2 3 4 5 7. I enjoy Spanish language movies 1 2 3 4 5 8. I enjoy reading books in Spanish 1 2 3 4 5 9. I write letters in English 1 2 3 4 5 10. My thinking is done in the English language 1 2 3 4 5 11. My thinking is done in the Spanish language 1 2 3 4 5 12. My friends are of Anglo origin 1 2 3 4 5 1995, Cuéllar, Arnold & Maldonado 124 CES-D Now I am going to read some statements about some ways people act and feel. Please tell me the number which best describes how often you felt or behaved this way in the past 4 weeks. Rarely/ None of the time Some of the time/ A little Occasionally/ Moderate amount of time Most/ All of the time Not Applicable I don’t know 1. I was bothered by things that usually don't bother me. 0 1 2 3 7 8 2. I did not feel like eating; my appetite was poor. 0 1 2 3 7 8 3. I felt that I could not shake off the blues even with help from my family or friends. 0 1 2 3 7 8 4. I had trouble keeping my mind on what I was doing. 0 1 2 3 7 8 5. I felt that I was just as good as other people. 0 1 2 3 7 8 6. I felt depressed. 0 1 2 3 7 8 7. I felt that everything I did was an effort. 0 1 2 3 7 8 8. I felt hopeful about the future. 0 1 2 3 7 8 9. I thought my life had been a failure. 0 1 2 3 7 8 10. I felt fearful. 0 1 2 3 7 8 11. My sleep was restless. 0 1 2 3 7 8 12. I was happy. 0 1 2 3 7 8 13. I talked less than usual. 0 1 2 3 7 8 14. I felt lonely. 0 1 2 3 7 8 15. People were unfriendly. 0 1 2 3 7 8 16. I enjoyed life. 0 1 2 3 7 8 17. I had crying spells. 0 1 2 3 7 8 18. I felt sad. 0 1 2 3 7 8 19. I felt that people disliked me. 0 1 2 3 7 8 20. I could not get "going." 0 1 2 3 7 8 125 PANAS This scale consists of a number of words that describe different feelings and emotions. Indicate to what extent you have felt this way in the past 4 weeks. Use the following scale to record your answers. (1) = Very slightly or not at all (2) = A little (3) = Moderately (4) = Quite a bit (5) = Extremely Very slightly or not at all A little Moderately Quite a bit Extremely 1. Interested 1 2 3 4 5 2. Distressed 1 2 3 4 5 3. Excited 1 2 3 4 5 4. Upset 1 2 3 4 5 5. Strong 1 2 3 4 5 6. Guilty 1 2 3 4 5 7. Scared 1 2 3 4 5 8. Hostile 1 2 3 4 5 9. Enthusiastic 1 2 3 4 5 10. Proud 1 2 3 4 5 11. Irritable 1 2 3 4 5 12. Alert 1 2 3 4 5 13. Ashamed 1 2 3 4 5 14. Inspired 1 2 3 4 5 15. Nervous 1 2 3 4 5 16. Determined 1 2 3 4 5 17. Attentive 1 2 3 4 5 18. Jittery 1 2 3 4 5 19. Active 1 2 3 4 5 20. Afraid 1 2 3 4 5 126 FACT-Cx Below is a list of statements that other people with cervical cancer have said are important. Please tell me how true each statement has been for you during the past 4 weeks. Body Image Scale (Hopwood, 1993) Now, I’d like to ask some questions about how you feel about your appearance, and about any changes that may have resulted from your disease or treatment. After I read each item please let me how you have been feeling about yourself, during the past 4 weeks. 0=Not at all 1=A little 3=Quite a bit 4=Very much ____1. Have you been feeling self-conscious about your appearance? ____2. Have you felt less physically attractive as a result of your disease or treatment? ____3. Have you been feeling less feminine as a result of your disease or treatment? ____4. Have you been feeling less sexually attractive as a result of your disease or treatment? ____5. Have you been feeling the treatment has left your body less whole? ____6. Have you felt dissatisfied with your body? What changes to your body bother you the most?____________________________ ___________________________________________________________________ Cx1. I am bothered by discharge or bleeding from my vagina ................................................... 0 1 2 3 4 Cx. 2 I am bothered by odor coming from my vagina ................................................................. 0 1 2 3 4 Cx.4 My vagina feels too narrow or short ........... 0 1 2 3 4 BL1. I have trouble controlling my urine ............. 0 1 2 3 4 Not at all A little bit Some -what Quite a bit Very much GP1. I have a lack of energy ............................. 0 1 2 3 4 GP2. I have nausea ........................................... 0 1 2 3 4 GP3. I have pain ................................................ 0 1 2 3 4 127 Female Sexual Function Index (FSFI) Many women who have been treated for cervical cancer say that they also experience changes in their sexual lives—especially in their interest in and ability to have sex. The next series of questions will focus on aspects of your sexual life during the past 4 weeks. These questions can be personal but your responses are important in helping us understand how illnesses can affect women’s lives. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential. In answering these questions the following definitions apply: Sexual activity can include caressing, foreplay, masturbation and vaginal intercourse. Sexual intercourse is defined as penile penetration (entry) of the vagina. Sexual stimulation includes situations like foreplay with a partner, self-stimulation (masturbation), or sexual fantasy. Let’s start with a few preliminary questions: A. In the past 4 weeks, how often have you engaged in sexual activity?______ intercourse?______ B. Is sexual activity an important part of your life? YES NO C. Would you like to be more sexually active than you are currently? YES NO D. Would you like to be less sexually active than you are currently? YES NO Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling receptive to a partner's sexual initiation, and thinking or fantasizing about having sex. 1. Over the past 4 weeks, how often did you feel sexual desire or interest? Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 2. Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest? Very high High Moderate Low Very low or none at all Sexual arousal is a feeling that includes both physical and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication (wetness), or muscle contractions. 3. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse? No sexual activity Almost always or always 128 Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 4. Over the past 4 weeks, how would you rate your level of sexual arousal ("turned on") during sexual activity or intercourse? No sexual activity Very high High Moderate Low Very low or none at all 5. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse? No sexual activity Very high confidence High confidence Moderate confidence Low confidence Very low or no confidence 6. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse? No sexual activity Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 7. Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse? No sexual activity Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 8. Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse? No sexual activity Extremely difficult or impossible Very difficult 129 Difficult Slightly difficult Not difficult 9. Over the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse? No sexual activity Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 10. Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse? No sexual activity Extremely difficult or impossible Very difficult Difficult Slightly difficult Not difficult 11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)? No sexual activity Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)? No sexual activity Extremely difficult or impossible Very difficult Difficult Slightly difficult Not difficult 13. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse? No sexual activity Very satisfied Moderately satisfied About equally satisfied and dissatisfied 130 Moderately dissatisfied Very dissatisfied 14. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner? No sexual activity Very satisfied Moderately satisfied About equally satisfied and dissatisfied Moderately dissatisfied Very dissatisfied 15. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner? Very satisfied Moderately satisfied About equally satisfied and dissatisfied Moderately dissatisfied Very dissatisfied 16. Over the past 4 weeks, how satisfied have you been with your overall sexual life? Very satisfied Moderately satisfied About equally satisfied and dissatisfied Moderately dissatisfied Very dissatisfied 17. Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration? Did not attempt intercourse Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 18. Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration? Did not attempt intercourse Almost always or always Most times (more than half the time) Sometimes (about half the time) A few times (less than half the time) Almost never or never 19.Over the past 4 weeks, how would you rate your level (degree) of discomfort or 131 pain during or following vaginal penetration? Did not attempt intercourse Very high High Moderate Low Very low or none at all SOCIO-SEXUAL ATTITUDES AND PRESSURE TO HAVE SEX Some women have certain beliefs about their intimate relationships, what’s expected of them and what it means to be a woman. 0= Disagree Completely 1=Disagree a little 2=Neither agree/disagree 3=Agree a little 4=Completely Agree To what extent do you agree with the following statements: ____1. Sex is a very important part of life. ____2. The main purpose of sex is to enjoy oneself. ____3. I personally believe it is acceptable for me to think or day dream about sexual activity ____4. A woman without her womb is not really a woman. ____5. It is a woman’s duty as a partner/wife to keep her partner sexually satisfied. ____6. Sometimes I feel pressured to have sex with my partner. ____7. Sometimes I have sex with my partner when I don’t feel like it. ____8. I don’t feel comfortable denying my partner sex. ____9. I worry about what will happen to my relationship if I don’t have sex with my partner. ____10. It is not appropriate for a woman to initiate sex. ____11. If a woman cannot have sex, she is worthless. ____12. Sex is not something one should talk about. 132 SEX-The Impact of Event Scale – Revised Now I’m going to read a list of difficulties people sometimes have after or during stressful life events. Please indicate how distressing each item has been DURING THE PAST 4 WEEKs with respect to PROBLEMS WITH SEXUAL FUNCTIONING, how much were you distressed or bothered by these difficulties? Not at all A little bit Moderately Quite a bit Extremely 1. Any reminder brought back feelings about it 0 1 2 3 4 2. I had trouble staying asleep 0 1 2 3 4 3. Other things kept making me think about it 0 1 2 3 4 4. I thought about it when I didn’t mean to 0 1 2 3 4 5. Pictures about it popped into my mind 0 1 2 3 4 6. I had waves of strong feelings about it 0 1 2 3 4 7. I had dreams about it 0 1 2 3 4 Brief COPE –Sex Now, I am going read to you some statements that deal with ways you've been coping with worries or thoughts you may have about your sexual functioning during the past 4 weeks. There are many ways to try to deal with problems. These items ask what you've been doing to cope with this specific one. I'm interested in how you've tried to deal with unwanted thoughts or worries about your sexual functioning. Before we start, what kinds of concerns about sex do you have at the moment?_______________________________________________________________________ _______________________________________________________________________________ ___________Now I want to know how often you've been doing what each item says to deal with the concerns you just shared. Don't answer on the basis of whether it seems to be working or not—just whether or not you're doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true FOR YOU as you can. ( Repeat that this should be about how they cope with SEX for each item) I haven’t been doing this at all I’ve been doing this a little bit. I’ve been doing this a medium amount I’ve been doing this a lot 1. I've been turning to work or other activities to take my mind off things. 1 2 3 4 2. I've been concentrating my efforts on doing something about the situation I'm in. 1 2 3 4 3. I've been saying to myself "this isn't real". 1 2 3 4 4. I've been using alcohol or other drugs to 1 2 3 4 133 make myself feel better. 5. I've been getting emotional support from others. 1 2 3 4 6. I've been giving up trying to deal with it. 1 2 3 4 7. I've been taking action to try to make the situation better. 1 2 3 4 8. I've been refusing to believe that it has happened. 1 2 3 4 9. I've been saying things to let my unpleasant feelings escape. 1 2 3 4 10. I’ve been getting help and advice from other people. 1 2 3 4 11. I've been using alcohol or other drugs to help me get through it. 1 2 3 4 12. I've been trying to see it in a different light, to make it seem more positive. 1 2 3 4 13. I’ve been criticizing myself. 1 2 3 4 14. I've been trying to come up with a strategy about what to do. 1 2 3 4 15. I've been getting comfort and understanding from someone. 1 2 3 4 16. I've been giving up the attempt to cope. 1 2 3 4 17. I've been looking for something good in what is happening. 1 2 3 4 18. I've been doing something to think about it less, such as going to movies, watching TV, reading, daydreaming, sleeping, or shopping. 1 2 3 4 19. I've been accepting the reality of the fact that it has happened. 1 2 3 4 20. I've been expressing my negative feelings. 1 2 3 4 21. I've been trying to find comfort in my religion or spiritual beliefs. 1 2 3 4 22. I’ve been trying to get advice or help from other people about what to do. 1 2 3 4 23. I've been learning to live with it. 1 2 3 4 24. I've been thinking hard about what steps to take. 1 2 3 4 25. I’ve been blaming myself for things that happened. 1 2 3 4 26. I've been praying or meditating. 1 2 3 4 Are there any other ways you have been coping with sexual difficulties? 134 Revised Dyadic Adjustment Scale (only partnered/sexually active/ or wishing to be sexually active) Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list. Always Agree Almost Always Agree Occasionally Disagree Frequently Disagree Almost Always Disagree Always Disagree 1. Religious matters 2. Demonstration of affection 3. Sex relations 4. Conventionality (correct or proper behavior) 5. Making major decisions 6. Career decisions All of the time Most of the time More often than not Occasionally Rarely Never 7. How often do you discuss or have you considered divorce/separatio n or terminating your relationship? 8. Do you ever regret that you married (or lived together)? 9. How often do you and your partner quarrel? 10. How often do you and your mate “get on each other’s nerves?” 11. Do you and your mate engage in outside interests together? 135 Never >once a month Once or twice a month Once or twice a week Once a day 12. How often do you both have a stimulating exchange of ideas 13. Work together on a project 14. Calmly discuss something Hispanic Stress Inventory (Version I: Immigrant) Instructions: Please tell me whether the following situations have occurred to you during the last 4 weeks. Then if it did occur to you, let me know how worried or tense the situation made you feel. If the situation did not happen to you, just say so and we will move on to the next item. Remember there is no right or wrong answer so try and be as honest as you can. Example 1: It has been difficult for me to find medical care. Has this occurred to you in the past 4 weeks? __Yes __No 1 Not at all worried/tense 2 A little worried/tense 3 Moderately worried/tense 4 Very worried/tense 5 Extremely worried/tense Example 2: I have been criticized about my work. Has this occurred to you in the past 4 weeks? __Yes __No 1 2 3 4 5 ____1. Because I do not know enough English, it has been difficult for me to interact with others. ____2. My children have been drinking alcohol. ____3. I have been discriminated against. ____4. My spouse expected me to be more traditional in our relationship. ____5. My spouse and I have disagreed on how to bring up our children. ____6. My spouse and I have had disagreements about who should control the household money. ____7. Because of American ideas about the children it has been difficult for me to decide how strict to be with my children. ____8. Because of my poor English people have treated me badly. ____9. I have felt that being too close to my family interfered with my own goals. 136 ____10. My children have not respected my authority the way they should. ____11. Because of the lack of family unity, I have felt lonely and isolated ____12. Because I am Latino, I have been expected to work harder. ____13. My spouse and I have disagreed on which language is spoken by our children at home. ____14. My spouse has not helped with household chores. ____15. My income has not been sufficient to support my family or myself. ____16. I feared the consequences of deportation. ____17. My legal status has been a problem in getting a good job. ____18. I have felt that my children’s ideas about sexuality are too liberal. ____19. There has been physical violence among members of my family. ____20. Because I am Latino I have had difficulty finding the type of work I want. ____21. My spouse has expected me to be less traditional in our relationship. ____22. My children have talked about leaving home. ____23. I have felt that family relationships are becoming less important for people who I’m close to. ____24. My children have received bad school reports (or grades). ____25. I have had to watch the quality of my work so others do not think I am lazy. ____26. Because I am Latino it has been hard to get promotions or salary raises. ____27. I have had serious arguments with members of my family. ____28. I have thought that if I went to a social or government agency, I would be deported. ____29. My personal goals have been in conflict with family goals. ____30. Both my spouse and I have had to work. ____31. I have been forced to accept low paying jobs. ____32. There have been conflicts among members of my family. ____33. I have felt pressured to learn English. ____34. Some members of my family have become too individualistic. Family Responsibility Scale The statements below are about the pressures you may feel in your family. There are no right or wrong answers. Please read each statement and circle the number on the right which answers best for you during the past 4 weeks. 1 2 3 4 5 6 7 Never Sometimes All of the Time ____1. Taking care of my family is overwhelming. ____2. The pressure of caring for family is very great. ____3. I feel completely worn out by all I must do at home. ____4. The demands placed on me at home are wearing me down. ____5. Caring for others is taking over my life. ____6. After handling my family needs. I have no energy for anything else. ____7. Not getting enough rest makes me upset with my family. 137 ____8. Because of all the things I must do, I hurry from one thing to the next. ____9. I feel I can’t keep up with everything that’s expected of me at home. ____10. Being responsible for others really wears me out.

Abstract (if available)

Abstract Research on the psychosocial experiences of Latina cervical cancer patients remains limited, despite the fact that Latinas continue to have the highest incidence rates of cervical cancer. An understudied area of adjustment for Latinas with cervical cancer is sexual functioning after treatment. In this study, interviews were conducted with 100 Latina cervical cancer patients in an urban county hospital in order to describe their sexual functioning and related psychosocial experiences, to identify cancer-related (physical symptoms and body image concerns) and contextual predictors (life burden) of sexual functioning, and to examine hypothesized mediators and moderators of the relations between sexual functioning and emotional states, specifically depression and affect. Problems with sexual functioning were prevalent (84% of sexually active (n=56) women met criteria for sexual dysfunction) and reported levels of dissatisfaction with sexual functioning were high. Aspects of the cancer experience (body image concerns) and of the context of patients’ lives (life burden) accounted for significant variance in sexual functioning in regression analyses. Sexual functioning was negatively associated with depression and negative affect, and positively associated with positive affect. Relations between sexual functioning and depression and negative affect were mediated by patients’ intrusive thoughts about sexual dysfunction and avoidant coping strategies used to manage these intrusive thoughts. Sociosexual attitudes, hypothesized to distinguish patients at risk for sex-specific intrusive thoughts, failed to moderate the relation between sexual functioning and sex-specific intrusive thoughts. Partial Least Squares path modeling was used to test the conceptual model, which adequately fit the data. The findings from this study suggest that sexual functioning, predicted by cancer-related and contextual factors, is a relevant area of adjustment for this sample, and is associated with emotional states through patients’ sex-specific intrusive thoughts and coping strategies used to manage them. Clinical implications and directions for future research are discussed.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator D'Orazio, Lina Mercedes (author)

Core Title Psychosexual adjustment among low-income Latinas with cervical cancer

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Psychology

Publication Date 08/20/2013

Defense Date 07/30/2013

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

Tag cervical cancer,coping,culture,Latinas,OAI-PMH Harvest,sexual attitudes,sexual functioning

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Meyerowitz, Beth E. (committee chair), Aranda, Maria P. (committee member), Huey, Stanley J., Jr. (committee member), John, Richard S. (committee member)

Creator Email lina.dorazio@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-321655

Unique identifier UC11287999

Identifier etd-DOrazioLin-2013.pdf (filename),usctheses-c3-321655 (legacy record id)

Legacy Identifier etd-DOrazioLin-2013.pdf

Dmrecord 321655

Document Type Dissertation

Rights D'Orazio, Lina Mercedes

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