Archives of Sexual Behavior, Vol. 13, No.

2, 1984

The Role of Anxiety in Sexual Dysfunctions: A Review

G. R. Norton, Ph.D., I and Derek Jehu, F.B.Ps.S 2

Studies are reviewed which (a) compare anxiety and other measures of psy-
chopathology between normals and dysfunctionals; (b) evaluate the
effectiveness of anxiety reduction procedures for treating sexual
dysfunctions; and (c) try to identify anxiety-related stimuli that alter sexual
arousal. The studies, in general, suggest that (a) anxiety is common among
people with sexual dysfunctions, but that the level and nature of the anxiety
may vary greatly between individuals; (b) anxiety reduction procedures
improve some, but probably not all, aspects of sexual dysfunctions; and (c)
recent research has begun to identify some anxiety-related factors that can
disrupt sexual arousal.

KEY WORDS: anxiety; sexual dysfunction; sexual arousal.

INTRODUCTION

Anxiety is considered by m a n y to be a m a j o r factor in the etiology of

sexual dysfunctions (e.g., Jehu, 1979; Kaplan, 1974; Masters and Johnson,
1970). The relationship between anxiety and' sexual dysfunction is
ambiguous, however. Some researchers and clinicians maintain that high
levels of generalized neurotic anxiety rend to impair sexual performance
(e.g., Pinderhughes et al., 1972; Stafford-Clark, 1954). Others (e.g.,
Cooper, 1968a, 1969a) have suggested that anxiety specifically related to
sexual activities m a y be more important than generalized, neurotic anxiety
in the etiology o f sexual dysfunctions. In addition to the relative importance
of generalized versus specific anxiety, there is the question of whether

The preparation of this manuscript was supported in part by a Social Science and Humanities
Research Council of Canada Leave Fellowship to G. R. Norton.
~Department of Psychology, University of Winnipeg, Winnipeg, Manitoba, R3B 2F9 Canada.
2psychological Service Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
165
0004-0002/84/0400-0165503.50/0 © 1984 Plenum Publishing Corporation
166 Norton and aehu

anxiety produces sexual dysfunctions or is the result of the dysfuncfion and

its concomitant disruption in other aspects of a relationship (e.g., Cooper,
1969a; Munjack et al., 1981). Finally, some investigators question whether
anxiety and sexual dysfunction are necessarily associated in the same
person, or if there are individual differences between people in this respect
(e.g., Cooper, 1969b; Derogatis and Meyer, 1979; Kockott et al., 1980a).
Part of the above confusion may be related to the concept of anxiety,
which is a complex construct (Kozak and Miller, 1982). Lang (1968) has
shown that anxiety can be viewed as having separate components (cognitive
or subjective, physiological, and behavioral) that do not necessarily covary.
Responses within each component may be under the control of different
variables (Borkovec, 1976), may be controlled by different brain hemi-
spheres (Tucker, 1981), and may have been acquired through different
learning mechanisms (Wolpe, 1981). Furthermore, anxiety can be viewed as
being highly generalized and pervasive (trait anxiety) or related to specific
situations (state anxiety) (Spielberger et al., 1970).
These different conceptualizations of anxiety have resulted in anxiety
being measured in a variety of ways. These measures are often not highly
correlated (Lang, 1968; Spielberger et al., 1970), producing problems when
comparing studies. This issue will be dealt with later in the paper.
The purpose of this paper is to review selected research relevant to the
role of anxiety in sexual dysfunctic ns. Three types of studies are considered.
First are studies that have compared anxiety reactions of normals with
people who have sexual dysfunctions, and between people with different
dysfunctions. These studies are reviewed to determine (a) if anxiety is
reliably associated with the occurrence of sexual dysfunctions and (b) if
anxiety is part of a sexual dysfunction syndrome, is it associated with a
general neurosis, or is the anxiety specific to the sexual dysfunction.
Second, studies are reviewed in which anxiety reduction procedures.
such as systematic desensitization, have been used in the treatment of sexual
dysfunction. These studies are reviewed to determine (a) if anxiety
reduction is consistently associated with a reduction in the sexual dys-
function or (b) if it affects some components of a person's problems but not
others.
Finally, studies that have experimentally manipulated variables related
to anxiety to determine their effects on sexual behaviors are considered.
These studies may help identify the specific mechanisms through which
anxiety impairs sexual functioning.

ANXIETY REACTIONS

Following Johnson's (1965) retrospective study of males with a

"primary disorder of potency," Cooper (1968a) attempted to clarify the
relationship between neuroses and sexual dysfunctions in males. Johnson
Anxiety in Sexual Dysfunction 167

(1965) reported that 48% of the dysfunctional males he studied had a

"neurotic constitution." Cooper (1968a) interviewed and tested 53 men with
potency disorders (impotence, premature ejaculation, and retarded
ejaculation). His results showed that only 10% of bis sample could be
classified as clinically neurotic. Based on these findings, Cooper suggested
that most potency disorders are likely to be of other than neurotic origin. In
a later study, Cooper (1969a) replicated these findings, showing that only
12% of bis sexually dysfunctional subjects were clinically neurotic. He
found, however, that 51% had a "marked coital anxiety." Cooper (1969a)
defined coital anxiety as "anxiety related temporarily to the act of coitus
(either imagined or actual) or sexual overtures and stimulations (imagined
or actual) short of intercourse, but which the male subject believed at the
time would culminate in a coital attempt" (pp. 143-144). Coital anxiety was
most frequently reported to occur as a result of fear of failure (73% of the
anxious subjects), being seen by the spouse as sexually inferior (43.5%), and
fear of being ridiculed (40%). Furthermore, Cooper believed that coital
anxiety directly caused sexual dysfunctions in only a few cases (14%) but
that dysfunctions and anxiety were more commonly the result of castiga-
tion by an unhappy, sexually frustrated spouse.
Cooper's (1969a) findings are important for two reasons. First, they
suggest that the onset of coital anxiety is often a result of sexual dysfunc-
tion, and the partner's reactions to it, although subsequently this anxiety
might maintain the dysfunction. Second, anxiety and sexual dysfunctions
might be produced by specific events associated with sexual activities rather
than deep-seated, unconscious, neurotic conflicts. If these conclusions are
correct, then they have important implications for the types of treatments
that are most appropriate for removing sexual dysfunctions.
Cooper's (1969a) findings have met with varying degrees of support.
Ansari (1975), on the basis of sexual histories of subjects with erectile dys-
function, classified his subjects into three categories: (a) acute onset,
(b) insidious onset associated with psychological or physical trauma, and (c)
insidious onset without discernible physical or psychological trauma. The
possible relationship between anxiety and sexual dysfunction is particularly
relevant for the first two groups. Of the acute onset patients, 66% reported
that their dysfunction developed as a reaction to discrete sexual experiences,
such as their first attempt at coitus, becoming engaged, following a
vasectomy, or during bereavement. Those with an insidious onset reported
that their dysfunction was associated with factors such as their wives' low
sexual response or "frigidity"; 45% of the patients in this group reported
that they were unhappy in their marriages, compared to only 18°70 in the
acute onset group. These findings provide some support for Cooper's
(1969a) claim that sexual dysfunctions in men are produced by aversive
sexual activities rather than general neurotic factors.
There is also evidence that a person's overall level of anxiety does not
affect the degree of sexual arousal produced by explicit sexual materials.
168 Norton and Jehu

Pawlowski (1979) divided male and female subjects into high, medium, and
mild anxiety groups based on their scores on the Taylor Manifest Anxiety
Scale. All subjects were then shown two films that varied in the explicitness
of sexual content. The results showed that there were no significant
differenced due to sex of the subject or the subject's anxiety levels on self-
rated arousal or psychological reactions to the films.
In an attempt to determine if sexually dysfunctionäl males are more
anxious (and show more general psychopathology) than nondysfunctional
males, Munjack et al. (1978) compared sexually dysfunctional males with
normals on a variety of psychological tests. They found that patients with
retarded ejaculation scored higher than normals on 5 of 8 measures of
anxiety and on both measures of depression, and showed more psycho-
pathology on 6 of 13 MMPI scales. Premature ejaculators scored higher
than normals on 2 o f 8 measures of anxiety, both depression measures, and
6 of 13 M M P I scales. The premature and retarded ejaculators differed
significantly on only one of the 24 measures. Although Munjack et al.
(1978) did not provide evidence for a causal relationship between anxiety (or
general psychopathology) and sexual dysfunctions, their data indicate that
sexually dysfunctional males experience more anxiety and psychopathology
than do normals.
In a more recent study, Munjack et al. (1981) found that the level of
psychopathology varied between different groups o f sexually dysfunctional
males. They compared MMPI scores of (a) sexually dysfunctional males.
patients attending a university hospital outpatient clinic, (b) sexually
dysfunctional patients at a private clinic, (c) psychiatric outpatients un-
screened for sexual disorders, and (d) normals. As expected, the psychiatric
outpatients scored higher than normals on 8 to 10 MMPI scales. Similarly,
sexually dysfunctional males attending the universil y clinic were higher than
normals on 7 of 10 scales, but the dysfunctional males attending the private
clinic were higher on only 4 of 10 MMPI scales. In addition, the dysfunc-
tionals attending the university clinic had higher neuroticism scores than
normals on the Eysenck Personality Inventory, but the private patients did
not. These results show that although men with sexual dysfunctions may
show more psychopathology than normals, other factors must be important
in modulating the relationship between psychopathology, especially
anxiety, and sexual dysfunctio ns.
Kockott et al. (1980a) also reported differences in anxiety and
general psychopathology between males with sexual dysfunctions. They
compared men whose erectile dysfunctions were considered to be psycho-
genic, men whose erectile dysfunctions were related to diabetes, and
normals. They did not find any differences between groups on measures of
neuroticism or social anxiety, but there were significant differences on
measures of depression and sexual anxiety. All patient groups, except those
who had recently developed premature ejaculation, were more depressed
Anxiety in Sexual Dysfunction 169

than normals. On the measure of sexual anxiety, the diabetics, although

significantly more anxious than the normals, were significantly less anxious
than the psychogenic patients.
The results of the studies by Munjack et al. (1981) and Kockott et al.
(1980a) demonstrate that men with sexual dysfunctions are more sexually
anxious than normals but that there are also differences between particular
groups of sexually dysfunctional men in sexual anxiety and general psycho-
pathology. Patients attending a private clinic showed less psychopathology
than did patients attending a university hospital clinic, and men whose
erectile dysfunctions were related to diabetes were less sexually anxious
than those whose dysfunctions were psychogenic in origin.
One possible difference between the patients attending the university
hospital and those attending the private clinic is their education and/or
socioeconomic level. Maurice and Guze (1970) determined the presence of
psychopathology of 20 couples attending Masters and Johnson's private
clinic and found that "the majority of patients were without any definable
psychiatric disorder other than the sexual dysfunctions" (p. 541). Most of
these people were highly educated and in the middle or higher
socioeconomic classes. In addition, Hoon et al. (1976) have reported signifi-
cant positive correlations between women's educational levels and their
sexual arousability.
Another variable that might modulate the relationship between
anxiety and sexual dysfunction is sexual sophistication. Cooper (1969a), for
example, found that most of his patients with dysfunctions were sexually
naive: few had had premarital sexual experiences, and several reported
erroneous concern with sexually related diseases. Derogatis and Meyer
(1979) also found that dysfunctional males and females were less informed
about sexuality and reported engaging in fewer types of heterosexual
activities. Dysfunctional males also reported having fewer distinct types of
sexual fantasies. This, however, was not true of females. In conclusion,
Derogatis and Meyer's (1979) statement that "clinicians no longer view
sexual dysfunctions as necessarily signaling deep-rooted conflicts ... but
rather recognize that sexual disorders reflect an etiological spectrum,
ranging from simple negative conditioning problems to profound character-
ological disturbances" (p. 202) best summarizes the research findings
relating anxiety and psychopathology to sexual dysfunctions.
The results of studies that have evaluated anxiety and
psychopathology of people with sexual dysfunctions have produced
inconsistent findings. Some studies have shown that people with sexual dys-
functions have more anxiety and psychopathology (Maurice and Guze,
1970). Several researchers have suggested that when anxiety and other
psychopathology is related to sexual dysfunction, "at least part of the
psychiatric disturbance reported [is] the result of sexuaI difficulties and con-
170 Norton and Jehu

comitant marital discord, and not the cause" (Munjack et al., 1981, pp. !29-
130).
Unfortunately, most of the research on personality characteristics of
people with sexual dysfunctions has focused on males. Since there is a
paucity of studies with women, our knowledge of the personality
characteristics of women with sexual dysfunctions is even less clear than for
men.

ANXIETY REDUCTION

Cooper (1968b, 1969b) reported two studies where he used relaxation

training as part of a therapeutic program for men with a variety of sexual
dysfunctions. In both studies, he found that fewer than 40% of his clients
were cured or improved following treatment. These results led Cooper
(1968b) to suggest that constitutional factors, not anxiety, might be
responsible for the poor treatment success. An alternative possibility is that
general relaxation training could be less effective than exposure to anxiety-
evoking situations while remaining calm and relaxed, as in systematic de-
sensitization. Although the specific mechanisms by which systematic
desensitization reduces anxiety is a matter of debate, the evidence indicates
that it is an effective procedure for reducing situationally specific anxieties
(Kazdin and Wilcoxin, 1976; McGlynn et al., 1981).
A large number of case studies and group treatment programs which
did not use control groups have claimed that systematic desensitization is
useful for treating some sexual dysfunctions, such as erectile dysfunction
and premature ejaculation (e,g., Bass, 1974; Ince, 1973; Friedman and
Lipsedge, 1971; Jones et al., 1972) and orgasmic dysfunction (e.g., Madsen
and Ullmann, 1967).
Several controlled studies are consistent with these clinical claims
(e.g., Obler, 1973; Auerbach and Kilmann, 1977; Sotile and Kilmann,
1978). In one of the first controlled outcome studies, Obler (1973)
compared the effectiveness of systematic desensitization to psychodynamic
group therapy and a nontreated control group. His results demonstrated
that systematic desensitization produced better sexual functioning and was
more effective in reducing sexual anxiety than was group therapy. These
results remained stable over a 1 V2-year follow-up. Unfortunately, Obler's
clients who received systematic desensitization also received assertiveness
and confidence training, which confounds the effects of systematic
desensitization, although the additional procedures were also aimed at
anxiety reduction.
More recently, W i n c z e and Caird (1976) compared standard
systematic desensitization using a videotaped presentation of anxiety
Anxiety in Sexual Dysfunction 171

hierarchy items with a no-treatment control condition. The subjects in this

study were all women with an "essential" sexual dysfunction ("frigidity")«
75°70 of whom were inorgasmic. Frigidity was defined as excessive anxiety
associated with most or all aspects of sexual behavior and an inability to
derive pleasure from erotic activities. The results showed that the subjects
who received videotaped desensitization improved more on measures of
sexual anxiety than did the subjects who received regular systematic
desensitization or the control subjects. On all other measures of anxiety, the
two treatment groups showed comparable improvement and were signifi-
cantly superior to the nontreated controls. In addition, all but one of the
subjects treated with video desensitization rated themselves as much or very
much improved, whereas only six of ten systematic desensitization subjects
indicated these levels of improvement. The effects of video desensitizati0n
were restricted to reducing anxiety related to sexual activities; however,
there was no major improvement in the frequency of achieving orgasm.
In a more elaborate study directed toward determining the effects of
systematic desensitization for nonorgasmic women, Sotile and Kilmann
(1978) found that group systematic desensitization produced reductions in
several measures of coital anxiety, improved pleasure during intercourse,
improved satisfaction with overall sexual functioning, and increased
extracoital stimulation. Although there was no difference in general
adjustment between primary and secondary orgasmic subjects, all of the
significant effects favored subjects with secondary orgasmic dysfunctions.
Anderson (1981) has also demonstrated that group systematic
desensitization is effective for reducing coital anxiety for inorgasmic
women.
Not all outcome studies have demonstrated the effectiveness of
systematic desensitization, however. In an especially well-controlled study,
Kockott et al. (1975) compared systematic desensitization, routine medical
treatment, and a no-treatment condition for men with erectile dysfunctions.
The results showed that the only measure demonstrating greater treatment
efficacy for systematic desensitization was a measure of anxiety taken while
the clients were imagining themselves in various sexual situations.
In conclusion, several studies, but not all, have demonstrated that sys-
tematic desensitization is an effective treatment procedure for some
components of sexual dysfunctions. Wincze and Caird (1976), Sotile and
Kilmann (1978), Anderson (1981), and Everaerd and Dekker (1982) have all
shown that systematic desensitization can reduce anxiety related to sexual
activities and improve sexual functioning. This concomitant variation of
anxiety and functioning is further support for their association, although
again the causal nature of this relationship remains an open question.
Systematic desensitization does not seem to improve female orgasmic
capacity. It may be that orgasmic dysfunction involves etiologica! factors
172 Norton and Jehu

other than anxiety, which call for different treatment procedures (Kaplan,
1974). Similarly, systematic desensitization may improve different aspects
of sexual functioning than do other procedures. Everaerd and Dekker
(1982) compared systematic desensitization with a program that included
sensate focus and sexual stimulation exercises. The results showed that
although both treatments improved sexual functioning, only systematic
desensitization reduced coital anxiety. Combining the treatment procedures
did not improve on the individual procedures, however.

INDUCED ANXIETY

Although it is commonly assumed that anxiety impairs sexual arousal,

several recent studies have indicated that heightened anxiety may increase
rather than diminish sexual arousal. Dutton and Aron (1974) demonstrated
that increased anxiety produced when subjects crossed a suspension bridge
or were told they were to receive an electrical shock increased subjects'
sexual imagery to TAT cards and attraction to female research
confederates. The investigators speculated that these seemingly paradoxical
effects might be due to the subjects misattributing their anxiety as sexual
attraction.
In an attempt to clarify the relationship between anxiety and sexual
arousal, Hoon et al. (1977) showed normal women neutral or anxiety-
evoking films, either before or after they viewed sexually arousing films.
They found that subjects who viewed a sexually arousing film experienced
more sexual arousal if they had previously seen an anxiety-evoking film
rather than a neutral film. If, however, the sexually arousing film was
viewed prior to the anxiety-evoking or neutral film, there was a more rapid
reduction in sexual arousal produced following the anxiety-evoking film.
This indicated that the effects of anxiety evocation on sexual arousal
depended, to a certain extent, on the temporal relationship between the
evocation of anxiety and sexual arousal. If anxiety was evoked before
sexual arousal, it was followed by an enhanced level of sexual arousal, but if
sexual arousal was evoked first, it appeared to be disrupted by the sub-
sequent anxiety.
The effect of anxiety-evoking films on subsequent sexual arousal to
erotic films has also been demonstrated with male subjects. Wolchik et al.
(1980) showed male subjects films that had previously been demonstrated to
evoke anxiety, depression, or neutral feelings prior to showing them erotic
films. Their results showed that exposure to a depressing film reduced sub-
sequent sexual arousal and that exposure to an anxiety-evoking film
increased sexual arousal compared to prior exposure to a neutral film.
Anxiety in Sexuai Dysfunction 173

P r i m a f a c i e , the results of the Hoon et al. (1977) and Wolchik et al.

(1980) studies seem contrary to Wolpe's (1958) suggestion that anxiety and
sexual arousal are mutually inhibitory and that anxiety disrupts sexual
arousal. These studies, in fact, indicate that under some conditions prior
anxiety may act to enhance sexual arousal. Wolpe (1978), however, has
stated that the Hoon ef al. (1977), and therefore the Wolchik et al. (1980),
study was not adequate to determine if anxiety and sexual arousal are
mutually inhibitory because, according to Wolpe's (1958) theory, for two
events to be mutually inhibitory, they must occur simultaneously. In the
Hoon et al. 1977) and Wolchik et al. (1980) studies, sexual arousal and
anxiety evoked by films was sequential rather than simultaneous.
Regardless of this criticism, Hoon et al. (1977) and Wolchik et al. (1980)
have demonstrated that anxiety can modulate sexual arousal. It is not yet
clear how this occurs. One possibility is that persisting anxiety in some way
enhances sexual arousal, perhaps by misattribution, as mentioned above.
There are alternative explanations, however; for instance, anxiety relief
(Wolpe, 1958) by the erotic film might facilitate sexual arousal.
Several studies have attempted to identify more precisely the character-
istics of stimuli that inhibit sexual arousal. Cooper (1969a), Kaplan (1974),
and Masters and Johnson (1970), among others, have speculated that coital
anxiety may be related to factors such as performance demands, failure
expectancies, and distracting cognitions produced by spectatoring. Wilson
and his colleagues (Briddell and Wilson, 1976; Wilson and Lawson, 1976,
1978) attempted to manipulate arousal expectancies by instructing subjects
that alcohol would either increase or decrease sexual arousal evoked while
watching erotic films. Only some of the subjects consumed alcohol,
permitting the researchers to evaluate expectancy effects independent of
alcohol consumption. Their results produced inconsistent findings: only
Wilson and Lawson (1976) found that subjects who were given arousal
expectancy instructions showed physiologically measured changes in
arousal. Sexual arousal, in this case was enhanced by positive expectancies.
A second study be the same investigators (Wilson and Lawson, 1978) did
show, however, that subjective measures of arousal were influenced by
expectancy instructions.
Farkas et al. (1979) evaluated the effects of several demand variables
in an attempt to identify which factors affected sexual arousal to erotic
films. They varied performance demand by instructing subjects that the
films were found to be highly erotic or not very erotic by other subjects.
Distraction was varied by having some subjects count the frequency of two
types of tones. Finally, subjects were asked to self-monitor moment-to-
moment arousal by moving a lever according to changes in their subjective
arousal. Distraction was the only significant factor influencing tumescence.
174 Norton and Jehu

There were no significant effects on subjective measures of arousai from

any of the demand variables manipulated in the study. Geer and Fuhr
(1976) have also shown that distraction is an effective inhibitor of arousal
evoked by erotic folms. They had subjects attend to different levels of
distracting stimuli presented via dichotic listening tasks. The results showed
that the more distracting the task, the lower the level of sexual arousal.
Wincze e t al. (1980) have suggested that self-monitoring of arousal
may affect arousal in a manner similar to Masters and Johnson's concept of
spectatoring. Wincze e t al. (1980) compared male and female subjects'
physiological measures of arousal during erotic films. The subjects also self-
monitored sexual arousal by moving a lever indicating their moment-to-
m o m e n t levels of arousal. These subjects' levels of arousal were compared
to other subjects who did not engage in the self-monitoring task. The
investigators found no differences between females who monitored their
arousal and those who did not, but males who monitored their arousal
showed significantly lower levels of tumescence than did those who were not
required to monitor.
Subsequent to the above study, Lange e t al. (t981) performed a
carefully controlled evaluation of several different factors that could affect
sexual arousal. Sexual arousal to erotic films was monitored for 24 normal
males under several conditions. Subjects viewed films after being injected
with epinephrine hydrochloride to artificially induce sympathetic nervous
system activity or saline solution as placebo, under high or low performance
demand condition (i.e., obtain an erection as quickly as possible and as
long as possible vs. do not focus on your erection, but just enjoy the film),
and with subjective monitoring or no monitoring with the response lever.
Their results showed that epinephrine hydrochloride increased subjects'
ratings of anxiety and decreased penile tumescence levels in the postfilm
period. Instructions to achieve an erection or to just enjoy Lhe film did not
produce differem levels of tumescence, nor did self-monitoring arousal
levels.
The result o f the studies that manipulated variables suspected to be
related to coital anxiety have provided two interesting findings. First. it
appears that under some circumstances, induced (and presumably
generalized) anxiety can either inhibit or enhance sexual arousal. Dutton
and Aron (1974), H o o n e t al. (1977), and Wolchick el al. (1980) have
demonstrated that sexual arousal to appropriate stimuli can be enhanced if
the person is made anxlous prior to being exposed to the sexual stimuli.
Dutton and Aron (1974) and others have argued that enhanced sexual
arousal may be due to the subjects' misattribution of their arousal. That is,
subjects exposed to sexual and anxiety-evoking stimuli may perceive the
arousal produced by the anxiety-evoking stimuli as sexual. Alternative
Anxiety in Sexual Dysfunction 175

explanations, such as anxiety relief effects, have not yet been excluded,
however.
Similar anxiety-evoking stimuli have also been shown to reduce sexual
arousal. Hoon et al. (1977) showed that sexual arousal was more rapidly
reduced if an anxiety-evoking film, rather than a neutral film, was shown
after an erotic film. Two other conditions shown to reduce sexual arousal
were (a) exposure to a film that evoked depressive feelings prior to being
shown an erotic film (Wolchik et a/., 1980) and (b) injections of epinephirne
hydrochloride (Lange et al., 1981), a chemical that increases sympathetic
nervous system activity.
The second interesting finding produced by these studies is that some
activities that distract attention away from erotic cues can rëduce sexual
arousal. This was demonstrated by Geer and Fuhr (1976) using a dichotic
listening task, by Farkas et al. (1979) by having subjects count tones, and by
Wincze et al. (1980) for male subjects who self-monitored arousal by
continuously moving a lever.
Performance demands, in the form of instructions (a) to rapidly
achieve an erection (Lange et al., 1981), (b) that a film should produce high
levels of arousal (Farkas et al., 1979), or (c) that consuming a drink that
supposedly contained alcohol (but did not) would reduce arousal (Briddell
and Wilson, 1976), were ineffective in reducing sexual arousal to erotic
films, however.
Unfortunately, the research that has thus far evaluated the effects of
manipulated anxiety on sexual arousal has used people who show normal
sexual arousal patterns. If the enhanced sexual arousal produced by
anxiety-evoking stimili (e.g., Dutton and Aron, 1974) is due to misattribut-
ing anxiety as sexual arousal, it is possible that people with sexual
dysfunctions might make very different attributions. It may be, for
example, that a person with a sexual dysfunction, and who also experiences
coital anxiety, might perceive sexual arousal as anxiety. These feelings could
then produce additional anxiety and sexual avoidance. Future research
should determine if normals and dysfunctionals respond similarly to
pairings of anxiety-evoking and erotic cues.

DISCUSSION

The studies reviewed suggest several tentative conclusions and raise a

number of important questions.
A first conclusion is that people with sexual dysfunctions often show
high levels of anxiety. The majority of studies comparing personality
characteristics of normals and people with sexual dysfunctions showed that
176 Norton and Jehu

dysfunctionals have higher levels of anxiety and psychopathology than

normals (e.g., Munjack, et al., 1978; Kockott et al., 1980b). In addition, most
studies that have used anxiety reduction procedures to treat sexual
dysfunctions have reported that, following treatment, subjects were less
sexually anxious and showed improvement in other areas of sexual func-
tioning (e.g., Obler, 1973; Sotile and Kilmann, 1978). Finally, several of the
studies that manipulated variables suspected of being relevant to coital
anxiety found that some variables such as distraction and chemically
induced sympathetic nervous system activity can reduce sexual arousal.
A second conclusion is that there is variabitity in the amount of
anxiety experienced by people with sexual dysfunctions. The amount of
anxiety a person experiences seems to be modulated, at least in part, by non-
sexual variables. Kockott et al. (1980a), for example, showed that anxiety
levels were lower for people with a sexual dysfuncfion resulting from an
organic cause than for those resulting from psychogenic factors. Similarly,
Munjack et al. (1981) and Derogatis and Meyer (1979), among others, have
suggested that a person's knowledge of sexual functioning or his
socioeconomic levels can affect anxiety levels occurring with sexua]
dysfunctions.
A final, tentative conclusion is that anxiety-evoking stimuli do not
necessarily disrupt sexual functioning. In fact, several studies (e.g., Hoon et
al., 1977; Wolchik et al., 1980) have demonstrated that under certain con-
ditions, anxiety-evoking stimuli may enhance sexual arousal of normal men
and women. This suggests the possibility that anxiety, by itself, may be
insufficient to produce sexual dysfunctions.
These conclusions taust be viewed tentatively, however, because of
methodological problems with some of the reviewed studies. The problems
are of three main types: (1) inadequate operationalization of anxiety, (2)
inadequate specification of subject characteristics, and (3) inadequate
outcome measures. These issues will be discussed in general and without
attempting to evaluate each study.

Operationalization of Anxiety

The studies that have evaluated personality characteristics of peop!e

with sexual dysfunctions and those describing treatments for sexual anxiety
have used a wide variety of self-report and clinical ratings of anxiety. Most
studies have relied almost exclusively on self-report measures, with only a
few providing psychophysiological, independent rater, or other additional
measures of anxiety. Although many of the recent studies (e.g., Kockott et
al., 1980a, 1980b; Wincze et al., 1978) have used standardized self-report
measures of anxiety and have measured several dimensions of anxiety, this
Anxiety in Sexual Dysfunction 177

was less true of earlier studies. The Wincze et al. (1978) study is an examplar
for future research. They used 14 separate measures, including a clinical
interview, standardized self-reports, behavioral records, and physiological
measures in their study of women experiencing low sexual arousal.
The use, by different experimenters, of nonstandardized tests and the
use of a wide variety of tests may be partially responsible for the differences
in conclusions about the roles of anxiety in sexual dysfunctions. Different
measures of anxiety, even those that have been validated, appear to measure
different dimensions of anxiety (Spielberger et al., 1970). It would be
desirable if future studies used, at least in part, similar tests for evaluating
anxiety in people with sexual dysfunctions. The MMPI is recommended as a
measure of general psychopathology and generalized anxiety, and the
Derogatis Sexual Functioning Inventory (DSFI; Derogatis and Meyer, 1979)
or the Sexual Arousal Inventory (SAI; Hoon et al., 1976) for measuring
coital anxiety. Furthermore, several studies have suggested that psycho-
physiological measures may be ideally suited for the study of sexual dys-
functions (Hatch, 1981; Kockott et al., 1980b). These procedures should be
used more frequently.

Subject Characteristics

Recent reviews of treatments for various sexual dysfunctions (e.g.,

Kilmann and Auerback, 1979; Munjack and Kanno, 1979; Sotile and
Kilmann, 1977) have consistently stated that the treatment literature has
failed to provide an adequate description of the demographic and personal
characteristics of their subjects. This type of information is crucial to the
understanding of the relationship between anxiety and sexual dysfunctions.
Some research (e.g., Levine and Yost, 1976) has shown that the frequency
of specific sexual dysfunctions may vary with social class. There is also
some indirect evidence that social class may be related to the amount of
anxiety associated with sexual dysfunctions (Hoon et al., 1976; Maurice and
Guze, 1970).
Second, information as to why subjects are participating in the
research could be very important. Farkas et al., (1978), for example, found
that volunteers and nonvolunteers can differ on several important
dimensions of sexual functioning. Normals can also have very different
psychological profiles than dysfunctionals (Derogatis and Meyer, 1979).
These considerations become especially important because several recent
studies evaluating the effects of anxiety on sexual arousal have used normal
volunteers as subjects (e.g., Hoon et al., 1977; Wolchik et al., 1980). The
information from these subjects may not be applicable to people with sexual
dysfunctions. Analogue research in other areas has shown that data
178 Norton and Jehu

obtained from normal volunteers may not be relevant to subjects with

clinical disorders (e.g., Craighead and Craighead, 1981). Furthermore,
clients with similar disorders, but who vary on other dimensions such as
socioeconomic status, may not respond equally to the same treatment
procedures (Munjack et al., 1981):

Inadequate O u t c o m e Measures

Much of the research that has attempted to treat sexual dysfunctions

by reducing anxiety is difficult to evaluate because of a restricted range of
outcome measures. Kilmann and Auerbach (1979), in their review of the
treatment literature for premature ejaculation and psychogenic impotence,
reported that, although there has been a "notable increase in the
methodological sophistication in the last 5 years relative to the early
literature. It is to be hoped that the public's continuing interest in obtaining
sexual treatment will lead to larger samples being used in investigations and
improved data gathering procedures" (p. 97). This concern for improved
specification of outcome measures has been echoed by Munjack and Kanno
(1979) and Sotile and Kilmann (1977).
The treatment studies reviewed in this paper have generally shown
adequate methodological controls (i.e., random subject assignment, control
groups, etc.) In fact, Kilmann and Auerback (1979) maintain that
"systematic desensitization procedures have the best controlled support in
the literature" (p. 95). They have, however, relied excessively on subjective
reports and have frequently only evaluated a limited range of variables that
might be affected by treatment. Two studies (Sotile and Kilmann, 1978;
Wincze et al., 1978) that measured a large number of variables showed t hat
some, but not all, measures changed as a function of exposure to the treat-
ment conditions. Sotile and Kilmann (1978), for example, found that
women with primary and secondary orgasmic dysfunctions improved on
several subjective measures of general and specific sexual adjustment. There
were, however, several significant differences between subjects with
secondary and primary inorgasmia. These might not have been detected if
fewer outcome measures had been used. Wincze et al. (1978), using both
subjective and objective measures, found that women with low sexual
arousal reported significant improvement on several subjective measures
but did not show clinically significant improvement on any of the objective
measures. This suggests that subjective measures might present a biased
outcome. The Wincze et al. (1978) study indicates that several different
measures can be conveniently used in sexual dysfunction treatment studies
and that the different measures can provide a different plcture of treatment
outcome.
Anxiety in Sexual Dysfunction 179

Future Directions

The studies evaluating the role of anxiety in sexual dysfunctions raise

several important questions concerning anxiety and sexual functioning.
First, is coital anxiety the same for different people? Ansari (1975) found
that some people become dysfunctional after a traumatic anxiety-evoking
event, whereas the process is more insidious for others. It is possible that the
feelings of anxiety experienced by these two groups of people are very
different. Wolpe (1981) has recently described two processes for the
development of anxiety. The first involves autonomic nervous system
arousal conditioning and the second cognitive learning experiences. These
different processes may lead to different patterns of expressing anxiety
(Davidson and Schwartz, 1976) that may not be responsive to the same
types of anxiety reduction therapies (Norton et al., 1983). ~If sexually
dysfunctional peopie do experience different types of anxiety, this should be
determined by careful assessment, and different treatment procedures may
be necessary to reduce different patterns of anxiety.
A second question is whether anxiety reduction plays an equally
prominent role in all treatment programs for sexual dysfunctions.
C0nsidering the variability in effectiveness of systematic desensitization for
sexual dysfunctions (e.g., Wincze and Caird, 1976; Kockott et al., 1975)
and that different causal factors (Kockott et al., 1980b) produce different
levels of coital anxiety, it is possible that anxiety reduction is more
important in treating some people than others.
Textbooks (e.g., Jehu, 1979; Kaplan, 1974) recommend that treatment
programs for sexual dysfunctions should include different procedures for
different aspects of a dysfunction. This is consistent with contemporary
approaches (e.g., Barlow, 1977; Wincze, 1980) for treating sexual
deviancies and modifying sexual preferences. Barlow (1977), for example,
has suggested that changing a homosexual to a heterosexual preference may
involve several different components that taust be addressed using different
procedures. Furthermore, the sequence of addressing each component can
differ for different people, a suggestion consistent with recent strategies for
treating sexual dysfunctions. Kaplan and Novick (1982), for example, sug-
gest that profoundly phobic and anxious women might benefit from antide-
pressant medications to reduce panic feelings prior to attempting other types
of treatment. It is of both theoretical and clinical importance to determine if
sexual dysfunctions can be subdivided into different components and which
treatment procedures are most effective with each component problem.
Several studies have found, for example, that systematic desensitization
reduces women's coital anxiety, increases their sexual pleasure, and
enhances other aspects of their sexual relationship, but fails to significantly
increase orgasmic frequency (e.g., Wincze and Caird, 1976; Anderson,
180 Norton and Jehu

1981). It may be, as Kaplan (1974) suggests, that coital an×iety and
orgasmic dysfunctions are different problems and may require different
treatments.
Finally, there isthe question as to what types of specific cognitive and
physiological events inhibit sexual arousal. The research showing that some,
but not other, cognitive, performance, and physiological activities inhibit
arousal indicates that the term anxiety is too broad for identifying events
that inhibit sexual arousal and functioning.
Research similar to that conducted by Hoon et al. (1977), Wolchik et
al. (1980), Farkas et al. (1979), and others should be done with people who
have sexual dysfunctions. It may be that normals and dysfunctionals
respond differently to different types of distractions, performance
demands, and sympathetic nervous system arousal factors. It is possible
that, because of their different learning histories, dysfunctionats will make
different attributions to these stimuli and show different patterns of se×ual
arousal.
In conclusion, although several recent studies have helped clarify the
relationship between anxiety and sexual dysfunctions, our ignorance still
exceeds our knowledge. Much basic and clinical research is needed before
we fully understand how anxiety affects sexual arousal and performance,
and how we can more effectively treat sexual dysfunctions.

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