896

ORIGINAL RESEARCH—PSYCHOLOGY

More than Sexual Function: Predictors of Sexual Satisfaction in a

Sample of Women Age 40–70 jsm_1557 896..904

Carolyn Marie Dundon, BA, and Alessandra H. Rellini, PhD

Department of Psychology, The University of Vermont, Burlington, VT, USA

DOI: 10.1111/j.1743-6109.2009.01557.x

ABSTRACT

Introduction. The literature provides a complex picture of sexual satisfaction and its predictors. To date, studies have
provided a list of predictors of sexual satisfaction, including relational and psychological factors, but very little
information is available on the direct effects of these predictors in midlife women, independently from the effects of
sexual function on sexual satisfaction.
Aim. The main aim of this article is to provide empirical evidence on factors that predict sexual satisfaction in
middle-aged women above and beyond the explanation provided by sexual function.
Main Outcome Measures. The three items on sexual satisfaction from the Female Sexual Functioning Index were
used to assess different aspects of sexual satisfaction.
Methods. A sample of 86 women age 40–70 years recruited from a clinic completed a battery of questionnaires on
sexual satisfaction and potential predictors, including, psychological well-being, body attitudes, menopausal symp-
toms, and relationship adjustment.
Results. Relationship adjustment, psychological well-being, and menopausal symptoms predicted sexual satisfaction
above and beyond sexual functioning. Body attitudes did not predict sexual satisfaction in midlife women.
Conclusions. Data supported the hypothesis that sexual satisfaction is only partially explained by sexual function.
Other factors involved in women’s lives, such as psychological well-being, relationship adjustment, and, to a lesser
extent, menopausal symptoms, affect sexual satisfaction independently from sexual function. Dundon CM, and
Rellini AH. More than sexual function: Predictors of sexual satisfaction in a sample of women age 40–70.
J Sex Med 2010;7:896–904.
Key Words. Sexual Satisfaction; Aging; Women; Midlife; Sexual Function; Menopause

Introduction operationalization of overall sexual satisfaction is

often inconsistent across studies, resulting in the

A lthough large population-based studies

suggest that between 17% and 25% of
women experience sexual dissatisfaction [1–4], the
definition and conceptualization of female sexual
satisfaction remain elusive. Researchers have alter-
natively conceptualized overall sexual satisfaction
as an interpersonal model of rewards and costs [5],
as a psychological construct appraising content-
ment with one’s overall sexual life [6], and as a
broad overall construct which includes the
entwined emotional/physical and relational
aspects of sexual satisfaction [7]. Consequently, the
difficulty of generalizing research findings.
At the Consensus Conference on female sexual
function disorders, held in 1999 by the Sexual
Function Health Council of the American Founda-
tion for Urologic Disease, it was proposed that a
sexual satisfaction disorder be added as a new diag-
nostic category for sexual dysfunction in the Diag-
nostic and Statistical Manual of Mental Disorders,
Fourth Edition [8]. Instigating this proposal were
clinical reports that a significant number of women
seeking help for sexual dysfunction are unable
to achieve subjective sexual satisfaction despite

J Sex Med 2010;7:896–904 © 2009 International Society for Sexual Medicine

Midlife Women Sexual Satisfaction
sufficient desire, arousal, and orgasm. However,
since a lack of epidemiological evidence or criteria
for diagnosis existed to support this diagnostic cat-
egory, the proposal was not adopted. Nonetheless,
the conference highlighted the importance of
investigating and determining the predictors of
women’s sexual satisfaction to provide data for
future reconsideration of this proposal. In
response, many researchers have investigated the
predictors of female sexual satisfaction; however,
very few have focused exclusively on women during
midlife, a time when many women experience
changes in their sexuality due to aging and meno-
pausal factors. To provide a better understanding of
the factors that influence sexual satisfaction in this
cohort of women, we investigated numerous psy-
chological, menopausal, relational, and body image
predictors of satisfaction in a sample of midlife
women while controlling for desire, arousal, and
orgasm functioning.
The variety of potential predictors for sexual
satisfaction highlights the complexity of concep-
tualizing female sexual satisfaction. Early research
established that overall sexual satisfaction is
strongly and positively predicted by coital satis-
faction and by frequency of orgasm and inter-
course [9–11]. In addition, many studies have
demonstrated the relationship between overall
sexual satisfaction and emotional, relational, and
communication factors [9,12–18]. Emphasizing
the importance of relationship factors, Barrientos
and Paez [12] found that being in love distin-
guishes between female sexual satisfaction and
dissatisfaction, and that women who believe in the
endurance of their relationship are more satisfied.
Moreover, research demonstrates that sexual sat-
isfaction and relationship satisfaction vary
together; as relationship satisfaction diminishes,
so does sexual satisfaction and vice versa,
although causality has not been established
[19,20].
At all ages, women’s satisfaction with their sexu-
ality is a complex and multifaceted phenomenon;
however, during midlife, women’s sexual satisfac-
tion is complicated by the effects of aging and
menopause, including a decrease in desire, arousal,
and orgasm functioning, and partnership dynamics
such as length of partnership and sexual function-
ing of partner [21–25]. These factors may all
directly or indirectly affect sexual satisfaction and,
indeed, research points to a decline in female
sexual satisfaction during midlife [9,26,27], specifi-
cally finding low sexual desire in midlife women
associated with a decline in sexual activity, less
897
satisfaction with sex life, and less satisfaction with
partner relationship [28,29].
In addition to sexual function and intimate part-
nership variables, other complications during
midlife that may directly or indirectly affect the
sexual satisfaction of women include psychological
well-being, menopausal-related vasomotor and
somatic symptoms, and changing body image.
Studies have shown that the menopause transition
is marked by an increased likelihood of depression
and anxiety [27–33], both of which are associated
with a decrease in sexual functioning and less sexual
satisfaction and pleasure [21,34–37]. Research also
finds that vasomotor and somatic symptoms related
to hormonal fluctuations at menopause have been
strongly associated with decreased sexual function-
ing [38,39] and reduced sexual satisfaction [21].
Lastly, although the relationship between body
image and sexual satisfaction during midlife is
unclear, studies find that older women consider
themselves less attractive than when they were
younger [40–42] and experience greater body
shame [43]. Since body shame has been shown to
negatively affect sexual pleasure and to promote
avoidance of sexual activities [44], it is conceivable
that body image concerns may negatively affect
women’s sexual satisfaction during midlife.
Recent literature suggests that especially among
middle-aged women, self-reported sexual prob-
lems (i.e., low sexual desire, sexual pain, difficulty in
becoming aroused, or difficulty in reaching an
orgasm) do not necessarily coincide with reports of
dissatisfaction with one’s sexual life [35,45], thus
indicating that there is more to sexual satisfaction
than normal sexual functioning. Taken in conjunc-
tion with research showing that women during
midlife experience less satisfaction with their sexual
lives and partner relationships compared with
younger women [22] and that their dissatisfaction
increases with age [12,22,24–27], these findings
indicate that for midlife women, sexual satisfaction
is a complex phenomenon potentially affected by an
array of psychological and biological factors.
This study followed the prevailing research
trend to distinguish between overall satisfaction
with one’s sexual life (i.e., subjective overall con-
tentment) and satisfaction from sexual activity (i.e.,
sexual enjoyment) [7,11,14,26,46], specifically uti-
lizing Philippsohn and Hartmann’s [7] proposed
model of sexual satisfaction. Their model distin-
guishes between satisfaction from sexual activity
(described as a two-dimensional construct includ-
ing sexual enjoyment and relational factors) and
overall satisfaction with sexual life. In this current
J Sex Med 2010;7:896–904
898 Dundon and Rellini

study, we investigated how factors involved with Measures

psychological well-being (e.g., depression and Demographics
anxiety), body satisfaction, menopausal symptoms Participants completed several items regarding
(somatic and vasomotor), and relationship adjust- their age, marital status and history, ethnicity,
ment affect the satisfaction of middle-aged women family structure, living arrangements, sexual ori-
with (i) their emotional closeness with their partner entation, education history, and income.
during sexual activity; (ii) their satisfaction with
their sexual relationship; and (iii) their satisfaction Brief Symptoms Inventory [47]
with their overall sexual life. We expected all these This scale was utilized to assess clinically relevant
factors to weight on the three aspects of female psychological symptoms in nine dimensions: (i)
sexual satisfaction even after controlling for levels somatization; (ii) obsessive-compulsive; (iii) inter-
of sexual desire, sexual arousal, sexual pain, and the personal sensitivity; (iv) depression; (v) anxiety; (vi)
ability to become lubricated and to reach an hostility; (vii) phobic anxiety; (viii) paranoid ide-
orgasm. ation; and (ix) psychoticism. The Brief Symptoms
Inventory (BSI) has shown adequate internal con-
Methods sistency (Cronbach’s a = 0.68 to 0.91) and excel-
lent test–retest reliability after a 2-week interval.
Participants Previous studies found good consistency between
We recruited 93 women between the ages of 40 the scale and scores on The Minnesota Multi-
and 70 years in a sexually active relationship from phasic Personality Inventory, supporting the valid-
a menopause clinic in a middle-size town. A ity of this instrument [47].
sample size of 88 was expected to be able to detect
a medium difference with a power of 0.9 (assuming Body Attitudes Questionnaire (BAQ) [48]
one tail and P = 0.05). The data analysis is This 44-item scale was utilized to assess a broad
computed on the 86 women who returned the range of attitudes women hold about their bodies.
completed questionnaires. Table 1 illustrates all Items address feeling fat (e.g., I feel so fat I ought to
demographics information for this sample. diet, I am worried that people see rolls of fat around
my waist and stomach), disparagement (e.g., People
Table 1 Demographics characteristics for all participants avoid me because how I look, My life has been
in the study ruined by the way I look), strength (e.g., I quickly
get exhausted, I am proud of my physical strength),
Variables N %
salience (e.g., I hardly think of the shape of my
Yearly household income body, There are more important things in life than
<$50,000 14 17.1
$50,001–$100,000 41 47.7 the shape of my body), attractiveness (e.g., I usually
>$100,001 27 31.4 feel physically attractive; People hardly ever find
Ethnicity me sexually attractive), and lower body fat (e.g., I
Caucasian 75 87.2
African American 1 1.2 think my buttocks are too large; I feel that I have fat
Hispanic 7 8.1 thighs). Each item is scored on a 5-point Likert
Other 3 3.5 scale, with higher scores indicating greater negative
Marital history
Previously divorced 38 44.2 attitudes toward one’s body. This scale includes
Currently married 80 93.0 attitudes that may be particularly relevant for
women in their midlife, such as strength, attractive-
M SD
ness, and salience. The scale has previously shown
N adults in the house 2.1 0.58 adequate internal validity (Cronbach’s a ª 0.87),
N children 1.7 1.16
N children at home 0.5 0.88 and good test–retest reliability after a period of 4
Kinsey Scale 0.2 0.77 weeks (subscale correlation range, r = 0.64–0.91),
Partner’s age 51.3 3.98 plus evidence for convergent validity of the scale
Age 52.0 6.05
Relationship length (years) 20.7 12.01 was established with body mass index scores and
FSFI discriminate validity was established with women
Desire 3.02 1.34 with and without anorexia nervosa [48].
Arousal 3.58 1.69
Lubrication 3.96 1.88
Pain 4.29 2.34
Greene Climacteric Scale [49]
Orgasm 3.63 1.93 The Greene Climacteric Scale (GCS), a 21-item
Kinsey Scale used to assess sexual orientation: 0 = exclusively heterosexual,
self-report inventory, assessed climacteric symp-
6 = exclusively homosexual. FSFI = Female Sexual Functioning Index. toms in two factors: somatic (feeling dizzy, diffi-

J Sex Med 2010;7:896–904

Midlife Women Sexual Satisfaction
culties breathing, headaches, muscle and joint
pains, numbness, and tingling in the extremities)
and vasomotor (hot flashes and night sweats)
symptoms. The scale measures symptoms in other
areas that were not utilized in this study because of
the overlap with other more specialized scales (i.e.,
sexual interest, anxiety, and depression, measured
with the Female Sexual Functioning Index [FSFI]
and the BSI). Each item is rated on a 0, “not at all,”
to 3, “extremely,” Likert scale. The factors and
items were derived from seven factorial studies of
climacteric symptoms. The scale differentiated
between premenopausal, perimenopausal, post-
menopausal, and post-hysterectomy women on
psychological, somatic, and vasomotor factors
[50], suggesting an adequate validity.
Dyadic Adjustment Scale [51]
The Dyadic Adjustment Scale (DAS), a 32-item
self-report questionnaire, measured relationship
adjustment and was based on a pool of approxi-
mately 300 items taken from other scales related to
marital adjustment. The DAS has four subscales:
dyadic satisfaction (considering divorce, willing-
ness to make things work out), dyadic cohesion
(shared interests and stimulating conversations),
dyadic consensus (agreement on how to handle
different decisions and task), and affectional
expression (difference in opinions in showing love
and affection). The scale showed good internal
consistency (Cronbach’s a = 0.96). Content valid-
ity was established by three judges who rated each
item on relevancy, consistency with definitions,
and wording. The total score discriminated
between couples who were married (M = 114.8)
and couples who were divorced (M = 70.7), sug-
gesting good criterion validity.
FSFI [52]
Based on the conceptualization of sexual satisfac-
tion provided by Philippsohn and Hartmann [7],
three items from the FSFI were used to assess the
three separate aspects of sexual satisfaction: How
satisfied have you been with the amount of emotional
closeness during sexual activity between you and your
partner? How satisfied have you been with your sexual
relationship with your partner? How satisfied have you
been with your overall sexual life? Although these
items are not identical to those asked by Philipp-
sohn and Hartmann, the first two items are similar
measures of relational/communication factors and
sexual enjoyment/pleasure which comprise their
two-dimensional construct of sexual satisfaction
with intercourse, while the last item is a similar
measure of overall sexual satisfaction. All items
899
were in reference to the previous 4 weeks and were
based on a 5-point Likert scale: very satisfied, mod-
erately satisfied, about equally satisfied and dissatisfied,
moderately dissatisfied, and very dissatisfied, higher
scores indicating greater satisfaction. The remain-
ing 16 items of the scale are subdivided into five
sexual functioning factors: desire, lubrication,
arousal, orgasm, and pain. These factors were used
as indication of levels of sexual functioning.
Procedure
All women in a relationship that completed a visit
at a menopause clinic were told by their clinician
about the study. After the visit, a research assistant
met in a private room with the potential partici-
pant and explained the study requirements and the
protocol. After signing the consent form, each par-
ticipant provided their contact information and
received a package including the battery of ques-
tionnaires and a self-addressed and stamped en-
velope to send the questionnaires back to the
researcher. Participants were encouraged to com-
plete the questionnaires in the same sitting that
evening or shortly after their visit. Participants
that did not return the questionnaire within a week
from the meeting with the research assistant were
contacted through email and through phone. Of
the 93 women approached by the research assis-
tant, 86 returned the completed questionnaires
(92.47% response rate). As approved from the
Institutional Review Board, participants received
$20 for completing the questionnaires.
Analytic Plan
The hypotheses were tested using a series of two-
step hierarchical regressions for (i) satisfaction
with emotional closeness with partner during sex;
(ii) satisfaction with sexual relationship; and (iii)
satisfaction with overall sex life (dependent vari-
ables). To determine the ability of the targeted
constructs to predict sexual satisfaction above and
beyond sexual functioning, scores on sexual desire,
sexual arousal, lubrication, orgasm, and pain from
the FSFI were included in the first step of the
hierarchical regression, along with age and length
of the relationship. The predictors included in the
second step were (i) psychological well-being
(BSI); (ii) body satisfaction (BAQ); (iii) meno-
pausal symptoms (GCS); and (iv) relationship
adjustment (DAS) (predictors). Each group of pre-
dictors was analyzed in a separate regression. The
hypothesized predicting factors were included in
the second step of the regression. Statistics on R2
J Sex Med 2010;7:896–904
900 Dundon and Rellini

changes are reported to elucidate the additive and fit, and feeling attractive were moderately cor-
effect of the predictors on sexual functioning. related with aspects of sexual satisfaction. Only
hostility, from the list of psychological symptoms,
was correlated with sexual satisfaction.
Results
Bivariate Correlations Predictors of Satisfaction with Emotional Closeness
Pearson’s r coefficients were moderate to high for during Sex
all aspects of sexual function and the three aspects Of the four hierarchical regressions (Table 3), only
of sexual satisfaction (Table 2). The highest corre- relationship adjustment, DR2 = 0.116, P < 0.01,
lation was found between sexual arousal function- predicted satisfaction with emotional closeness
ing and satisfaction with overall sexual life above and beyond sexual function, age, and
(r = 0.804; P < 0.001). These high correlation relationship length. Sexual function, age, and rela-
coefficients suggest that much of the variance in tionship length predicted a large variance in satis-
these three aspects of sexual satisfaction is faction with emotional closeness, DR2 = 0.507,
explained by sexual functioning. Dyadic adjust- P < 0.001, which makes it even more remarkable
ment was correlated with all three aspects of sexual that a set of variables could explain the variance
satisfaction. Somatic complaints that are typical of above and beyond what was already explained by
the menopausal transition were moderately corre- sexual function. An analysis of correlation coeffi-
lated with satisfaction with sexual relationship and cients reveals that none of the factors of the DAS
satisfaction with overall sexual life. Few aspects of provides a unique and independent contribution to
body attitudes, such as feeling fat, feeling strong the model (P > 0.05), meaning that the overall
relationship adjustment predicts satisfaction with
Table 2 Pearson r bivariate correlations for the sexual
emotional closeness during sex, rather than a spe-
satisfaction variables cific aspect of relationship adjustment.
Psychological well-being, DR2 = 0.072, P >
Satisfied with
emotional Satisfied Satisfied
0.05, body attitudes, DR2 = 0.077, P > 0.05, and
closeness with sexual with overall menopausal symptoms, DR2 = 0.004, P > 0.05, did
Variables during sex relationship sexual life not predict satisfaction with emotional closeness
FSFI during sex above what was already predicted by
Desire 0.428*** 0.545*** 0.686*** sexual function, age, and relationship length.
Arousal 0.645*** 0.676*** 0.804***
Lubrication 0.551*** 0.500*** 0.666***
Orgasm 0.514*** 0.492*** 0.636*** Predictors of Satisfaction with the
Pain 0.553*** 0.387*** 0.470*** Sexual Relationship
BSI
Somatic -0.061 -0.191 -0.243*
Both menopausal symptoms, DR2 = 0.042, P =
Obsessive -0.170 -0.125 -0.139 0.05, and relationship adjustment, DR2 = 0.134,
Depression -0.181 -0.192 -0.179 P < 0.01 (Table 3), provided a significant explana-
Anxiety -0.129 -0.183 -0.178
Hostility -0.114 -0.230* -0.188
tion to satisfaction with the sexual relationship
Phobia -0.121 -0.131 -0.177 above and beyond what was already predicted by
Paranoia -0.112 -0.107 -0.100 sexual function, age, and relationship length,
Psychoses -0.138 -0.124 -0.150
BAQ
DR2 = 0.491, P < 0.001. Correlation coefficients
Feeling fat -0.297** -0.245* -0.183 revealed that somatic symptoms, b = -0.195, P <
Disparage -0.081 -0.112 -0.153 0.05, and dyadic satisfaction, b = 0.355, P < 0.05,
Strength-fit 0.070 0.166 0.260*
Salience -0.016 -0.030 -0.085
predicted a significant portion of satisfaction with
Attractive 0.311** 0.128 0.269* sexual relationship.
Lower body fat -0.133 0.014 0.052 Psychological well-being, DR2 = 0.094, P =
GCS
Somatic -0.196 -0.313** -0.322**
0.093, and body satisfaction, DR2 = 0.038, P =
Vasomotor -0.102 -0.133 -0.167 0.569, did not predict levels of satisfaction with
DAS sexual relationship above and beyond what sexual
Consensus 0.371*** 0.284* 0.072
Affection expression 0.383*** 0.463*** 0.375***
function, age, and relationship length provided.
Dyadic satisfaction 0.374*** 0.373*** 0.188
Dyadic cohesion 0.378*** 0.330** 0.288** Predictors of Satisfaction with Overall Sex Life
*P < 0.05; **P < 0.01; ***P < 0.001. Psychological well-being, DR2 = 0.086, P < 0.01,
BAQ = Body Attitudes Questionnaire; BSI = Brief Symptoms Inventory;
DAS = Dyadic Adjustment Scale; FSFI = Female Sexual Functioning Index;
and menopausal symptoms, DR2 = 0.034, P < 0.05,
GCS = Greene Climacteric Scale. provided a significant contribution to the explana-

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Midlife Women Sexual Satisfaction 901

Table 3 Results for two-step hierarchical regressions predicting three aspects of sexual satisfaction
Satisfaction with Satisfaction with Satisfaction with
emotional closeness sexual relationship overall sex life
Variable DR 2 b DR 2 b DR 2 b
Block 1: Demographics and Sexual Function (FSFI) 0.507*** 0.49*** 0.681***
Age 0.028 0.031 0.030
Relationship length 0.010 0.093 0.048
Desire -0.065 0.120 0.224*
Arousal 0.793*** 0.828* 0.707***
Lubrication -0.147 -0.374 -0.114
Orgasm 0.355 0.107 0.030
Pain -0.197** 0.018 0.032
Block 2: Psychological well-being (BSI) 0.07 0.094 0.086**
Somatic 0.214 -0.106 -0.110
Obsessive -0.191 0.043 0.071
Depression -0.253 -0.404* -0.265
Anxiety -0.197 -0.025 0.006
Hostility -0.165 -0.209 -0.274**
Phobia 0.010 0.072 0.070
Paranoia -0.002 0.147 0.200
Psychoses 0.398 0.217 0.050
Block 2: Body satisfaction (BAQ) 0.077 0.038 0.026
Feeling fat -0.262 -0.223 -0.050
Disparage 0.244 0.101 -0.007
Strength-fit -0.129 0.066 0.113
Salience -0.046 -0.027 -0.036
Attractive 0.107 -0.130 -0.047
Lower body fat -0.109 0.057 0.123
Block 2: Menopausal symptoms (GCS) 0.004 0.42† 0.034*
Somatic -0.185 -0.195* -0.136
Vasomotor 0.392 -0.053 -0.100
Block 2: Relationship adjustment (DAS) 0.116** 0.134** 0.051
Consensus 0.120 -0.132 -0.216
Affectional expression 0.008 0.153 0.176
Dyadic satisfaction 0.231 0.355* 0.251
Dyadic cohesion 0.054 0.054 -0.030
†
P = 0.05; *P < 0.05; **P < 0.01, ***P < 0.001.
BAQ = Body Attitudes Questionnaire; BSI = Brief Symptoms Inventory; DAS = Dyadic Adjustment Scale; FSFI = Female Sexual Functioning Index; GCS = Greene
Climacteric Scale.

tion of variance in satisfaction with overall sexual
life above and beyond the contribution provided
by sexual function, age, and relationship length,
DR2 = 0.681, P < 0.001. None of the regression
coefficients provided an independent contribution
to the model, indicating that it is overall psycho-
logical well-being and overall menopausal symp-
toms that affect satisfaction with overall sexual life.
Body satisfaction, DR2 = 0.026, P = 0.523, and
relationship adjustment, DR2 = 0.051, P = 0.071,
did not provide a unique contribution to satisfac-
tion with overall sexual life above and beyond the
explanation provided by sexual function, age, and
relationship length.
Discussion
This study aimed at providing empirical evidence
for factors involved with sexual satisfaction inde-
pendent from sexual function. Data collected from
a convenience sample of middle-aged women
showed that relationship adjustment, psychologi-
cal well-being, and menopausal symptoms pre-
dicted variance in different aspects of sexual
satisfaction above and beyond the explanation pro-
vided by sexual functioning in the areas of desire,
sexual arousal, lubrication, orgasm, and sexual
pain. It is noteworthy that sexual function pre-
dicted a large portion of variance in sexual satis-
faction independently from the aspect of
satisfaction tested, with effect sizes ranging from
49% to 68% of variance in sexual satisfaction. Sta-
tistically, these are considered large effect sizes,
and therefore, it is even more meaningful that
variables entered during step 2 provided a further
significant contribution to the model, indicating
the meaningful and independent contribution of
factors other than sexual function on the variance
in sexual satisfaction.
Specific patterns emerged for the predictors of
different aspects of sexual satisfaction, with rela-
tionship adjustment showing a stronger relation-

J Sex Med 2010;7:896–904

902
ship with the aspects of sexual satisfaction
associated with partnership, such as satisfaction
with emotional closeness achieved during sex and
satisfaction with sexual relationship. Conversely,
psychological well-being and menopausal symp-
toms had a stronger predictive ability with satis-
faction with overall sexual life.
Contrary to our hypotheses, attitudes toward
one’s body did not predict sexual satisfaction.
Despite the relationship that previous literature
reported between body image and sexual satisfac-
tion, and between aging and body image [39–44],
data did not support a relationship between body
attitudes and sexual satisfaction in midlife women.
Given the strong media association between a
young and healthy body and sexuality, it is encour-
aging to see that the sexual satisfaction of midlife
women does not depend on their feelings about
body fat, attractiveness, and distress with body
image.
The findings that relationship adjustment pre-
dicts satisfaction with emotional closeness during
sex and satisfaction with sexual relationship during
midlife support Philippsohn and Hartmann’s
theory [7] that satisfaction from sexual intercourse
is comprised of interwoven emotional/physical and
relational components and corroborate the impor-
tance of viewing sexuality as a dyadic phenomenon.
Moreover, these results are in agreement with
prior studies that emphasize the importance of
relationship variables on the sexual satisfaction of
women of all ages while offering unique insight
into the factors that affect satisfaction from sexual
activity during midlife, suggesting that relational
factors and emotional connection during sexual
activity maintain their importance. Interestingly,
since dyadic adjustment did not predict satisfaction
with overall sexual life, it is feasible that when
middle-aged women consider satisfaction with
their overall sexual life, aspects specific to their
current partner become less important and more
individual aspects, such as general well-being, gain
greater importance. Indeed, satisfaction with
overall sexual life was predicted by psychological
symptoms and menopausal symptoms.
Limitations noteworthy in this study include
the use of a convenience sample recruited from a
menopause clinic, and the utilization of single
items as outcome variables. It is feasible that indi-
viduals attending a menopause clinic may experi-
ence more medical and psychological symptoms
than the general population, which could affect
our results. Future studies that either utilize a
random sample or that recruit participants from a
J Sex Med 2010;7:896–904
Dundon and Rellini
nonclinical population would be able to determine
whether the findings reported by this study pertain
exclusively to the clinical population. Although the
items utilized for outcome variables belong to a
validated scale that has shown adequate reliability
and validity [52], they were not validated to be
used individually. Utilizing single items to assess
rates of prevalence and incidence is a common
practice in epidemiology science; however, the use
of single items can lead to a number of statistical
problems. Unfortunately, the literature currently
does not provide an instrument that assesses sexual
satisfaction in the three domains highlighted here:
satisfaction with emotional closeness during sex,
with the sexual relationship, and with overall
sexual life. The development of an instrument that
is able to assess these three domains of sexual sat-
isfaction in both men and women is sorely needed.
Finally, it should be noted that our sample was
relatively small. Small samples have less power,
so it is harder to find a significant relationship
between variables even in situations when there
are relationships (increased Type II error).
However, data from smaller samples can also cause
instability of beta coefficients. Therefore, future
studies corroborating these findings are needed.
Given the emerging literature on the role of
cognitive–affective mechanisms to better under-
stand overall psychopathology and functioning
[53], it is feasible that factors affecting overall
sexual functioning may also be vulnerabilities for
developing sexual dissatisfaction. Future studies
investigating the role of cognitive–affective
mechanisms such as distress tolerance and
emotion dysregulation on general psychological
well-being and sexual satisfaction and functioning
may be able to better explain the factors that may
be relevant for satisfaction with overall sexual life.
In conclusion, the assessment of women’s sexual
satisfaction during midlife should include an
assessment of their satisfaction with aspects of
sexuality that pertain to the relationship as well as
general overall sexual satisfaction. Treatments
addressing the sexual dissatisfaction with overall
sexual life may benefit from focusing on psycho-
logical and medical symptoms more than relation-
ship factors, while a lack of satisfaction with
aspects of sexuality related to the relationship
require a stronger focus on dyadic adjustment.
Corresponding Author: Alessandra H. Rellini, PhD,
Department of Psychology, University of Vermont,
John Dewey Hall/2 Colchester, Burlington, VT 05461,
USA. Tel: 802-656-4110; Fax: 802-656-8783; E-mail:
arellini@uvm.edu
Midlife Women Sexual Satisfaction
Conflict of Interest: None.
Statement of Authorship
Category 1
(a) Conception and Design
Alessandra H. Rellini; Carolyn Marie Dundon
(b) Acquisition of Data
Alessandra H. Rellini
(c) Analysis and Interpretation of Data
Alessandra H. Rellini
Category 2
(a) Drafting the Article
Carolyn Marie Dundon; Alessandra H. Rellini
(b) Revising It for Intellectual Content
Carolyn Marie Dundon; Alessandra H. Rellini
Category 3
(a) Final Approval of the Completed Article
Alessandra H. Rellini
References
1 Fugl-Meyer A, Fugl-Meyer K. Sexual disabilities,
problems and satisfaction in 18–74 year-old Swedes.
Scand J Sexol 1999;2:79–105.
2 Dunn K, Jordan K, Croft P, Assendelft W. System-
atic review of sexual problems: Epidemiology and
methodology. J Sex Marital Ther 2002;28:399–422.
3 Laumann E, Paik A, Rosen R. Sexual dysfunction in
the United States: Prevalence and predictors. JAMA
1999;281:537–44.
4 Lindau S, Schumm L, Laumann E, Levinson W,
O’Muircheartaigh C, Waite L. A study of sexuality
and health among older adults in the United States.
N Engl J Med 2007;357:762–74.
5 Lawrence K, Byers E. Sexual satisfaction in long-
term heterosexual relationships: The interpersonal
exchange model of sexual satisfaction. Pers Relatsh
1995;2:267–85.
6 Meston C, Trapnell P. Development and validation
of a five-factor sexual satisfaction and distress
scale for women: The Sexual Satisfaction Scale for
Women (SSS-W). J Sex Med 2005;2:66–81.
7 Philippsohn S, Hartmann U. Determinants of
sexual satisfaction in a sample of German women.
J Sex Med 2009;6:1001–10.
8 Basson R, Berman J, Burnett A, Derogatis L, Fer-
guson D, Fourcroy J, Goldstein I, Graziottin A,
Heiman J, Laan E, Leiblum S, Padma-Nathan H,
Rosen R, Segraves K, Segraves RT, Shabsigh R,
Sipski M, Wagner G, Whipple B. Report of the
International Consensus Development Conference
on Female Sexual Dysfunction: Definitions and
classifications. J Sex Marital Ther 2001;27:83–94.
903
9 Haavio-Mannila E, Kontula O. Correlates of
increased sexual satisfaction. Arch Sex Behav 1997;
26:399–419.
10 Laumann E, Gagnon J, Michael R, Michaels S. The
social organization of sexuality: Sexual practices in
the United States. Chicago, IL: University of
Chicago Press; 1994.
11 Waite L, Joyner K. Emotional satisfaction and
physical pleasure in sexual unions: Time horizon,
sexual behavior, and sexual exclusivity. J Marriage
Fam 2001;63:247–64.
12 Barrientos J, Paez D. Psychosocial variables of
sexual satisfaction in Chile. J Sex Marital Ther
2006;32:351–68.
13 Bridges S, Lease S, Ellison C. Predicting sexual sat-
isfaction in women: Implications for counselor edu-
cation and training. J Couns Dev 2004;82:158–66.
14 Christopher F, Sprecher S. Sexuality in marriage,
dating and other relationships: A decade review.
J Marriage Fam 2000;62:999–1017.
15 González M, Viáfara G, Cabab F, Molina T, Ortiz
C. Libido and orgasm in middle-aged women.
Maturitas 2006;53:1–10.
16 Haning R, O’Keefe S, Randall E, Kommor M,
Baker E, Wilson R. Intimacy, orgasm likelihood,
and conflict predict sexual satisfaction in hetero-
sexual male and female respondents. J Sex Marital
Ther 2007;33:93–113.
17 MacNeil S, Byers S. Role of sexual self-disclosure in
the sexual satisfaction of long-term heterosexual
couples. J Sex Res 2009;1:3–14.
18 Sprecher S. Sexual satisfaction in premarital rela-
tionships: Associations with satisfaction, love, com-
mitment, and stability. J Sex Res 2002;39:190–6.
19 Byers E, MacNeil S. Further validation of the inter-
personal exchange model of sexual satisfaction. J Sex
Marital Ther 2006;32:53–69.
20 Rosen R, Bachmann G. Sexual well-being, happi-
ness, and satisfaction, in women: The case for a new
conceptual paradigm. J Sex Marital Ther 2008;34:
291–7.
21 Avis N, Stellato R, Crawford S, Johannes C, Long-
cope C. Is there an association between menopause
status and sexual functioning? Menopause: JNAMS
2000;7:297–309.
22 Dennerstein L, Dudley E, Burger H. Are changes in
sexual functioning during midlife due to aging or
menopause? Fertil Steril 2001;76:456–60.
23 Laumann E, Nicolosi A, Glasser D, Paik A, Gingell
C, Moreira E, Wang T. Sexual problems among
women and men aged 40–80 years: Prevalence and
correlates identified in the Global Study of Sexual
Attitudes and Behaviors. Int J Impot Res 2005;
17:39–57.
24 Lutfey K, Link C, Rosen R, Wiegel M, McKinlay J.
Prevalence and correlates of sexual activity and
function in women: Results from the Boston Area
Community Health (BACH) Survey. Arch Sex
Behav 2009;38:514–27.
J Sex Med 2010;7:896–904
904
25 Aslan E, Beji N, Gungor I, Kadioglu A, Dikencik B.
Prevalence and risk factors for low sexual function in
women: A study of 1,009 women in an outpatient
clinic of a university hospital in Istanbul. J Sex Med
2008;9:2044–52.
26 Laumann E, Paik A, Glasser D, Kang J, Wang T,
Levinson B, Moreira E, Nicolosi A, Gingell C. A
cross-national study of subjective sexual well-being
among older women and men: Findings from the
global study of sexual attitudes and behaviors. Arch
Sex Behav 2006;35:145–61.
27 Tomic D, Gallicchio L, Whiteman M, Lewis L,
Langenberg P, Flaws J. Factors associated with
determinants of sexual functioning in midlife
women. Maturitas 2006;53:144–57.
28 Dennerstein L, Koochaki P, Barton I, Graziottin A.
Hypoactive sexual desire disorder in menopausal
women: A survey of western European women. J Sex
Med 2006;3:212–22.
29 Lara L, Useche B, de Silva J, Ferriani R, Reis R, de
Sá M, Carvalho B, Carvalho M, Silva A. Sexuality
during the climacteric period. Maturitas 2009;62:
127–33.
30 Bromberger J, Meyer P, Kravitz H, Sommer B,
Cordal A, Powell L, Ganz P, Sutton-Tyrrell K. Psy-
chologic distress and natural menopause: A multi-
ethnic community study. Am J Public Health 2001;
91:1435–42.
31 Freeman E, Sammel M, Liu L, Gracia C, Nelson D,
Hollander L. Hormones and menopausal status as
predictors of depression in women in transition to
menopause. Arch Gen Psychiatry 2004;61:62–70.
32 Maartens L, Knottnerus J, Pop V. Menopausal tran-
sition and increased depressive symptomatology: A
community based prospective study. Maturitas
2002;42:195–200.
33 Tangen T, Mykleton A. Depression and anxiety
through the climacteric period: An epidemiological
study (HUNT-II). J Psychosom Obstet Gynaecol
2008;29:125–31.
34 Bradford A, Meston C. The impact of anxiety on
sexual arousal in women. Behav Res Ther 2006;44:
1067–77.
35 Frohlich P, Meston C. Sexual functioning and self-
reported depressive symptoms among college
women. J Sex Res 2002;39:321–5.
36 Cyranowski J, Bromberger J, Youk A, Matthews K,
Kravitz H, Powell L. Lifetime depression history
and sexual function in women at midlife. Arch Sex
Behav 2004;33:539–48.
37 Shifren J, Monz B, Russo P, Segreti A, Johannes C.
Sexual problems and distress in United States
women: Prevalence and correlates. Obstet Gynecol
2008;112:970–8.
38 Mishra G, Kuh D. Sexual functioning throughout
menopause: The perceptions of women in a British
cohort. Menopause 2006;13:880–90.
39 Blümel J, Chedraui P, Baron G, Belzares E, Ben-
cosme A, Calle A, Espinoza MT, Flores D, Izaguirre
J Sex Med 2010;7:896–904
Dundon and Rellini
H, Leon-Leon P, Lima S, Mezones-Holguin E,
Monterrosa A, Mostajo D, Navarro D, Ojeda E,
Onatra W, Royer M, Soto E, Vallejo S, Tserotas K;
for the Collaborative Group for Research of the
Climacteric in Latin America (REDLINC). Sexual
dysfunction in middle-aged women: A multicenter
Latin American study using the Female Sexual Func-
tion Index. Menopause 2009 May 19. [Epub ahead of
print] doi: 10.1097/gme.0b013e3181a4e317.
40 Koch P, Mansfield P, Thurau D, Carey M. “Feeling
frumpy”: The relationships between body image
and sexual response changes in midlife women. J Sex
Res 2005;42:215–23.
41 Deeks A, McCabe M. Menopausal stage and age and
perceptions of body image. Psychol Health 2001;
16:367–79.
42 McLaren L, Hardy R, Kuh D. Women’s body sat-
isfaction at midlife and lifetime body size: A pro-
spective study. Health Psychol 2003;22:370–7.
43 McKinley N, Lyon L. Menopausal attitudes, objec-
tified body consciousness, aging anxiety, and body
esteem: European American women’s body experi-
ences in midlife. Body Image 2008;5:375–80.
44 Sanchez D, Kiefer A. Body concerns in and out of
the bedroom: Implications for sexual pleasure and
problems. Arch Sex Behav 2007;36:808–20.
45 Hayes R, Dennerstein L, Bennett C, Sidat M,
Gurrin L, Farley C. Risk factors for female sexual
dysfunction in the general population: Exploring
factors associated with low sexual function and
sexual distress. J Sex Med 2008;5:1681–93.
46 Carpenter L, Nathanson C, Kim J. Physical women,
emotional men: Gender and sexual satisfaction in
midlife. Arch Sex Behav 2009;38:87–107.
47 Derogatis L, Melisaratos N. The Brief Symptom
Inventory: An introductory report. Psychol Med
1983;13:595–605.
48 Ben-Tovim D, Walker M. The development of the
Ben-Tovim Walker Body Attitudes Questionnaire
(BAQ), a new measure of women’s attitudes towards
their own bodies. Psychol Med 1991;21:775–84.
49 Greene J. Constructing a standard climacteric scale.
Maturitas 1998;29:25–31.
50 Barentsen R, van de Weijer P, van Gend S,
Foekeman H. Climacteric symptoms in a represen-
tative Dutch population sample as measured with
the Greene Climacteric Scale. Maturitas 2001;38:
123–8.
51 Spanier G. Measuring dyadic adjustment: New
scales for assessing the quality of marriage and
similar dyads. J Marriage Fam 1976;38:15–28.
52 Rosen R, Brown C, Heiman J, Leiblum S, Meston
C, Shabsigh R. The Female Sexual Function Index
(FSFI): A multidimensional self-report instrument
for the assessment of female sexual function. J Sex
Marital Ther 2002;26:191–208.
53 Zvolensky M, Otto M. Affective intolerance, sensi-
tivity, and processing: Advances in clinical science
introduction. Behav Ther 2007;38:228–33.