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An Online, Mindfulness-Based, Cognitive-

Behavioral Therapy for Female Sexual
Difficulties: Impact on Relationship
Functioning
a a
Alice Hucker & Marita P. McCabe
a
Centre for Mental Health and Wellbeing, Deakin University,
Melbourne, Australia
Accepted author version posted online: 10 Oct 2013.Published
online: 05 Dec 2013.

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To cite this article: Alice Hucker & Marita P. McCabe (2014) An Online, Mindfulness-Based, Cognitive-
Behavioral Therapy for Female Sexual Difficulties: Impact on Relationship Functioning, Journal of Sex
& Marital Therapy, 40:6, 561-576, DOI: 10.1080/0092623X.2013.796578

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 JOURNAL OF SEX & MARITAL THERAPY, 40(6), 561–576, 2014
Copyright 
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ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/0092623X.2013.796578

An Online, Mindfulness-Based, Cognitive-Behavioral

Therapy for Female Sexual Difficulties: Impact
on Relationship Functioning
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Alice Hucker and Marita P. McCabe

Centre for Mental Health and Wellbeing, Deakin University, Melbourne, Australia

This article presents the evaluation of an online treatment for female sexual difficulties as it relates to
relationship functioning. Pursuing Pleasure was an online, mindfulness-based, cognitive behavioral
therapy for female sexual difficulties. In Study 1, 26 women completed treatment and changes were
compared with a waitlist control group (n = 31). In Study 2, 16 women from the control group then
completed treatment. The authors did not use a control group in Study 2. Results demonstrated that
both treatment groups observed significant improvements in sexual intimacy and communication,
and emotional intimacy improved significantly in the Study 1 treatment group. Most improvements
were maintained at follow-up.

Female sexual difficulties often occur within the context of a relationship, and relationship factors
have been consistently identified as contributing to the precipitation and maintenance of sexual
difficulties in women (Basson, 2000; Hawton, Catalan, & Fagg, 1991). It also appears that the
association between sexual difficulties and relationship factors may be bidirectional (Basson,
2000), and such factors include relationship quality and duration (Kelly, Strassberg, & Turner,
2006; Witting et al., 2008), and power dynamics within the relationship (McCabe & Cobain,
1998). Communication difficulties and low levels of intimacy between partners may also play a
central role in the development and maintenance of female sexual difficulties (Kelly et al., 2006;
McCabe, 1991, 1997).
Because of the central role of these relationship factors, sex therapy interventions should
ideally include both members of the couple and should target common relationship factors
through communication and intimacy interventions. These methods are recommended on the
basis of the understanding that relationship factors may act as a barrier to improvements in sexual
functioning, and previous research has demonstrated that partner engagement and cooperation in
treatment is associated with better prognosis for female sexual difficulties (LoPiccolo & Stock,
1986).
Internet-based cognitive behavioral therapy has recently been introduced as a novel method
for the treatment of sexual difficulties. This platform of therapy uses traditional cognitive and
behavioral approaches to sex therapy (e.g., Masters & Johnson, 1970; McCabe, 2001) and offers

Address correspondence to Marita P. McCabe, School of Psychology, Deakin University, 221 Burwood Highway,
Melbourne, Victoria 3125, Australia. E-mail: marita.mccabe@deakin.edu.au
 562 A. HUCKER AND M. P. MCCABE

increased convenience, privacy, and anonymity. Internet-based interventions demonstrate some

similarities to the various self-help methods that have been developed for the treatment of sexual
difficulties, such as bibliotherapy and videotherapy (van Lankveld, 2009). In addition to the
benefits that are inherent in self-help methods, such as privacy and convenience, Internet-based
interventions can offer a more interactive treatment and draw together a community of clients
while maintaining anonymity (Jones & McCabe, 2010; Leusink & Aarts, 2006; McCabe & Price,
2008; Tate & Zabinski, 2004).
Preliminary evidence suggests that as well as addressing sexual functioning, online cognitive
behavioral therapy for male sexual dysfunction can also be effective in increasing relationship
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functioning and may be a suitable alternative to face-to-face sex therapy (Giles & McCabe, 2009;
Leusink & Aarts, 2006; McCabe & Price, 2008; McCabe, Price, Piterman, & Lording, 2008; van
Diest, van Lankveld, Leusink, Slob, & Gijs, 2007).
In relation to female sexual difficulties, Jones and McCabe (2011) investigated the effectiveness
of an Internet-based cognitive behavioral therapy program for mixed sexual difficulties, the Revive
program. Revive consisted of five online modules that included sensate focus, communication
exercises, and unlimited e-mail contact with a therapist. The main aim of the e-mail contact was
to provide cognitive therapy alongside the predominantly behavioral online modules (Jones &
McCabe, 2011). As well as targeting sexual functioning in women, Revive also aimed to address
relevant relationship problems, and the results of this study suggested that the treatment group
improved significantly in measures of communication and intimacy as compared with the control
group, but not in overall relationship satisfaction.
The authors of Revive commented on various limitations in their study. First, there were signif-
icant problems in engaging participants in cognitive therapy over e-mail (Jones & McCabe, 2011)
and this may have limited the extent to which both sexual and relationship factors were addressed.
To overcome this limitation, the authors suggested that future Internet-based interventions use
online chat groups to enhance the cognitive aspects of the program. Another limitation in the
Revive program was that, although partners were required to participate in the exercises, they
were never directly addressed by the therapist and they received no psychoeducation about female
sexual difficulties or relationship functioning (Jones & McCabe, 2011). It has previously been
suggested that providing partners with psychoeducation, and also validating and normalizing
their experiences throughout treatment, may help in forming a stronger partner alliance during
the treatment of sexual difficulties, and potentially lead to better treatment outcomes (LoPiccolo
& Stock, 1986; Schneidman & McGuire, 1976).
Last, the authors of Revive suggested that future online interventions for female sexual dif-
ficulties incorporate mindfulness meditation, a recent addition to the psychological treatment of
female sexual dysfunctions (Althof, 2010; Brotto, Basson, & Luria, 2008a; Brotto et al., 2008;
Jones & McCabe, 2011). Mindfulness meditation is a Buddhist meditation practice that aims to
cultivate present moment awareness and nonjudgmental observation of experiences (Kabat-Zinn,
Lipworth, & Burney, 1985). In the context of female sexual difficulties, mindfulness exercises
can help to decrease cognitive distractions and anxiety during sexual activity, while increasing
present moment attention and the awareness of pleasurable sensations (Brotto et al., 2008a;
Brotto, Heiman, et al., 2008; Brotto, Seal, & Rellini, 2012; Silverstein, Brown, Roth, & Britton,
2011).
Pursuing Pleasure (PP) is an online, mindfulness-based, cognitive behavioral therapy program
for women experiencing sexual difficulties that aims to extend upon prior research into the
Internet-based treatment of female sexual difficulties. PP contains sensate focus, communication
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 563

exercises and unlimited e-mail contact with a therapist, and is the first online treatment for sexual
dysfunction to incorporate mindfulness exercises. PP is also the first online treatment for sexual
dysfunction to make use of online chat groups as a platform for cognitive therapy and social
support.
Although it is important to assess the effect of PP on the sexual functioning of the women and
partners in treatment, it is also relevant to assess changes in relationship functioning because of
the relationship factors that may be involved in the maintenance of female sexual difficulties. The
current studies evaluated the impact on the PP program on such relationship factors.
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STUDY 1

METHOD

Aim

The aim of Study 1 was to evaluate the effectiveness of the PP program, as it relates to relationship
functioning, for women experiencing mixed self-reported sexual difficulties as compared with a
waitlist control. It was hypothesized that the women in the treatment group would demonstrate
significant improvements in relationship functioning as compared with a waitlist control, and that
treatment gains would be maintained for 3-months following the completion of PP.

Participants

All participants were female, older than 18 years of age, currently experiencing self-reported
sexual difficulties (related to desire, arousal, orgasm, and/or pain), in a stable heterosexual
relationship, reported no significant mental illness and no significant relationship problems (e.g.,
violence, abuse), were English speaking, and had regular access to Internet. It was also necessary
for partners to be willing to participate in treatment because some components of the program
required partner involvement (see the “Treatment” section).
This study excluded women in same-sex relationships due to past research into the online
treatment of female sexual difficulties focusing on women in heterosexual relationships only, and
a lack of research literature focusing on therapeutic interventions for women experiencing sexual
difficulties in same-sex relationships. Regarding mental illness and relationship problems, women
were not formally screened for mental illness or significant relationship problems, but rather these
exclusion criteria were communicated to women via e-mail prior to them being accepted into
the study. Two women who had completed the pretest assessment (one from the treatment group
and one from the control group) were excluded from the study because of disclosure of current
mental illness (see Figure 1).

Materials

Program content was delivered online on a password-protected website. Participants completed

online surveys at pre- and posttreatment and at 3-month follow-up. All chat-groups were con-
ducted in a password-protected chat-room using real-time text conversation.
 564 A. HUCKER AND M. P. MCCABE

300 women responded

to study
advertisements

Online consent from

102 couples after
receiving PLS
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52 women were randomly 11 women 39 women were randomly

assigned to treatment group and withdrew from assigned to wait-list control
completed pre-treatment the study group and completed pre-
questionnaire waitlist questionnaire

1 woman screened out due to

mental illness; 5 women withdrew; 46 1 woman screened out due to
women began treatment mental illness; 31 women completed
post-waitlist questionnaire

26 women (56.52%) completed the program Control group offered treatment; 22 women
and the post-treatment questionnaire. began program; 9 women declined
Attrition (20 women; 43.48%):
• 4 in module 1. Reasons: time commitment (3);
partner unsupportive (1).
• 9 in module 2. Reasons: time commitment (4);
relationship ended (1); expectations of
16 women (72.72%) completed the program
treatment not met (2); natural disaster (2).
and the post-treatment questionnaire.
• 4 in module 3. Reasons: time commitment (1);
Attrition (6 women - 27.27%):
partner unsupportive (1); expectations of
• 3 in module 1. Reasons: time commitment (3).
treatment not met (1); no reason (1).
• 2 in module 2. Reasons: partner unsupportive
• 1 in module 4. Reason: ambivalence about
(1); no reason (1).
receiving treatment.
• 1 in module 4. Reason: expectations of
• 1 woman in modules 5. No reason given.
treatment not met.
• 1 woman in modules 6. No reason given.

15 women completed the

All 26 women completed the 3-month 3-month follow-up questionnaire
follow-up questionnaire

FIGURE 1 Flowchart of recruitment stages and attrition. PLS = Plain Language Statement.

Demographic Information

Participants provided information on their age, relationship status, and relationship duration.
Women also reported on their perception of their own sexual difficulties, including type, duration
and frequency of sexual difficulties, and their perception of their partner’s sexual functioning.
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 565

Sexual Function Scale

The Sexual Function Scale (McCabe, 1998) is a self-report questionnaire developed to assess a
range of etiological factors involved in sexual dysfunction. The communication and relationship
satisfaction subscales were used, with participants asked to decide which response best describes
their current relationship. Lower scores are indicative of poorer communication within the rela-
tionship and lower relationship satisfaction. High internal consistency has been reported for all
subscales (α = .60 to .90; McCabe, 1998) and the reliability scores for the present study were
communication (α ≥ .67) and relationship satisfaction (α ≥ .73).
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The Personal Assessment of Intimacy in Relationships Scale

This scale is a self-report questionnaire that measures five areas of intimacy in relationships
(Schaefer & Olson, 1981). The sexual intimacy and emotional intimacy subscales were used and
participants were asked to complete the subscale as it applies to their current relationship. Scores
on each subscale range from 6 to 30 with lower scores indicating poorer levels of intimacy.
The reliability of the Personal Assessment of Intimacy in Relationships has been established
by Schaefer and Olson (1981; α = .70). The reliability for emotional intimacy in the present
study was as expected (α ≥ .77), while the alpha level for sexual intimacy was much lower than
expected (α ≥ .38). This low alpha result for sexual intimacy is most likely the result of the small
sample size leading to imprecise alpha estimates (Charter, 2003). However, the reliability score
did improve at posttest (α ≥ .65) and follow-up (α ≥ .63).

Female Sexual Function Index

This index (Rosen et al., 2000) is a 19-item self-report assessment tool aimed at measuring
women’s sexual functioning. The index is based on respondents’ past 4 weeks of sexual activity
and contains six subscales (desire, arousal, lubrication, orgasm, pain, and satisfaction) with lower
scores indicating poorer sexual functioning. Scores on all subscales are summed to compute the
total Female Sexual Function Index score, with a score of ≤ 26 indicating that a woman meets the
criteria for clinical levels of female sexual dysfunction (Wiegel, Meston, & Rosen, 2005). The
Female Sexual Function Index has been shown to have high internal consistency (α ≥ .82), and
high test–retest reliability (α = .79 – .88; Rosen et al., 2000). Reliability scores for the present
study were as follows sexual desire, α ≥ .81; sexual arousal, α ≥ .91; lubrication, α ≥ .92;
orgasm, α ≥ .89; satisfaction, α ≥ .68; pain, α ≥ .85, and total score, α ≥ .89.

Female Sexual Distress Scale–Revised

This scale (DeRogatis, Clayton, Lewis-D’Agostino, Wunderlich, & Fu, 2008) is a 13-item
self-report measure that assesses the degree of personal distress associated with female sexual
functioning. Scores range from 0 to 52 with higher scores indicating greater distress. Scores of
≥11 suggest a level of sexual function-related distress that is indicative of a diagnosis of female
sexual dysfunction (DeRogatis et al., 2008). The reliability of the Female Sexual Distress Scale-
Revised was established by Derogatis and colleagues (2008; α = .87 to .97). The reliability score
for the present study was α ≥ .93.
 566 A. HUCKER AND M. P. MCCABE

Treatment

PP was an online, mindfulness-based, cognitive behavioral therapy treatment for women with
mixed female sexual difficulties (see the Appendix for a summary of the program content). The
aim of the PP program was twofold: (a) To decrease the symptoms of sexual dysfunction that
women were experiencing, through both sexual activity-based and relationship-based interven-
tions; and (b) To decrease the level of distress associated with sexual functioning. To achieve
these aims, the program consisted of both change-based interventions (e.g., challenging negative
automatic thoughts, behavioral exercises) and acceptance-based interventions (e.g., mindfulness,
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normalizing through psychoeducation).

The program consisted of six progressive online modules, the first lasting a minimum of
one week, and the others lasting a minimum of 2 weeks each. All women began the program
at the same time and were encouraged to finish each module within 2 weeks, although the
program did allow for flexible timing depending on the needs of each couple. Each module
contained psychoeducation and related cognitive behavioral therapy exercises that aimed to
help women identify and challenge negative automatic thoughts and beliefs about sexuality and
sexual activities. Each module included printouts for partners that covered information on female
sexuality, female sexual difficulties, and associated relationship issues, as well as explanations
of the treatment exercises. These printouts also incorporated statements aimed at normalizing
the process for men and validating their experiences of treatment. Each module also contained
communication exercises and sensate focus exercises, and both of these interventions required
partner participation.
Mindfulness exercises were used throughout the program to assist women in cultivating
present moment awareness, and the use of mindfulness was encouraged during sensate focus to
help women manage difficult thoughts and feelings, and remain more present and aware. The
mindfulness exercises were adapted from Brotto, Basson, and Luria’s (2008b) Group Psychoe-
ducation Treatment manual. In PP, mindfulness was first introduced through basic nonsexual
mindfulness exercises focusing on a present moment experience (e.g., meditating on the breath,
mindfulness of thoughts). Women were encouraged to practice this exercise for 5 min each day
throughout the program. More sensory-focused mindfulness exercises were then introduced, such
as mindful eating, mindful movement and an exercise involving sensual body awareness while
having a shower or bath. In later modules, mindfulness exercises became more sexually oriented
and were incorporated into sensate focus sessions.
The online chat groups ran for 1 hr each and occurred every 2 weeks, containing approximately
4–8 women in each group. All groups were facilitated by a therapist specializing in the treatment
of female sexual difficulties and dysfunctions. The chat groups were run with a loose structure:
greetings, review of module exercises and experiences of the program over the past 2 weeks,
discussion of challenges and barriers to change, specific intervention suggestions (if necessary),
and closing of session. In addition, the concluding sessions had a greater focus on reflection and
relapse prevention. During the chat groups, the facilitator guided women to focus on the causal and
maintaining factors of their sexual difficulties, and to explore barriers to change throughout the
treatment, as well as potential solutions. The facilitator drew upon cognitive behavioral therapy
and mindfulness techniques to reinforce the concepts from the PP program. Participants were also
offered unlimited e-mail contact with the therapist. See Hucker and McCabe (in press) for further
details about the content of the chat groups and the themes that emerged from these discussions.
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 567

Each module concluded with a hurdle requirement, which consisted of a list of questions
summarizing the exercises that should be completed before moving to the next module. Women
were required to agree that they had achieved these goals and were ready to move on, by marking
the questions electronically, before being provided with the password to access the next module
of PP.

Procedure
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Ethics approval was gained for these studies from the University Human Research Ethics Com-
mittee. Women were recruited via worldwide health websites, a press release in two Australian
newspapers, noticeboards in an Australian university, and through a database of previous partici-
pants in a project completed by the second author. This database included women from a general
Australian population recruited via similar methods to the present study, and were not exclusively
women with sexual difficulties. See Figure 1 for a summary of the recruitment stages and study
attrition. Women registered interest via e-mail and were then sent a reply e-mail explaining the
inclusion and exclusion criteria. Those still interested were sent a link to the online plain language
statement that provided comprehensive treatment information for couples, and the couples gave
consent on the plain language statement website. Women were then randomly assigned to either
the treatment group or waitlist control, and all participants completed a pretest online question-
naire. In total, 26 women completed treatment and 31 women in the control group remained for
the full waitlist period. All participants completed the posttest questionnaire, and all treatment
participants completed the 3-month follow-up questionnaire.
To investigate women with both clinical and subclinical levels of sexual difficulties, women
were not formally screened for female sexual dysfunction before being accepted into the study.
Clinical and subclinical levels of female sexual dysfunction were determined based on clinical
cutoffs of the Female Sexual Function Index and the Female Sexual Distress Scale–Revised.
Inspection of pretest differences between the treatment group and the women who dropped out of
treatment indicated that the women who dropped out reported significantly lower levels of sexual
desire, sexual arousal, and sexual satisfaction. However, there were no significant differences
on relationship variables, and no significant difference in the percentage of women who met
diagnostic criteria for female sexual dysfunction. Women who completed the waitlist period were
then offered the PP treatment (see Study 2).

Data Analyses

Because of the design of the study, it was predicted that changes would occur from pretest
to posttest, and that these changes would be maintained at the 3-month follow-up. It was not
expected that further improvements would occur from posttest to follow-up. Given the small
sample size, it was predicted that analyses that used repeated measures over the three time
points would not appropriately represents the changes from pretest to posttest, and the mainte-
nance of results at follow-up, as a result of the stabilization of results from posttest to follow-
up. Therefore, separate analyses were conducted from pretest to posttest and from posttest to
follow-up.
 568 A. HUCKER AND M. P. MCCABE

TABLE 1
Types of Sexual Difficulties Reported by the Treatment and Control Groups at Pretest Assessment

Treatment group (n = 26) Control group (n = 31)

Type of sexual difficulty n % n %

Low sexual desire 25 96.2 30 96.8

Failure to become 21 80.8 18 58.1
aroused/lubricated
Inability to orgasm 15 57.7 16 51.6
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Delayed orgasm 15 57.7 13 41.9

Painful intercourse 10 38.5 13 41.9
Reduced satisfaction 6 23.1 10 32.3

RESULTS

Demographic Information

The mean age of the women in the treatment group and control group was 33.31 years (SD =
7.4) and 31.94 years (SD = 5.17) respectively, t(55) = 0.79, p > 0.05. Relationship duration
for the treatment group and control group were 7.94 years (SD = 5.52) and 8.84 years (SD =
5.29), respectively, t(55) = –0.63, p > 0.05. Of the treatment group, 69% were married and of the
control group, 71% were married; the other women identified themselves as de facto, partnered,
or cohabitating.
Regarding sexual functioning, the mean duration of sexual difficulties was 4.1 years for both
the treatment and the control group (treatment SD = 0.8 years; control SD = 0.7 years), t(55)
= 0.10, p > .05. See Table 1 for a summary of the types of sexual difficulties reported by each
group. On the basis of clinical cutoffs from the Female Sexual Distress Scale–Revised, all women
from the treatment and control groups reported a level of sexual function-related distress that
is indicative of a female sexual dysfunction diagnoses. On the basis of clinical cutoffs of the
Female Sexual Function Index, 5 women (21.7%) in the treatment group and 4 women (16%) in
the control group did not meet criteria for female sexual dysfunction. Because of a lack of sexual
activity and/or intercourse in the previous 4 weeks, 10 women (3 from the treatment group; 7
from the control group) could not be categorized. Last, 42.3% of the treatment group and 51.6%
of the control group indicated that their partner had some form of sexual difficulty.

Effects of PP on Relationship Functioning

To compare changes in relationship functioning between the treatment group and control group
from pretest to posttest, we conducted a repeated-measures multivariate analysis of variance. The
between-subject factor for the multivariate analysis of variance was group (treatment vs. control)
and the repeated-measures factor was time (pre- and posttest). The dependent variables were
sexual intimacy, emotional intimacy, communication, and relationship satisfaction. See Table 2
for the means and standard deviations of the dependent variables. The multivariate analysis
of variance revealed a significant Group × Time interaction effect, F(4, 51) = 5.29, p < .01;
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 569

TABLE 2
Means and Standard Deviations of Dependent Variables at Pre- and Posttest for the Treatment and Control
Groups

Treatment group (n = 26) Control group (n = 31)

Pretest Posttest Pretest Posttest
Dependent variablea M SD M SD M SD M SD

Sexual intimacy 20.84 3.04 23.12 2.71∗∗ 20.90 2.70 20.34 3.60
Emotional intimacy 23.28 3.79 24.32 3.34∗ 23.67 3.62 23.00 3.34
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Communication 20.41 2.62 25.04 3.02∗ 21.47 2.05 23.99 3.43

Relationship satisfaction 31.44 3.11 34.12 3.93∗ 31.33 2.56 32.55 4.99

Note. Changes from pretest to posttest: ∗ p < .05. ∗∗ p < .01.

aLower scores indicate poorer functioning.

Pillai’s trace = 0.29, suggesting that the treatment group observed significant improvements in
relationship variables from pretest to posttest as compared with the control group. The univariate
results suggest significant improvements in the treatment group on scores of sexual intimacy, F(1,
55) = 18.54, p < .01; partial η2 = .26, emotional intimacy, F(1, 55) = 4.93 , p < .05; partial η2
= .08, and communication, F(1, 55) = 4.69, p < .05; partial η2 = .08, but not for relationship
satisfaction, F(1, 55) = 1.29, p = .26; partial η2 = .02, from pretest to posttest as compared with
the control group.

Maintenance of Treatment Gains

To assess maintenance of treatment gains in relationship functioning, posttest scores on dependent

variables were compared with 3-month follow-up scores for the treatment group. Paired-samples
t tests demonstrated no significant differences at the p < .05 level for emotional intimacy, t(25)
= 1.93, p = .07, communication, t(25) = 1.24, p = .23, and relationship satisfaction, t(25) =
0.54, p = .60, but not for sexual intimacy, t(25) = 2.42, p = .02. These results demonstrate that
suggest that improvements in emotional intimacy and communication were maintained over the
3-month follow-up period, but that the improvements in sexual intimacy were not maintained
(see Table 3).

STUDY 2

The aim of Study 2 was to evaluate changes in relationship functioning after the control crossover
group completed the PP treatment. It was hypothesized that the control crossover group would
experience similar improvements in relationship functioning as the original treatment group. It
was also hypothesized that participation after the waitlist period would result in lower attrition
as compared with the original treatment group as a result of a belief that engagement in the full
waitlist period would lead to an increased level of motivation upon entering treatment.
 570 A. HUCKER AND M. P. MCCABE

METHOD

Participants

The waitlist control group was offered the PP treatment after their final waitlist questionnaires
were completed. Most women in the control group who did not start treatment (n = 5) did not
indicate why, but those who did respond (n = 3) indicated timing issues, a lack of interest, and a
relationship breakdown.
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Materials and Treatments

Please refer to Study 1. The same questionnaire assessment measures and treatment was used for
this group.

Procedure

Twenty-two women accepted the offer of treatment after being in the waitlist control group and
completing the final waitlist questionnaire (from Study 1). These questionnaires were used as the
new baseline for Study 2. Of the women who accepted the offer of treatment, 16 completed the PP
program and the posttest questionnaire, and 15 completed the 3-month follow-up questionnaire
(see Figure 1).

RESULTS

Demographic Information

The mean age of the women in the control crossover group was 30.75 years (SD = 5.12 years).
The mean relationship duration of this group was 8.60 years (SD = 4.34), and 68.80% reported
being married, while the remaining women identified as de facto, partnered and/or cohabitating.
Types of sexual difficulties reported were as follows: low sexual desire/interest (93.8%), failure

TABLE 3
Means and Standard Deviations of Dependent Variables at Posttest and 3-Month Follow-Up for the
Treatment Group (n = 26)

Posttest 3-month follow-up

Dependent variablea M SD M SD t

Sexual intimacy 23.19 2.68 22.35 2.76∗ 2.42

Emotional intimacy 24.31 3.27 23.45 3.40 1.93
Communication 24.92 3.02 24.13 3.48 1.24
Relationship satisfaction 34.12 3.93 33.80 4.85 0.54

Note. Changes from posttest to 3-month follow-up: ∗ p < .05.

aLower scores indicate poorer functioning.
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 571

TABLE 4
Means and Standard Deviations of Dependent Variables at Pre- and Posttest for the Control Crossover
Group (n = 16)

Pretest Posttest
Dependent variablea M SD M SD t η2

Sexual intimacy 19.51 3.43 23.06 2.69∗∗ –3.25 0.41

Emotional intimacy 22.51 4.36 24.06 2.82 –1.50 0.13
Communication 23.56 2.58 26.25 2.82∗ –2.53 0.30
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Relationship satisfaction 32.31 4.44 34.26 3.79 –1.45 0.12

Note. Changes from pretest to posttest: ∗ p < .05. ∗∗ p < .01.

aLower scores indicate poorer functioning.

to become aroused/lubricated (56.3%), inability to orgasm (37.5%), delayed orgasm (31.3%),

painful intercourse (18.8%), and reduced satisfaction (37.5%). On the basis of scores from the
Female Sexual Distress Scale–Revised, all women in the control crossover group reported a level
of sexual function-related distress that is indicative of a female sexual dysfunction diagnoses. On
the basis of clinical cutoffs of the Female Sexual Function Index, 1 (7.7%) woman in the control
crossover group did not meet criteria for a female sexual dysfunction diagnosis, and 3 women
could not be categorized because of a lack of sexual activity or sexual intercourse in the 4 weeks
preceding assessment. Last, 56.25% of the control crossover group indicated that their partner
had some form of sexual difficulty.

Effects of PP on Relationship Functioning

To assess changes in relationship functioning in the control crossover group, we conducted

paired-samples t tests to compare pretest scores with posttest scores for all dependent variables.
The results suggested that the control crossover group demonstrated significant improvements in
sexual intimacy, t(15) = –3.25, p < .01, and communication, t(15) = –2.53, p < .05, but not
for emotional intimacy, t(15) = –1.50, p = .15, and relationship satisfaction, t(15) = –1.45, p =
.17. Because of the reduced sample size in the control crossover group, effect sizes, presented as
eta squared (η2) in Table 4, were calculated for each t test. The effect sizes for sexual intimacy
and communication were large, according to Cohen (1988), and the effect sizes for emotional
intimacy and relationship satisfaction were moderate. See Table 4 for a summary of means,
standard deviations and effect sizes for the control crossover group from pretest to posttest.

Maintenance of Treatment Gains

To assess maintenance of treatment gains in relationship functioning, posttest scores from the
control crossover group on all dependent variables were compared with 3-month follow-up
scores. Paired-samples t tests demonstrated no significant differences at the p < .05 level for
any of the variables: sexual intimacy, t(14) = 0.75, p = .46, emotional intimacy, t(14) = 0.37, p
= .72, communication, t(14) = 0.68, p = .51, and relationship satisfaction, t(14) = –0.35, p =
.72. These results demonstrate that the benefits of the program were maintained over a 3-month
 572 A. HUCKER AND M. P. MCCABE

TABLE 5
Means and Standard Deviations of Dependent Variables at Posttest and 3-Month Follow-Up for the Control
Crossover Group (N = 15)

Posttest Follow-up
Dependent variablea M SD M SD t η2

Sexual intimacy 23.00 2.78 22.13 3.85 0.75 0.04

Emotional intimacy 24.27 2.79 23.87 2.93 0.36 0.01
Communication 26.27 2.91 25.60 2.50 0.68 0.03
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Relationship satisfaction 33.94 3.70 34.53 4.16 −0.35 0.01

Note. No significant changes posttest to follow-up at p < .05.

aLower scores indicate poorer functioning.

follow-up period. See Table 5 for a summary of means, standard deviations and effect sizes for
the control crossover group posttest to 3-month follow-up.

DISCUSSION

As well as aiming to improve women’s sexual functioning, the PP program aimed to target
relationship factors involved in female sexual functioning. Women who completed the PP pro-
gram in Study 1 demonstrated significantly greater improvements in sexual intimacy, emotional
intimacy and communication as compared with the control group. This is consistent with past
evaluations of the online treatment for female sexual difficulties (Jones & McCabe, 2011), and is
not surprising given that the program consisted of communication- and intimacy-based exercises.
Despite these improvements, the treatment group in Study 1 did not report significantly greater
improvements in overall relationship satisfaction as compared with the control group, and this
is also consistent with prior research (Jones & McCabe, 2011). On inspection of the content of
the relationship satisfaction subscale used (also used by Jones and McCabe), it is likely that this
result is due to the subscale measuring aspects of relationship functioning not addressed in the
program, such as division of labor, differing religious beliefs, financial conflict, and parenting,
and this result may therefore not represent a limitation of the PP program itself.
In Study 2, the control crossover group demonstrated similar significant improvements in sex-
ual intimacy and communication, but did not demonstrate significant improvements in emotional
intimacy. It is hypothesized that this lack of significant findings for emotional intimacy is due
to the smaller sample size observed in the control crossover group, and it should be noted that
a moderate effect size was observed for changes in emotional intimacy from pretest to posttest.
Similarly to the results in Study 1, this group did not demonstrate significant changes in overall
relationship satisfaction.
In Study 1, the significant improvements in emotional intimacy and communication were
maintained at the 3-month follow-up, but not the improvements in sexual intimacy. These results
differ from past research into Internet-based treatment for female sexual difficulties where im-
provements in sexual intimacy were maintained at 3-month follow-up (Jones & McCabe, 2011).
In Study 2, all significant improvements were maintained at follow-up. Overall, the results from
Study 1 and Study 2 suggest that improvements in some areas of relationship functioning can be
 FEMALE SEXUAL DIFFICULTIES AND RELATIONSHIP FUNCTIONING 573

achieved through the online treatment of female sexual difficulties. Further research is necessary
to establish which areas of relationship functioning are most amendable to long-term improve-
ment after online treatment of female sexual difficulties. In qualitative feedback from the women
in both studies, the mindfulness exercises, online chat groups and communication exercises were
reported as some of the most helpful aspects of the program. However, it is not possible to
ascertain which of the various components of the PP program were effective in the improvements
observed over the PP studies.
Regarding the hypothesis that the control crossover group would demonstrate lower attrition,
this was confirmed with the control crossover group losing only 27.27% of participants, while the
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treatment group lost 43.48% of participants. In addition, the attrition in the treatment group was
similar to that reported in previous Internet-based and face-to-face studies for sexual dysfunction
and it has been noted that attrition is commonly high amongst sex therapy clients (Jones &
McCabe, 2011; McCabe & Price, 2008; Sarwer & Durlak, 1997). It is hypothesized that the
lower attrition demonstrated in the control crossover group was due to the women in Study 2
entering treatment with a higher level of motivation after completing the waitlist period. It is also
possible that other confounding variables could explain this difference in attrition, such as the
knowledge that other women (from Study 1) had already managed to complete treatment.
Despite the positive results from the PP studies, there were several limitations in need of
discussion. First, although Study 1 included a larger sample size than the Revive program (Jones
& McCabe, 2011), both of the PP studies involved small samples sizes, which were exacerbated by
attrition and the crossover design of the study. These small sample sizes limit the generalizability
of the results and may have restricted the power of statistical analyses to detect significant
differences. Future research could therefore serve to replicate these results with a larger sample.
Second, because of the use of volunteers in the study, it is possible that both studies contained
a group of women more motivated than the greater population of women experiencing sexual
difficulties. This limitation is particularly relevant to the control crossover group, who were
likely to be especially invested in the treatment after engaging in the entire waitlist period,
as hypothesized in Study 2. Third, we collected all data using self-report, which is inevitably
subjective. These data included the hurdle requirement for each module, and although it was
assumed that participants were being honest in their reports of exercises completed, there was no
way to ascertain which, or how many, exercises had been completed.
A fourth limitation of the study relates to the exclusion criteria of the studies. Although
the results are supportive of the use of Internet-based treatments for female sexual difficulties
in heterosexual relationships, the results from the PP studies may not be generalizable to all
women experiencing sexual difficulties, such as women in relationships with significant discord,
women experiencing significant mental illness, women in same-sex relationships, and single
women. Future research could serve to develop a modified Internet-based intervention for single
women experiencing sexual difficulties, with less focus on couple exercises, and greater focus on
intergenerational, individual and past relationship factors. Future research could also explore the
use of either an online program specifically targeted to women experiencing sexual difficulties
in same-sex relationships, or an Internet-based intervention for female sexual difficulties that
accommodates women in both heterosexual and nonheterosexual relationships.
Last, the PP studies lacked a comparison to medical interventions for female sexual difficulties,
or a combined medical and psychological intervention group. Given the multiple determinants
of female sexual difficulties, combined medical and psychological treatment for female sexual
 574 A. HUCKER AND M. P. MCCABE

difficulties is likely to be beneficial to women (Althof, 2010) and future research could serve
to evaluate the effectiveness of a combined medical and psychological treatment approach for
female sexual difficulties.

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Appendix
Summary of Program

Module 1
This module is intended to allow couples to emotionally reconnect before beginning touch exercises and for women to
start thinking about their attitudes toward sex. A “no-sex rule” (no intercourse or sexual activity) is explained to
couples. Psychoeducation is provided on the different types of female sexual difficulties and common myths about sex.
Women complete a written exercise to explore the usefulness of their current beliefs about sex, and couples begin
communication exercises in the form of discussion letters. Nonsexual mindfulness exercises (e.g., meditating on the
breath, mindfulness of thoughts, mindful eating) are introduced as a 5-min daily practice.
Module 2
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This module includes psychoeducation on female sexual anatomy and possible causal, perpetuating, and protective
factors involved in female sexual difficulties. Women complete a written exercise to explore the development and
maintenance of their sexual difficulties. Couples continue the communication exercises, and women are introduced to a
mindfulness exercise focusing on body awareness (mindfulness in the shower/bath) to draw attention to the pleasurable
sensations of their bodies. Sensate focus is introduced to couples with nonsexual body-touching sessions. Participants
are encouraged to use mindfulness skills (such as focusing on body sensations, noticing thoughts without judgment,
letting go of expectations, and imagining thoughts floating away down a river), to remain present and to manage
difficult thoughts and emotions.
Module 3
This module provides psychoeducation on female sexual desire/interest and factors that may negatively or positively
impact this. Women complete a written cognitive behavioral therapy exercise focused on factors that may be impacting
sexual desire/interest. Couples continue communication exercises and nonsexual massages. Self-touching is introduced
and participants are encouraged to use mindfulness skills to remain present and to manage difficult thoughts and
emotions.
Module 4
This module includes psychoeducation on male sexual anatomy, and the relationship between body image and sexual
enjoyment. Women complete a written cognitive behavioral therapy exercise on body image and sex. Couples continue
communication exercises. Genital touching is introduced to sensate focus sessions and participants are encouraged to
use mindfulness skills to help them remain present and to manage difficult thoughts and emotions.
Module 5
Module 5 contains psychoeducation on sexual intercourse in a way that aims to make definitions of sex more broad and
flexible, and to enable increased enjoyment during penetration. Women complete a written cognitive behavioral therapy
exercise focused on thoughts and feelings during intercourse. Couples continue communication exercises but are given
the option of continuing the letters, or discussing the questions without the use of letters. Penetration is introduced to
sensate focus sessions and participants are encouraged to use mindfulness skills to help them remain present and to
manage difficult thoughts and emotions.
Module 6
This final module provides psychoeducation on sexual erotica, toys, and aids, as well as an explanation of medical
interventions for female sexual dysfunctions. Couples continue communication exercises, either with or without letters.
Couples continue intercourse in sensate focus sessions with a focus on mindful awareness. Women complete a written
exercise focusing on gains made throughout PursuingPleasure and anticipated difficulties following the program, and
use this to create a relapse prevention plan.