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Sexual modes questionnaire: Measure to assess the interaction among

cognitions, emotions, and sexual response
Pedro J. Nobre ab;José Pinto-Gouveia c
a
Universidade de Trás-os-Montes e Alto Douro, Miranda do Douro, Portugal b Rua Amorim de
Carvalho, PORTUGAL c Universidade de Coimbra, Portugal

Online publication date: 11 January 2010

To cite this Article Nobre, Pedro J. andPinto-Gouveia, José(2002) 'Sexual modes questionnaire: Measure to assess the
interaction among cognitions, emotions, and sexual response', Journal of Sex Research, 40: 4, 368 — 382
To link to this Article: DOI: 10.1080/00224490209552203
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 Sexual Modes Questionnaire: Measure to Assess the Interaction Among
Cognitions, Emotions, and Sexual Response
Pedro J. Nobre
Universidade de Trás-os-Montes e Alto Douro, Miranda do Douro, Portugal
José Pinto-Gouveia
Universidade de Coimbra, Portugal

The goal of the present article is to present a new measure developed to assess cognitive and emotional factors of sexu-
al function. This instrument was developed especially to test some hypotheses derived from Beck's new theoretical concep-
tualization (the modes theory; A. T. Beck, 1996). This model, characterized by its systemic and integrated approach, consti-
tutes a remarkable development from a linear to a network perspective of the cognitive-emotional-behavioral processes. The
new concept of mode, as a composite of schemas (cognitive, emotional, and behavioral) interacting together, is theoretical-
ly sound and supported by recent research findings from clinical and experimental sets (see A. T. Beck, 1996, for a revision).
Our aim is to develop a new measure specifically created to assess these integrated and interdependent processes in the field
of sexuality. The Sexual Modes Questionnaire (SMQ; male and female versions) is a combined measure constituted by three
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interdependent subscales: automatic thoughts, emotions, and sexual response presented during sexual activity. Psychometric
studies showed good reliability and validity results in both versions, and high correlations between several dimensions of
the three subscales support the concept of mode and its interactional character. Moreover, the capacity showed by the SMQ
to discriminate between sexually functional and dysfunctional subjects and its high correlations with measures of sexual
functioning emphasize the role of cognitive-emotional processes on sexual problems, supporting the clinical value of the
measure.

Recently, a growing body of research on the role of cog-
nitions and emotions in sexual response has emerged. In
fact, since Barlow's formulation on cognitive-affective
factors of sexual dysfunction (Barlow, 1986; Cranston-
Cuebas & Barlow, 1990; Sbrocco & Barlow, 1996), sever-
al laboratory and clinical studies were conducted to analyze
the role of some cognitive and emotional dimensions in the
sexual health field. Cognitive distraction (J. G. Beck,
Barlow, Sakheim, & Abrahamson, 1987; Dove &
Wiederman, 2000; Elliot & O'Donohue, 1997; Farkas,
Sine, & Evans, 1979; Geer & Fuhr, 1976; Przybyla &
Byrne, 1984), efficacy expectancies (Bach, Brown, &
Barlow, 1999; Creti & Libman, 1989; Palace, 1995), causal
attributions (Fichten, Spector, & Libman, 1988; Weisberg,
Brown, Wincze, & Barlow, 2001), and perfectionism
This research was partially supported by a grant from PRODEP. The authors
would like to thank to Allen Gomes, M.D., Hospitals da Universidade de
Coimbra, Portugal, for making possible the collection of the clinical sample and
also for his comments and suggestions. Thanks also to D. Rijo, M.A., C.
Salvador, M.A., M. Lima, Ph.D., Faculdade de Psicologia, Universidade de
Coimbra, Portugal; A. Gomes, M.A., L. Fonseca, M.A., A. Carvalheira, M.A., J.
Teixeira, M.D., G. Santos, M.D., J. Quartilho, M.D., Ph.D., P. Abrantes, M.D.,
and A. Canhao, M.D., Hospitais da Universidade de Coimbra, for their sugges-
tions and help in sample collection. H. Ramsawh, M.A., L. Scepkowski, M.A.,
and M. Santos, B.A., Center for Anxiety and Related Disorders, Boston
University, for reviewing the English version of the measures. John Wincze,
Ph.D., Brown University and Center for Anxiety and Related Disorders, Boston
University, for his review and suggestions on a previous version of the paper.
Thanks also to participants who volunteered to participate in the study.
Address correspondence to Pedro Nobre, Rua Amorim de Carvalho, 97,4460
SENHORA DA HORA, PORTUGAL; e-mail: pedro.j.nobre@clix.pt.
(DiBartolo & Barlow, 1996) are among the most studied
cognitive dimensions in sexual functioning. In general,
results from these studies support the main role performed
by cognitive factors in sexual dysfunction processes.
For the present discussion cognitive distraction studies
assume a central role. Research with both male and
female samples suggests that distraction from sexual cues
during sexual activity decreases subjective and physio-
logical arousal in both males and females (J. G. Beck et
al., 1987; Dove & Wiederman, 2000; Elliot &
O'Donohue, 1997; Farkas et al., 1979; Geer & Fuhr,
1976; Przybyla & Byrne, 1984). These psychophysiolog-
ical studies support several clinical suggestions that dys-
functional subjects, when in sexual situations, focus their
attention on negative thoughts rather than on sexually
erotic thoughts. In males, these thoughts are mostly relat-
ed to performance concerns (erection concerns), antici-
pating failure and its consequences (Hawton, 1985;
Wincze & Barlow, 1997; Zilbergeld, 1999), whereas
females orient their attention to self-body-image con-
cerns, sexual performance concerns, and failure thoughts
(Dove & Wiederman, 2000; Hawton, 1985). Despite these
laboratory findings and clinical suggestions, there is still
a lack of naturalistic empirical studies investigating the
cognitive content of sexually dysfunctional males and
females during sexual activity. With the exception of the
Dove and Weiderman study (2000), which indicates a
negative impact of distraction thoughts (sexual perfor-
mance and bodily appearance) on female sexual function-
ing, there is no published data about cognitive content

The Journal of Sex Research Volume 40, Number 4, November 2003: pp. 368-382 368
 Nobre and Pinto-Gouveia
during sexual activity and its influence on sexual perfor-
mance.
Moreover, studies about the role of emotions on sexual
functioning, although receiving some recent attention, are
still lacking. Research on depressed affect has shown some
consistent results suggesting a negative impact on sexual
arousal. Heiman and Rowland (1983) and J. G. Beck and
Barlow (1986) found that dysfunctionals reported signifi-
cantly more negative affect during erotic exposure.
Experimental studies have further supported these findings,
showing that manipulated negative affect in sexually func-
tional subjects produced a delay in subjective sexual
arousal (Meisler & Carey, 1991) and a decrease in penile
tumescence (Mitchell, DiBartolo, Brown, & Barlow, 1998).
Research on the role of anxiety in sexual functioning
has also shown some consistent results in both men and
women. Contradicting classic theoretical perspectives
based on clinical observations (Kaplan, 1974; Masters &
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Johnson, 1970), results systematically suggest a neutral or
even a facilitative effect of anxiety on both male and
female sexual arousal (Barlow, Sakheim, & J. G. Beck,
1983; Elliot & O'Donohue, 1997; Laan, Everaerd,
Aanhold, & Rebel, 1993; Palace & Gorzalka, 1990).
Studies on the impact of anger and worry on sexual
functioning are lacking and present some inconsistent
results. Yates, Barbaree, and Marshall (1984), studying
the relationship between anger and deviant sexual
arousal, showed that this emotion might facilitate sexual
arousal, while Bozman and J. G. Beck (1991) reported
that anger decreases both desire and arousal. Katz and
Jardine (1999) analyzed the relationship between a ten-
dency to worry and sexual desire and aversion in a non-
clinical population, and found some moderate but not
conclusive correlations.
Despite this growing body of scientific literature, we
think there is a lack of integrated studies on the link
between cognitions and emotions and their impact on
sexual functioning. Our purpose is to move in that direc-
tion using cognitive theory as a preferential framework
to better understand the processes involved in sexual
dysfunction. In fact, cognitive theory has led to a better
understanding of the cognitive processes involved in a
large spectrum of psychopathological situations and has
been successfully used in the comprehension and treat-
ment of several disorders: depression (A. T. Beck, Rush,
Shaw, & Emery 1979), anxiety (A. T. Beck & Emery,
1985), relationship disorders (A. T. Beck, 1988), person-
ality disorders (A. T. Beck & Freeman, 1990), substance
abuse disorders (A. T. Beck, Wright, Newman, & Liese,
1993), and hostility (A. T. Beck, 2000).
Of particular interest is the later development of A. T.
Beck's theoretical thinking (1996). In this recent revi-
sion, Beck proposed a new conception for the structure
and processes involved in psychopathology. He devel-
oped the modes theory, substituting the linear schematic
processing for a more integrated and interactional
model. In this new concept, the central role of cognitive
369
processing (mediating emotional and behavioral reac-
tions) is substituted by a network of interdependent cog-
nitive, emotional, and behavioral dimensions. Modes are
conceptualized as specific suborganizations within the
personality organization composed of cognitive, affec-
tive, and behavioral systems. A. T. Beck (1996) suggests
that the various psychopathological disorders can be
conceptualized in terms of modes. For example, specific
phobia would be characterized by specific dangerous
thoughts, anxiety responses, and a behavioral impulse to
escape, whereas depression would be characterized by
loss thoughts accompanied by sadness and regression
behaviors.
Our goal is to study sexual dysfunctions using this the-
oretical perspective, which, besides its conceptual sound-
ness, is largely based in empirical findings and proven to
be clinically effective in a wide range of psychopatho-
logical situations (A. T. Beck, 1996). For this purpose,
we developed the Sexual Modes Questionnaire (SMQ),
specifically oriented to assess the interaction between the
automatic thoughts and the related emotions and sexual
responses. We hypothesized that dysfunctional subjects
when in sexual situations activate negative cognitive
schemas, which elicit a synchronic and interactional
response by the cognitive, emotional, and behavioral sys-
tems. This interactional response would be characterized
by negative automatic thoughts and emotions and low
sexual response. Thus, dysfunctional subjects would pre-
sent thoughts not relevant to the sexual task (i.e., lack of
sexual or erotic thoughts) but oriented to performance
demands (focus on erection) or anticipating failure and
its consequences in males, and sexual abuse thoughts,
failure and disengagement thoughts, or low self-body-
image thoughts in females. These negative automatic
thoughts would be associated with negative emotions
(mostly related to depressed mood—lack of pleasure and
satisfaction accompanied by sadness, disillusion, or
guilt) and with poor sexual response (i.e., low sexual
arousal levels). These three systems, once activated, will
feed each other and maintain the dysfunctional cycle.
This study is also part of a more global research pro-
ject developed to assess the role of cognitive-emotional
variables in sexual functioning (Nobre, 2003). For this
purpose, two other measures were also created to study
different levels of cognitive interference: a measure of
sexually dysfunctional beliefs (Nobre, Pinto-Gouveia, &
Gomes, 2003; meant to assess sexual beliefs hypothe-
sized as vulnerability factors to sexual dysfunction) and a
measure of cognitive schemas activated in sexual context
(Nobre & Pinto-Gouveia, 2003; assessing the cognitive
schemas activated by nonsucceeded sexual situations).
We hypothesized that sexual beliefs would stipulate the
conditions for the activation of the cognitive schemas in
specific sexually unsuccessful experiences. Once activat-
ed, these cognitive schemas would elicit a systemic struc-
ture composed of thoughts, emotions, and sexual
response. Past research with erectile disorders seems to
 370 Sexual Modes Questionnaire

support this model (Nobre, 1997; Nobre & Pinto-
Gouveia, 2000).
METHOD
Participants and Procedures
A total of 456 subjects (201 females and 255 males) partic-
ipated in the study. A community sample of 360 people
(154 females and 206 males) and a clinical sample of 96
people (47 females and 49 males) constituted the group.
Participants from the community sample were recruited
with the help of volunteers in different country regions.
Volunteers directly contacted participants, explained the
purpose of the study (to assess psychological variables
associated with sexual functioning), and gave them the
questionnaire with the respective instructions. These partic-
ipants were instructed to answer the questionnaires when
alone and in the privacy of their homes and then to return
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sexual desire (38%), vaginismus (24%), and orgasmic dis-
orders (20%) were the main female complaints.
To perform a discriminant analysis, we also selected a
control group. Participants (46 females and 49 males) were
selected from the community sample above to match the
clinical group regarding age, marital status, and education
level. Subjects from this control group were also screened
using the International Index of Erectile Function (IIEF;
Rosen et al., 1997) and the Female Sexual Function Index
(FSFT; Rosen et al., 2000) to eliminate sexual dysfunction.
Detailed demographic data from both male and female
clinical and control groups are presented in Table 2.
Materials
Sexual Modes Questionnaire (SMQ)
This questionnaire was developed to evaluate the modes
model proposed by A. T. Beck (1996). Because of the

them by mail using prestamped envelopes. We did not pay interactional character of the modes concept, we created a
participants for their participation. The response rate was questionnaire that assesses three different areas (automatic
30.6% (demographic characteristics presented in Table 1). thoughts, emotional response, and sexual response).
We recruited the clinical sample from the sexology clin- Automatic thought subscale (AT). A 30-item male and a
ic of Coimbra's University Hospital. Subjects diagnosed 33-item female scale were developed to evaluate automatic
with sexual dysfunction using the Diagnostic and Statistical thoughts and images presented by the participants during
Manual of Mental Disorders (DSM-IV; American sexual activity. We asked participants to rate the frequency
Psychiatric Association, 1994) criteria constituted this clin- (from 1 = never to 5 = always) with which they usually
ical group. Participants answered the questionnaire after experience those automatic thoughts during their sexual
completing a clinical assessment for sexual dysfunction activity. Thoughts included in the scale were selected based
conducted by a group of trained sex therapists from the on their theoretical and clinical relevance. Using some of
clinic. One of the researchers involved in the project the empirical and clinical findings presented above, we
explained the study purpose, and participants signed a con- selected items to assess whether the thought content was
sent form. Participants then answered the questionnaires by oriented to sexual and erotic stimuli or to nonrelevant cues.
themselves in a private space and returned them directly to Among the nonsexual thoughts, we assessed several dimen-
the member of the research team present. Erectile disorder sions. For the male version we generated items to cover
(70%) and premature ejaculation (25%) were the most sexual performance thoughts (mostly oriented to the
common diagnoses in the male sample, while hypoactive
Table 2. Participants' Demographic Characteristics From
Clinical and Control Groups
Table 1. Demographic Characteristics of the Community Female Male
Sample
Clinical Control Clinical Control
Female Male sample sample sample sample
(n = 154) (n = 206) (n = 47) (n = 46) (n = 49) (n = 49)
Age Age
M 24.4 30.6 M 28.7 29.2 43.0 42.7
Min-Max 18-55 18-56 Min-Max 19-50 18-48 18-67 18-56
SD 7.2 9.4 SD 6.7 8.6 14.4 15.7
% % % %
Marital status Marital status
Single 82.2 55.2 Single 25.5 28.2 26.5 22.4
Married 15.8 39.8 Married 63.8 60.9 61.2 71.4
Divorced 0.0 2.5 Divorced 4.3 0.0 2.1 2.0
Living together 2.0 2.5 Living together 6.4 6.5 10.2 4.1
Education level Education level
0-4 years 3.0 8.5 0-4 years 10.6 10.9 38.8 36.0
5-6 years 3.0 3.5 5-6 years 10.6 10.9 24.5 8.0
7-9 years 2.0 5.1 7-9 years 6.4 6.5 12.2 22.0
10-12 years 23.4 17.1 10-12 years 31.9 34.8 22.4 30.0
13-15 years 8.1 7.0 13-15 years 10.6 4.3 0.0 0.0
16 or more years 60.5 58.8 16 or more years 29.8 32.6 2.0 4.0
 Nobre and Pinto-Gouveia
erectile response), failure anticipation thoughts, negative
thoughts toward sexuality (conservative thoughts), and
thoughts about the negative impact of age on sexual func-
tioning. We generated items for the female version to assess
failure and disengagement thoughts, low body-image
thoughts, sexual abuse thoughts, thoughts about a partner's
lack of affection, and sexual passivity and control thoughts.
An index of negative automatic thoughts was calculated by
summing all automatic thought items (thoughts related to
erotic cues were scored in reverse order). The negative
automatic thought score ranges for both male and female
versions are presented in the factor analysis and domain
score section.
Emotional response subscale (ER). We developed a 30-
item male and a 33-item female scale to evaluate emotions
experienced by the subjects during sexual activity. The
items were directly connected to the items of the automat-
ic thought scale. So, for each automatic thought, subjects
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indicate their emotional response. A list of ten emotions
was presented (worry, sadness, disillusion, fear, guilt,
shame, anger, hurt, pleasure, satisfaction), and participants
were asked to check which they usually experienced
whenever they endorsed each automatic thought. An index
for each emotional response was calculated based on the
following formula: total number of each emotion endorsed
/ total number of emotions endorsed. The indices based on
this formula represent the ratio at which participants usu-
ally experience each emotion during sexual activity. The
emotional response index ranges from 0.0 to 1.0.
Sexual response subscale (SR). We developed a 30-item
male and a 33-item female scale to evaluate the subjective
sexual response during sexual activity (subjective sexual
arousal). The items were directly connected to the items of
the automatic thought scale. So, for each automatic
thought presented, the subjects were asked to rate the
intensity of their subjective sexual arousal (from 1 = very
low to 5 = very high). An index of sexual response was cal-
culated based on the following formula: sum of the sexual
response for each item / total number of sexual response
items endorsed. The index based on this formula gives an
indication of the average sexual response (subjective sexu-
al arousal) presented by the participants during sexual
activity. The sexual response index ranges from 1 to 5.
Convergent Validity
To assess convergent validity, we used measures of male
and female sexual functioning: the International Index of
Erectile Function (IIEF; Rosen et al., 1997) and the
Female Sexual Function Index (FSFI; Rosen et al., 2000).
The International Index of Erectile Function (IIEF).
The IIEF (Rosen et al., 1997) is a brief 15-item self-admin-
istered measure of erectile function, evaluating five
domains: erectile function, orgasmic function, sexual
desire, intercourse satisfaction, and overall satisfaction.
Psychometric studies supported the validity (significant
mean difference scores between a clinical and a control
group) and reliability (Cronbach's a values of .73 and
371
higher and test-retest from r = .64 - .84) of the measure.
Studies with clinical samples also demonstrated its sensi-
tivity and specificity for detecting treatment-related
changes (Rosen et al., 1997).
The Female Sexual Function Index (FSFI). The FSFI
(Rosen et al., 2000) is a 19-item instrument, easily admin-
istered and scored, providing detailed information on the
major dimensions of sexual function: sexual interest and
desire, sexual arousal, lubrication, orgasm, sexual satisfac-
tion, and sexual pain. The measure presents acceptable
test-retest reliability (r = .79 - .86), internal consistency
(Cronbach's a = .82 and higher), and validity (demonstrat-
ed by significant mean difference scores between a clinical
and a control group).
RESULTS
This section presents data regarding the psychometric
characteristics of the questionnaire. The process used for
item generation and selection is explained, and data about
reliability (internal consistency and test-retest) are present-
ed. We also present factorial analysis of both male and
female versions, as well as convergent validity (relation-
ship between our measure and sexual function instru-
ments) and divergent validity analysis (comparing the
mean scores from a clinical and a control group).
Item Analysis
To develop the automatic thought subscale, we completed
an item analysis of an initial pool of 68 items (female ver-
sion) and 54 items (male version). This initial pool was
generated by the authors with the help of a panel of experts
on sex therapy (group of sex therapists from the sexology
clinic of Coimbra's University Hospital). As presented
above, item generation was based on theoretical and clini-
cal data with the purpose of testing some hypotheses
derived from cognitive distraction studies. This initial pool
of items was submitted to an item analysis, where item-
total correlation was calculated, as well as its relationship
with sexual function instruments (IIEF and FSFI). Items
presenting low correlations with the total (r < .35) as well
as nonsignificant correlations with the IIEF (male version)
or the FSFI (female version) were excluded. We then con-
ducted an exploratory factor analysis and excluded items
not loading significantly on any of the factors extracted or
presenting factor loadings higher than .4 on more than one
factor. The remaining 33 items (female version) and 30
items (male version) constitute the final version of the
automatic thoughts subscale.
Reliability Studies
Test-Retest Reliability
Test-retest reliability of both male and female automatic
thought subscales was assessed by computing a Pearson
product-moment correlation between two consecutive
administrations with a 4-week interval (Table 3). Results
from the female version clearly show the stability of our
 372 Sexual Modes Questionnaire

measure across time with a very high correlation for the
total scale (r = .95, p < .01) and moderate to high correla-
tions when considering the specific dimensions assessed
(correlations range from r = .52, p < .05 to r = .90, p < .01).
Regarding the male version, results show a more mod-
erate Pearson product-moment correlation between the
two consecutive administrations (r = .65, p = .08).
However, despite this moderate result, correlations for the
several specific dimensions of our measure show statisti-
cally significant results for every domain except one (cor-
relations range from r = .71, p < .05 to r = .95, p < .01).
One of the dimensions assessed (negative thoughts toward
sex) presented very low stability across time (r = .20, p =
.61) and was responsible for the moderate reliability of the
total scale. However, since this analysis was based on a
small sample (n = 9), no consistent conclusion should be
made regarding test-retest reliability for both total and
dimensional scales.
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subscale (AT), we performed a factor analysis of both male
and female measures.
Female Version
We performed a principal component analysis (using vari-
max rotation) on the 33 items of the female version (Table
4). Six factors were identified using the Catell's scree test
criteria, explaining 53.1% of the total variance (Fl =
23.2%, F2 = 10.0%, F3 = 6.0%, F4 = 5.3%, F5 = 4.4%, F6
= 4.2%). A Kaiser-Meyer-Olkin measure of .84 supported
the adequacy of the sample, and Bartlett's test of spherici-
ty was significant (%2 = 528, p < .001).
The item selection for each factor was based on sta-
tistical and interpretability criteria. We based our inclu-
sion decisions on loadings higher than .4 on the respec-
tive factor. Items that didn't load high on any of the fac-
tors or that presented high correlations with more than
one factor were excluded (two items were excluded

using this criteria: Item 13, "I'm not satisfying my part-

Internal Consistency ner"; and Item 18, "He only does what I want when he
Internal consistency of both male and female automatic needs me for sex"). The six factors identified were as
thoughts subscales was assessed using Cronbach's oc for follows:
the total scale and for each dimension separately (Table 3). 1. Sexual Abuse Thoughts: the dimension that express
Results were high for male and female total scales (a = .87 es thoughts of being abused, disrespected, and even
and .88 for female and male versions, respectively), show- violated by the sexual partner.
ing the general consistency of the measures. Looking at the 2. Failure and Disengagement Thoughts: the domain
internal consistency of the specific dimensions assessed by that is constituted by thoughts of incapacity for sex-
our instrument, we may also observe high interitem corre- ual performance and lack of motivation to engage in
lations within each factor. Cronbach's a statistics range sexual activity.
from .71 to .80 for the female version and from .69 to .83 3. Partner's Lack of Affection: the factor characterized
for the male one. by thoughts of not being treated with care and affec-
tion by the partner during sexual activity. This
Factor Analysis and Scores dimension reflects the dichotomy between sex as an
To study the internal structure of the automatic thought affective activity and sex as a physical activity.
4. Sexual Passivity and Control: the dimension repre-
sented by thoughts of female sexual passivity and
Table 3. Test-Retest Reliability and Internal Consistency of control, reflecting the idea that women must wait for
Male and Female AT Factors and Total
the male's first step in order to match cultural values
Factors IV items Pearson r Cronbach's a
(not being seen as frivolous) and also to prevent
a
Female sample eventual emotional harm.
Sexual Abuse Thoughts 8 .84** .74 5. Lack of Erotic Thoughts: the domain formed by
Failure and Disengagement
Thoughts 4 .82** .80 thoughts of sexual erotic content. Since these items
Partner's Lack of Affection 5 .75** .71 were scored in reverse order, higher results on this
Sexual Passivity and Control 6 .90** .74 factor represent lack of erotic thought content during
Lack of Erotic Thoughts 5 .52* .74 sexual activity.
Low Self-Body-Image Thoughts 3 .79** .77 6. Low Self-Body-Image Thoughts: the factor charac-
Total 31 .95** .87
terized by thoughts of not being comfortable with
Male sampleb
Failure Anticipation Thoughts 7 .95** .82
one's body image.
Erection Concern Thoughts 7 .77* .83 The factor intercorrelations (Table 5) show the strong
Age and Body Related Thoughts 4 .71* .74 relationships between the factors identified, suggesting
Negative Thoughts Toward Sex 5 .20 .71 they assess concepts that are somehow related to each
Lack of Erotic Thoughts 4 .72* .69 other. We may observe that, with the exception of Factor 5
Total 27 .65 .88
(Lack of Erotic Thoughts), all other dimensions present
Note. Subjects used in the analysis were taken from the community statistically significant intercorrelations.
sample.
a
For female sample: Pearson's r, n = 23; Cronbach's a, n = 154. b For The range, means, and standard deviations of possible
male sample: Pearson's r, n = 9; Cronbach's a, n = 206. factor and total scores for the automatic thought subscale
*p<.05. **p<.01. (female version) are presented in Table 6. Higher scores on
 Nobre and Pinto-Gouveia 373

Table 4. Principal Component Analysis of the Automatic Thought Subscale (Female Version) With Varimax Rotation
(N = 154)
Automatic thought items Factors

Factor 1: Sexual Abuse Thoughts

1. He is abusing me .69 .06 .32 .12 16 -.12
2. How can I get out of this situation? .50 .39 -.04 .13 14 .11
3. He only wants to satisfy himself .53 .11 .28 .12 02 -.08
4. Sex is all he thinks about .63 .18 .17 .10 05 .21
6. He is violating me .65 .06 .02 .12 01 .02
15. This is disgusting .40 .30 .24 .15 26 .14
32. I have other more important matters to deal with .39 .26 .24 .23 08 .10
33. If I refuse to have sex, he will cheat on me .52 .28 .28 -.08 01 .15
Factor 2: Failure / Disengagement Thoughts
19. I'm not getting turned on .26 .74 -.01 .01 05 .22
22. I can't feel anything -.03 .53 .32 .17 20 -.02
26. When will this be over? .36 .72 .05 .12 31 .08
30. I'm only doing this because he asked me to .39 .64 .14 .11 21 .03
Factor 3: Partner's Lack of Affection
7. This way of having sex is immoral .15 .17 .59 .08 11 .06
12. He is not being as affectionate as he used to .34 .00 .57 .11 14 .22
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24. Why doesn't he kiss me? -.08 .16 .42 .38 05 .21
27. If only he'd whisper something romantic in my ear .27 .07 .54 .17 06 .10
28. He only loves me if I'm good in bed .27 .19 .63 .14 07 .11
Factor 4: Sexual Passivity and Control
10. If I let myself go he is going to think I'm promiscuous .33 -.10 .20 .48 11 .05
14. I must not show that I'm interested .21 -.06 .42 .60 11 -.20
17. I should not take the lead in sexual activity -.00 .15 .26 .74 04 .03
21. These activities shouldn't be planned ahead of time .21 .03 -.21 .57 12 .27
23. I don't want to get hurt emotionally .34 .10 -.01 .54 06 .35
29. I should wait for him to make the first movement .04 .28 .19 .66 13 -.01
Factor 5: Lack of Erotic Thoughts
5. The way he is talking turns me on a -.08 .16 .17 -.08 70 -.07
8. These movements and positions are fabulousa .00 .07 -.14 .02 74 -.10
11. Making love is wonderfula .04 .33 -.10 .01 66 -.01
25. My body turns him on a -.01 -.15 -.06 -.11 67 .18
31. I'm the happiest woman on earth a .38 .30 .14 -.12 55 -.08
Factor 6: Low Self-Body-Image Thoughts
9. I'm getting fat/ugly .06 -.01 -.01 .12 01 .79
16. I'm not as physically attractive as I used to be .10 .11 .29 .12 01 .77
20. I'm not feeling physically attractive .04 .32 .26 -.01 04 .71
' Items scored in reverse order.

the total scale represent negative automatic thoughts dur-
ing sexual activity.
Male Version
Regarding the male version, we identified five factors after
performing a principal component analysis (Table 7) using
varimax rotation on its 30 items (using the Catell's scree test
criteria). The factors explained 54.7% of the total variance
(Fl = 31.8%, F2 = 7.8%, F3 = 6.0%, F4 = 5.1%, F5 = 4.1%).
A Kaiser-Meyer-Olkin measure of .88 supported the ade-
quacy of the sample, and Bartlett's test of sphericity was sig-
nificant (x2 = 435, p < .001).
The item selection for each factor was based on statisti-
cal and interpretability criteria. We based our inclusion
decision on loadings higher than .4 on the respective factor.
Items that didn't load high on any of the factors or that pre-
sented high correlations with more than one factor were
excluded. Three items were excluded using this criteria:

Table 5. Female AT Factor Intercorrelations (Pearson r; N = 154)

Factors Fl F2 F3 F4 F5 F6
Sexual Abuse Thoughts
Failure/Disengagement Thoughts .57** —
Partner's Lack of Affection .54** .40**
Sexual Passivity and Control .45** .52** .51**
Lack of Erotic Thoughts .20** .21** .01 -.13
Low Self-Body-Image Thoughts .29** .37** .36** .29** -.02
p<.05.
 374 Sexual Modes Questionnaire

Table 6. Means, Standard Deviations, Minimums, and Maximums of Female AT Factors and Totals
Factors Item number Means SD Minimum Maximum
Sexual Abuse Thoughts 1,2,3,4,6,15,32,33 13.26 5.84 8 40
Failure/Disengagement Thoughts 19, 22, 26, 30 7.15 2.66 4 20
Partner's Lack of Affection 7, 12, 24, 27, 28 8.56 3.32 5 25
Sexual Passivity and Control 10, 14,17,21,23,29 10.11 3.71 6 30
Lack of Erotic Thoughts 5,8, 11,25,31 12.28 2.92 5 25
Low Self-Body-Image Thoughts 9, 16, 20 6.90 2.77 3 15
Total 57.29 14.85 31 155
Note. Items 5, 8, 11, 25, and 31 are scored in reverse order.

Item 13, "What is she thinking about me?"; Item 15, "If
others know that I can't perform..."; and Item 27, "I must
show my virility." The five factors identified were the fol-
lowing:
1. Failure Anticipation and Catastrophyzing Thoughts:
the factor characterized by thoughts of incapacity to
perform, failure anticipation, and magnifying the
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factor represented by thoughts of being old and its
implications regarding sexual activity and partner's
attraction.
4. Negative Thoughts Toward Sex: the factor character-
ized by conservative and negative thoughts toward
sexuality.
5. Lack of Erotic Thoughts: the dimension represented

negative consequence of failure.
2. Erection Concern Thoughts: the dimension constitut-
ed by thoughts specifically related to penis reaction
and concerns about capacity for intercourse.
3. Age and Body Function Related Thoughts: the
by sexual and erotic thoughts. Since these items were
scored in reverse order, higher values on this domain
represent lack of erotic thought content during sexu-
al activity.
The factor intercorrelations presented in Table 8 show

Table 7. Principal Component Analysis of The Automatic Thought Subscale (Male Version) Using Varimax Rotation (N = 206)
Automatic thought items Factors
1 2 3 4 5
Factor 1: Failure Anticipation Thoughts
1. It would be better to die than to be like this .50 .25 -.02 .31 .01
2. This time I cannot disappoint my partner .60 .24 .29 -.01 -.12
3. She will replace me with another guy .64 .05 .25 .22 -.16
4. I'm condemned to failure .73 .35 .13 .25 .06
6. This is not going anywhere .65 .05 .03 .29 -.12
7. I'm not satisfying her .71 .17 .11 -.04 -.05
16. If I fail again I'm a lost cause .60 .43 .24 .22 .06
Factor 2: Erection Concern Thoughts
5. I must be able to have intercourse .20 .57 .35 .26 -.16
8. I must achieve an erection .11 .66 .36 .08 -.05
9. I'm not penetrating my partner .27 .55 .25 -.09 -.02
10. My penis is not responding .16 .61 .01 .23 -.09
11. Why isn't this working? .16 .74 .03 .07 -.06
12. I wish this could last longer .39 .47 .18 .26 -.24
29. If I can't get an erection, I will be embarrassed .25 .65 .38 .24 -.04
Factor 3: Age and Body Related Thoughts
19. If I don't climax now, I wont be able to later .15 .25 .59 .21 .03
21. She doesn't find my body attractive anymore .26 .08 .70 .20 -.09
22. I'm getting old .06 .12 .73 -.01 .01
28. It will never be the same again .11 .32 .71 .10 -.06
Factor 4: Negative Thoughts Toward Sex
20. She is not being as affectionate as she used to .05 -.02 .43 .57 -.10
23. This is disgusting .41 .16 .00 .73 .13
24. This way of having sex is immoral -.02 .44 .14 .60 .17
25. Telling her what I want sexually would be unnatural .21 .12 .39 .44 -.21
30. I've other more important matters to deal with .37 .16 .17 .62 -.05
Factor 5: Lack of Erotic Thoughts
14. These movements and positions are fabulous a -.02 -.03 -.01 -.11 .75
17. I'm the happiest man on earth a .01 -.09 -.08 .05 .74
18. This is turning me on a .06 -.09 -.04 .02 .77
26. She is really turned on a -.21 .04 -.02 .03 .55
a
Items scored in reverse order.
 Nobre and Pinto-Gouveia 375

Table 8. Male AT Factor Intercorrelations (Pearson r; N = 206)

Factors Fl F2 F3 F4 F5
Failure Anticipation Thoughts
Erection Concern Thoughts .63**
Age and Body Related Thoughts .47** .57**
Negative Thoughts Toward Sex .50** .53** .51**
Lack of Erotic Thoughts .11 .17* .08 -.01
p<.05. **/?<.01.

once again the strong relationships among all factors, with
the exception of Lack of Erotic Thoughts.
The range, means, and standard deviations of possible
factor and total scores for the automatic thought scale
(male version) are presented in Table 9. Higher scores on
the total scale represent negative automatic thoughts dur-
ing sexual activity.
Correlations Between the Questionnaire Subscales
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ship between what people think during sexual activity and
their sexual response (measured as the amount of subjec-
tive arousal experienced). Results show statistically signif-
icant negative correlations among all dimensions of the
automatic thought subscale and the sexual response index.
The greater the number of negative thoughts, the less the
subjective arousal experienced (Table 11).
Emotions and Sexual Response

To test the integrative nature of the cognitive, emotional,
and behavioral systems, we conducted a series of correla-
tional studies between the automatic thought, emotional
response, and sexual response subscales.
Automatic Thoughts and Emotions
Correlations between the automatic thought subscale (AT)
and the emotional response subscale (ER) show the strong
link between these two dimensions (Table 10). For the
total score of the female automatic thought subscale (neg-
ative automatic thought index) we observed a statistically
significant relationship with almost all emotions present-
ed: sadness, disillusionment, fear, guilt, shame, pleasure,
and satisfaction. So, the greater the negative thoughts pre-
sented during sexual activity, the greater the tendency to
experience negative emotions and the lesser the tendency
to feel pleasure and satisfaction.
For the male sample, correlations between the different
dimensions of the automatic thought subscale and the
emotional response subscale proved to be statistically sig-
nificant in several factors. In summary, the greater the dys-
functional thoughts presented during sexual activity, the
greater the probability of experiencing disillusionment,
sadness, and shame and the lesser the tendency to feel
pleasure and satisfaction.
Automatic Thoughts and Sexual Response
Correlations between the automatic thought subscale and
the sexual response subscale highlight the strong relation-
Correlations between the emotions experienced during
sexual activity and the intensity of sexual response show
that there is a link between some emotional responses and
behavioral dimensions in sexual expression. Emotions of
sadness, disillusionment, guilt, shame, anger, and hurt
were inversely related to sexual response intensity, where-
as pleasure and satisfaction feelings correlated positively
and significantly with sexual response indices (Table 12).
Correlational studies supported the strong links among
the three subscales assessed in our questionnaire. In fact,
thoughts, emotions, and sexual response showed high cor-
relational levels, supporting the usefulness of an interac-
tional assessment strategy.
Convergent Validity
To assess the convergent validity of our measure, we used the
Female Sexual Function Index (FSFT; Rosen et al., 2000) and
the International Index of Erectile Function (IIEF; Rosen et
al., 1997). We expected that the automatic thoughts and emo-
tions presented during sexual activity would be strongly cor-
related with measures of sexual functioning.
Regarding the correlations between the automatic
thought subscale and both male and female sexual function,
we found several statistically significant correlations. This
shows that when participants were in sexual situations, their
thoughts and mental images were closely related to their
sexual functioning (Table 13). Looking at the female sam-
ple, the FSFI presented high negative correlations with
Sexual Abuse Thoughts (Fl), Failure and Disengagement

Table 9. Means, Standard Deviations, Minimums, and Maximums of Male AT Factors and Totals
Factors Item numbers Means SD Minimum Maximum
Failure Anticipation Thoughts 1,2,3,4,6,7,16 13.10 5.41 7 35
Erection Concern Thoughts 5,8,9, 10, 11, 12,29 14.03 5.57 7 35
Age and Body Related Thoughts 19,21,22,28 8.20 3.22 4 20
Negative Thoughts Toward Sex 20, 23, 24, 25, 30 9.24 3.72 5 25
Lack of Erotic Thoughts 14, 17, 18, 26 11.29 3.11 4 20
Total 54.24 14.70 27 135
iVore. Items 14, 17, 18, and 26 are scored in reverse order.
 376 Sexual Modes Questionnaire

Table 10. Correlations of Male and Female Automatic Thought Subscale Factors With the Emotional Response (ER) Indices
ER indices
AT factors Worry Sadness Disillusion Fear Guilt :Shame Anger Hurt Pleasure Satisfaction
Females (n = 154)
Sexual Abuse Thoughts .10 .09 .16* .08 .20** .18* .21** .12 -.36** -.27**
Failure/Disengagement Thoughts .22** .22** .26** .04 .24** .03 .22** .14 -.46** -.19*
Partner's Lack of Affection .01 .11 .18* .11 .24** .16* .11 .11 -.37** -.21**
Sexual Passivity and Control .25** -.07 .06 .34** .17* .25** .02 -.06 -.34** -.29**
Lack of Erotic Thoughts -.04 .28** .11 .00 .17* .13 .17* .15 -.24** -.14*
Low Self-Body-Image Thoughts .18 .20* .09 .10 .19* .11 -.05 .03 -.21** -.28**
Total .13 .20* .28** .20* .28** .30** .08 .14 -.45** -.38**
Males (n = 206)
Failure Anticipation Thoughts .02 .26* .25* .12 .16 .38** .10 .13 -.45** -.38**
Erection Concern Thoughts .19 .39** .30** -.02 .11 .23* -.01 .20 -.46** -.47**
Age and Body Related Thoughts -.05 .34** .34** .06 .14 .43** .01 .11 -.34** ..44**
Negative Thoughts Toward Sex -.03 .05 .19 .07 .37** .49** .09 .08 -.28** -.34**
Lack of Erotic Thoughts .04 .36** .45** -.06 -.17 -.11 -.05 .02 -.31** -.24*
Total .11 .37** .42** .04 .19 .40** .02 .17 -.52** -.51**
* p<.05. **p<m.
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Thoughts (F2), and Lack of Erotic Thoughts (F5).
Interestingly, Partner's Lack of Affection (F3) and Low
Self-Body-Image Thoughts (F6) presented low correlations
with sexual functioning. Sexual Passivity and Control
Thoughts (F4), although not strongly correlated with the
sexual function index, presented statistically significant neg-
ative correlations with the FSFI dimensions of arousal,
lubrication, and orgasm.
Regarding the male sample, there were strong negative
correlations between the IIEF total scores and Failure
Anticipation Thoughts (Fl), Erection Concern Thoughts
(F2), and Lack of Erotic Thoughts (F5). Negative
Thoughts Toward Sex (F4), although not correlated highly
with the sexual function index, showed a statistically sig-
nificant negative correlation with the orgasm dimension.
Correlations between the emotional response subscale
(ER) and the male and female sexual function indices are
presented in Table 14. Regarding the female sample, we
Table 11. Correlations of the Male and Female Automatic
Thought Subscale Factors With the Sexual
Response (SR) Index
AT factors SR index
observed strong negative correlations between the female
sexual function index and sadness, guilt, and anger, and sig-
nificantly positive correlations with pleasure. In the male
sample, higher correlations were observed between the IIEF
and sadness, disillusionment, pleasure, and satisfaction.
Discriminant Validity
To perform a discriminant validity analysis, we used a t
test of mean differences between the clinical group (sub-
jects who presented themselves in a sexology clinic com-
plaining of a sexual difficulty) and the control group
(demographic data for both groups presented in Table 2).
We hypothesized that dysfunctional subjects would pre-
sent higher scores on both male and female negative auto-
matic thoughts, as well as more negative emotions and
lower sexual response indices, supporting our hypothesis
that the SMQ assesses automatic thoughts and emotions
that play an important role in the development and main-
tenance of sexual problems.
Results demonstrated that there were several statistically
significant differences in the automatic thoughts, emotions,
^ J T^

Females (n = 154) lable 12. Correlations ot the Male anu remaie nmouunai
Response Indices With the Sexual Response Indices
Sexual Abuse Thoughts -.47**
Failure/Disengagement Thoughts .^44** Sexual Response Indices
Partner's Lack of Affection -.25** Emotional Response Female Male
Sexual Passivity and Control -.19* Indices in = 154) (n = 206)
Lack of Erotic Thoughts -.40** Worry -.10 -.07
Low Self-Body-Image Thoughts -.26** Sadness -.18* -.34**
Total -.48** Disillusion -.27 ** -.48**
Males (n = 206) Fear -.12 -.09
Failure Anticipation Thoughts -.48** Guilt -.22 ** -.07
Erection Concern Thoughts -.57** Shame -.19*- -.24*
Age and Body Related Thoughts -.43** Anger -.19* -.17
Negative Thoughts Toward Sex -.36** Hurt -.20, * -.10
Lack of Erotic Thoughts -.39** Pleasure .55** .58**
Total -.63** Satisfaction .21 ** .49**
* p<.05. **p<.01. * p<.05. **p<M.
 Nobre and Pinto-Gouveia 377

Table 13. Correlations of the Male and Female Automatic Thought Subscale Factors With the FSFI and IIEF Domains and Total
Female sample (n = 154)
]FSFIDomains
AT Factors Desire Arousal Lubrication Orgasm Satisfaction Pain Total
Sexual Abuse Thoughts -.16* -.10 -.08 -.09 -.37** -.08 -.28**
Failure / Disengagement Thoughts -.35** -.17* -.02 -.14 .49** -.21** -.53**
Partner's Lack of Affection -.07 -.01 .01 -.09 -.07 .05 -.03
Sexual Passivity and Control -.06 -.20** -.23** -.16* -.11 -.13 -.12
Lack of Erotic Thoughts -.52** -.38** -.30** -.32** -.47** -.30** -.49**
Low Self-Body-Image Thoughts .14 -.04 .04 -.08 -.05 -.02 .06
Total -.31** -.33** -.20* -.31** -.59** -.29** _ 49**
Male sample (n = 163)
AT Factors IIEF Domains
Overall Intercourse
Desire Erection Orgasm satisfaction satisfaction Total
Failure Anticipation Thoughts -.20* -.20* -.19* -.17* -.29** -.31**
Erection Concern Thoughts -.07 -.32** -.12 -.19* -.13 -.31**
Age / Body Related Thoughts -.08 -.03 -.14 -.05 -.19* -.11
Negative Thoughts Toward Sex -.07 -.10 -.26** -.12 -.17* -.16
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Lack of Erotic Thoughts -.14 -.10 -.05 -.12 -.21** -.22**

Total -.37** -.61** -.41** -.46** -.66** -.60*
Note. FSFI = (Female Sexual Function Index); IIEF = (International Index of Erectile Response).
* p<.05. **p<.01.

and sexual responses between clinical and control groups in
both male and female samples (Table 15). In the female
sample, the clinical group presented significantly higher
scores on Failure and Disengagement Thoughts (F2), Lack
of Erotic Thoughts (F5), and the total scale.
In the male sample, the clinical group presented signif-
icantly higher scores (compared to the control group) on
Failure Anticipation (Fl), Erection Concern (F2), and
Lack of Erotic Thoughts (F5). Interestingly, subjects from
the control group presented significantly higher results in
Negative Thoughts Toward Sexuality (F4), possibly indi-
cating that dysfunctional males do not necessarily have
negative thoughts or ideas about the sexual act itself.
These results show that our questionnaire measures
thoughts and images in sexual situations that are closely
related to sexual problems, and that its assessment and
analysis may be important in understanding human sexu-
al difficulties.
As observed for the automatic thought scale, emotion-
al response during sexual activity also discriminated clin-
ical from nonclinical populations. Observing the results
in Table 16, we may conclude that sexually dysfunction-
al subjects present significant differences from function-
al subjects in several emotional responses facing sexual

Table 14. Correlations of the Male and Female Emotional Response (ER) Indices With the FSFI and IIEF Domains and Total
ER indices
Worry Sadness Disillusion Fear Guilt Shame Anger Hurt Pleasure Satisfaction
Females (n = 154)
FSFI Domains
Desire .06 -.23** .02 -.01 -.26** -.08 -.24** -.05 .26** .07
Arousal -.05 -.21** .02 -.07 -.13 -.11 -.07 -.11 .32** -.03
Lubrication -.05 -.15 .07 -.04 -.04 -.11 -.09 -.03 .23** -.04
Orgasm -.06 -.18* .03 -.11 -.11 -.16* -.04 -.06 .29** -.03
Satisfaction -.08 -.36** -.08 -.08 -.20* -.07 -.13 -.14 .38** .07
Pain -.01 -.21** .00 -.14 -.12 -.18* -.04 -.01 .28** -.01
Total -.04 -.27** -.03 -.07 -.25** -.09 -.18* -.06 .31** .06
Males (n = 99)
IIEF Domains
Desire .05 -.29** -.27** .03 .12 -.06 .03 .03 .12 .26*
Erection -.10 ..44** -.34** .09 -.06 -.10 .09 -.10 .41** .33**
Orgasm -.04 -.36** -.15 -.00 -.09 -.11 -.03 -.06 .39** .19
Overall satisfaction -.04 -.38** -.31** .08 -.05 -.12 .03 -.05 .38** .27**
Intercourse satisfaction -.02 -.41** -.43** .04 .05 -.09 -.07 .02 .43** .36**
Total -.01 -.45** -.37** .09 -.06 -.10 .03 -.08 .41** .33**
Note. FSFI = (Female Sexual Function Index); IIEF = (International Index of Erectile Response).
* p<.05. **p<.0l.
 378 Sexual Modes Questionnaire

Table 15. Means and SD of the Clinical and Control Groups in the Male and Female AT Factors and Between-Groups t Test
Clinical group Control group
AT factors N Mean SD N Mean SD
Female sample
Sexual Abuse Thoughts 42 15.36 4.53 38 13.26 5.84 1.80
Failure / Disengagement Thoughts 46 10.80 3.27 39 7.15 2.66 5.58**
Partner's Lack of Affection 42 8.86 3.80 39 8.56 3.32 0.37
Sexual Passivity and Control 41 10.71 4.19 38 10.11 3.71 0.67
Lack of Erotic Thoughts 41 16.90 4.14 36 12.28 2.92 5.59**
Low Self-Body-Image Thoughts 45 6.87 2.82 39 6.90 2.77 -0.05
Total ^f. 68 89 1?Q1 ^ ^7?Q 1485 7, <;•?**

Male sample
Failure Anticipation Thoughts 47 15.85 6.39 41 13.10 5.41 2.16*
Erection Concern Thoughts 44 20.25 7.74 37 14.03 5.57 4.08**
Age / Body Related Thoughts 45 8.67 3.55 40 8.20 3.22 0.63
Negative Thoughts Toward Sex 45 7.42 2.71 41 9.24 3.72 -2.61*
Lack of Erotic Thoughts 47 14.89 3.45 42 11.29 3.11 5.16**
Total 42 67.24 17.41 34 54.24 14.70 3.47**
p<.05. **/?<.01.
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situations. This is true for both male and female samples.
The female clinical group showed significantly higher
scores on hurt and lower scores on pleasure and satisfac-
tion. Male dysfunctional subjects presented significantly
higher results on sadness and lower results on pleasure and
satisfaction. These results highlight the importance and
significance of assessing emotional responses in a sexual
context.
Regarding the sexual response subscale, the results
suggest that this measure presents a capacity to discrimi-
nate between clinical and nonclinical groups (Table 17).
As expected, scores on both the male and female sexual
response index were significantly higher in sexually
functional subjects than in dysfunctionals (t = -4.26, p <
.001 for male sample and t = -3.94, p < .001 for female
subjects).
DISCUSSION
The aim of this study was to develop a new measure to
assess the interdependent character of the mode concept
and apply it to the sexual field. Since this is a recent
development from A. T. Beck's cognitive theory, and
since there is a lack of integrated cognitive-emotional
studies in the area of sexual problems, we felt the need
to develop this assessment tool to meet new theoretical
advances.

Table 16. Means and SD of the Clinical and Control Groups in the Male and Female ER Indices and Between-Groups t Test
Clinical group Control group
ER indices N Mean SD N Mean SD t
Female sample
Worry 46 .17 .14 34 .13 .09 1.54
Sadness 46 .18 .10 34 .14 .12 1.67
Disillusion 46 .12 .09 34 .13 .12 -0.45
Fear 46 .07 .09 34 .04 .07 1.70
Guilt 46 .06 .07 34 .03 .06 1.74
Shame 46 .05 .07 34 .03 .05 0.68
Anger 46 .10 .09 34 .07 .09 1.25
Hurt 46 .05 .06 34 .02 .04 2.09*
Pleasure 46 .10 .11 34 .21 .13 - 4.37**
Satisfaction 46 .11 .11 34 .19 .12 -2.80**
Male sample
Worry 47 .25 .20 42 .18 .17 1.44
Sadness 47 .19 .19 42 .09 .11 2.35*
Disillusion 47 .16 .17 42 .09 .08 1.86
Fear 47 .09 .14 42 .05 .08 1.41
Guilt 47 .03 .08 42 .06 .07 -1.31
Shame 47 .05 .06 42 .04 .07 0.30
Anger 47 .04 .07 42 .07 .10 -1.46
Hurt 47 .04 .06 42 .05 .11 -0.79
Pleasure 47 .08 .09 42 .19 .14 -3.68**
Satisfaction 47 .08 .10 42 .19 .14 -3.89**
P<.Q5. **p<m.
 Nobre and Pinto-Gouveia
Table 17. Means and SD of the Clinical and Control
Groups in the Male and Female SR Indices and
Between-Groups t Test
Sexual Response Index
Clinical sroup Control group
JV Mean SD N Mean SD t being abused, failure and disengagement thoughts, and
Female 35 2.52 0.67 20 3.24 0.59 -3.94**
Male 34 2.52 0.81 32 3.22 0.75 -4.26**
* p < .05. * * n <:.01.
In the present article, the Sexual Modes Questionnaire
(with its three subscales: automatic thoughts, emotional
response, and sexual response) was described, and several
psychometric studies were presented. Both male and
female automatic thought subscales were submitted to a
principal component analysis, with six factors identified in
the female version (Sexual Abuse Thoughts, Failure and
Disengagement Thoughts, Partner's Lack of Affection,
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Sexual Passivity and Control, Lack of Erotic Thoughts,
and Low Self-Body-Image Thoughts) and five in the male
version (Failure Anticipation Thoughts, Erection Concern
Thoughts, Age Related Thoughts, Negative Thoughts
Toward Sex, and Lack of Erotic Thoughts).
Correlational studies between the three subscales indi-
cated strong relationships between several dimensions of
the automatic thoughts, emotions, and sexual responses. It
is interesting to note that the emotional responses which
correlated more strongly with the negative automatic
thought index (sadness, disillusionment, pleasure, and sat-
isfaction in the male version and disillusionment, guilt,
pleasure, and satisfaction in the female version) also cor-
related strongly with the sexual response index in both
male and female versions. Moreover, the automatic
thought factors strongly correlated with the mentioned
emotions (Sexual Abuse Thoughts and Failure and
Disengagement Thoughts in the female version, and
Failure Anticipation and Erection Concern Thoughts in the
male version) were also strongly correlated with the sexu-
al response index. These results indicate that some cogni-
tive and emotional variables have a common component
which seems to be related to the subjective sexual arousal
experienced during sexual activity. The strong correlations
among these variables also support our strategy of assess-
ing these three variables as interdependent dimensions.
Test-retest reliability analysis supported the stability of
the female version (r = .52 - .90 for the factors and r = .95
for the total scale). Results for the male version were not so
strong (r = .20 - .95 for the factors and r = .65 for the total
scale) and should be interpreted with caution since they
were based on a small sample (n = 9). Also, the test-retest
correlation for the Negative Thoughts Toward Sex factor (r
= .20) raises the question of its reliability. Future analyses
should be carried out to achieve a more stable estimate.
Cronbach's a of .87 for the female and .88 for the male ver-
sion supported the general consistency of the measures.
Correlational studies with measures of sexual function-
ing (IIEF, FSFI) and discriminant analysis using clinical
379
and control groups suggest that cognitions and emotions in
sexual situations play an important role in sexual function.
Specifically, some patterns of automatic thoughts not ori-
ented to erotic cues (failure anticipation, erection con-
cerns, and lack of erotic thoughts in males and thoughts of
lack of erotic thoughts in females) and emotions of sad-
ness, guilt, anger, and lack of pleasure or satisfaction seem
to be strongly related to sexual dysfunction. These findings
seem to support some previous studies on cognitive dis-
traction (J. G. Beck et al., 1987; Dove & Wiederman,
2000; Elliot & O'Donohue, 1997; Farkas et al., 1979; Geer
& Fuhr, 1976; Przybyla & Byrne, 1984), depressed mood
(Meisler & Carey, 1991; Mitchell et al., 1998), and anger
(Bozman & J. G. Beck, 1991), providing an integrated
conceptualization of the role of these cognitive and emo-
tional variables in the sexual dysfunction process.
However, some dimensions from both the automatic
thoughts and emotional response subscales failed to dis-
criminate between the clinical and the control groups.
Thoughts related to partner's lack of affection, sexual pas-
sivity and control, or low self-body-image in the female
sample and age related thoughts or negative thoughts
toward sex in the male sample appear less related to sexu-
al dysfunction processes. Also, emotions of worry and fear
seem to be unrelated to sexual functioning.
These findings, although interesting, need to be inter-
preted with caution. The main purpose of the present study
was not to test hypotheses regarding the role of the pre-
sented cognitive and emotional variables but rather to
develop a measure to assess those variables in an integrat-
ed perspective. Thus, results should be understood as pre-
liminary and further research using larger clinical and con-
trol samples should be conducted (now in progress).
In conclusion, we would like to highlight the innovative
character of the Sexual Modes Questionnaire, developed to
assess the interdependent roles played by cognitive, emo-
tional, and behavioral variables in sexual functioning.
Systematic use of this reliable and valid measure could
help shed some light on the processes involved in sexual
dysfunction. We hope this will be an important aid in the
implementation of cognitive behavioral therapy approach-
es for treating sexual dysfunction in men and women.
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 Nobre and Pinto-Gouveia 381

APPENDIX A

SEXUAL MODES QUESTIONNAIRE

(SMQ - male version; P. Nobre & Pinto-Gouveia, 2002)
The items presented below are a list of thoughts one can have during sexual activity. In the first column, please indicate the
frequency of which you experience these thoughts by circling a number (1-never to 5-always). Next, indicate the types of emotions
you typically experience when having these thoughts by marking an X in the columns for the appropriate emotions. Finally, in the
last column, for each thought experienced indicate the intensity of your typical sexual response (arousal) while you are having that
thought by circling a number (1-very low to 5-very high).
NOTE: For thoughts that you indicate as never experiencing, you do not need to fill out the emotion or sexual response column.

Example: Imagine that the thought "making love is wonderful" comes to your mind very often whenever you are engaged in a
sexual activity, and that this idea is accompanied by pleasurable emotions, and your sexual arousal becomes very high. In this
case your answer should be:

THOUGHTS EMOTIONS SEXUAL

RESPONSE
FREQUENCY TYPES OF EMOTIONS INTENSITY

Satisfaction
Disillusioned
TYPE OF THOUGHTS

Verv hi eh
Moderate
Very low
Pleasure
Sadness
Always
Seldom

Shame
Worry
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Anger
Never

Often

Guilt

High
Hurt

Low
Fear
O

Example: Making love is wonderful 1 2 3 X 5 X 1 2 3 4 X

THOUGHTS EMOTIONS SEXUAL

RESPONSE
FREQUENCY TYPES OF EMOTIONS INTENSITY

Disillusioned

Satisfaction
Sometimes

Verv high
Verv low
Pleasure
Sadness
Always

S
Seldom

TYPE OF THOUGHTS

Shame

Anger
Never

Often

Guilt

High
Hurt
Fear

Low
1
1. It would be better to die than to be like this 1 2 3 4 5 1 2 3 4 5
2. This time I cannot disappoint my partner 1 2 3 4 5 1 2 3 4 5
3. She will replace me with another guy 1 2 3 4 5 1 2 3 4 5
4. I'm condemned to failure 1 2 3 4 5 1 2 3 4 5
5. I must be able to have intercourse 1 2 3 4 5 1 2 3 4 5
6. This is not going anywhere 1 2 3 4 5 1 2 3 4 5
7. I'm not satisfying her 1 2 3 4 5 1 2 3 4 5
8. I must achieve an erection 1 2 3 4 5 1 2 3 4 5
9. I'm not penetrating my partner 1 2 3 4 5 1 2 3 4 5
10. My penis is not responding 1 2 3 4 5 1 2 3 4 5
11. Why isn't this working? 1 2 3 4 5 1 2 3 4 5
12. I wish this could last longer 1 2 3 4 5 1 2 3 4 5
13. What is she thinking about me? 1 2 3 4 5 1 2 3 4 5
14. These movements and positions are fabulous 1 2 3 4 5 1 2 3 4 5
15. What if others knew I'm not capable... 1 2 3 4 5 1 2 3 4 5
16. If I fail again I am a lost cause 1 2 3 4 5 1 2 3 4 5
17. I'm the happiest man on earth 1 2 3 4 5 1 2 3 4 5
18. This is turning me on 1 2 3 4 5 1 2 3 4 5
19. If I don't climax now, I won't be able to later 1 2 3 4 5 1 2 3 4 5
20. She is not being as affectionate as she used to 1 2 3 4 5 1 2 3 4 5
21. She doesn't find my body attractive anymore 1 2 3 4 5 1 2 3 4 5
22. I'm getting old 1 2 3 4 5 1 2 3 4 5
23. This is disgusting 1 2 3 4 5 1 2 3 4 5
24. This way of having sex is immoral 1 2 3 4 5 1 2 3 4 5
25. Telling her what I want sexually would be unnatural 1 2 3 4 5 1 2 3 4 5
26. She is really turned on 1 2 3 4 5 1 2 3 4 5
27. I must show my virility 1 2 3 4 5 1 2 3 4 5
28. It will never be the same again 1 2 3 4 5 1 2 3 4 5
29. If I can't get an erection, I will be embarrassed 1 2 3 4 5 1 2 3 4 5
30. I have other more important matters to deal with 1 2 3 4 5 1 2 3 4 5
 382 Sexual Modes Questionnaire

APPENDIX B
SEXUAL MODES QUESTIONNAIRE
(SMQ - female version; P. Nobre & Pinto-Gouveia, 2002)
The items presented below are a list of thoughts one can have during sexual activity. In the first column, please indicate the
frequency of which you experience these thoughts by circling a number (1 -never to 5-always). Next, indicate the types of
emotions you typically experience when having these thoughts by marking an X in the columns for the appropriate emotions.
Finally, in the last column, for each thought experienced indicate the intensity of your typical sexual response (arousal) while you
are having that thought by circling a number (1-very low to 5-very high).
NOTE: For thoughts that you indicate as never experiencing, you do not need to fill out the emotion or sexual response column.
Example: Imagine that the thought "making love is wonderful" comes to your mind often whenever you are engaged in a
sexual activity, and that this idea is accompanied by pleasurable emotions, and your sexual arousal becomes very high. In this
case your answer should be:
THOUGHTS EMOTIONS SEXUAL
RESPONSE
TYPE OF THOUGHTS FREQUENCY TYPES OF EMOTIONS INTENSITY

Satisfaction
Sometimes

Disillusioned

Vervhigh
Very low

Middlina
Pleasure
Sadness
Seldom

Shame
1

Regret
Worry

Anger
Never

Often

Guilt

High
Low
Fear
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Making love is wonderful 1 2 3 X 5 X 1 2 3 4 X

THOUGHTS EMOTIONS SEXUAL
RESPONSE
TYPE OF THOUGHTS FREQUENCY TYPE OF EMOTIONS INTENSITY

Disillusionment

Satisfaction

Vervhigh
01

Pleasure
Sadness
o
Seldom

Shame
1

Anger
J
Never

1
Often

High
Guilt
1 1

Hurt

Low
Fear
1. He is abusing me 1 2 3 4 5 1 2 3 4 5
2. How can I get out of this situation? 1 2 3 4 5 1 2 3 4 5
3. He only wants to satisfy himself 1 2 3 4 5 "P2 3 4 5
4. Sex is all he thinks about 1 2 3 4 5 1 2 3 4 5
5. The way he is talking turns me on 2 3 4 5 i 2 3 4 5
6. He is violating me 2 3 4 5 1 2 3 4 5
7. This way of having sex is immoral 2 3 4 5 1 2 3 4 5
8. These movements and positions are fabulous 2 3 4 5 1 2 3 4 5
9. I'm getting fat/ugly 2 3 4 5 1 2 3 4 5
10. If I let myself go he is going to think I'm promiscuous 2 3 4 5 1, 2 3 4 5
11. Making love is wonderful 2 3 4 5 2 3 4 5
v
12. He is not being as affectionate as he used to be 2 3 4 5 l 2 3 4 5
13. I'm not satisfying my partner 1 2 3 4 5 I 2 3 4 5
14. I must not show that I'm interested I 2 3 4 5 i 2 3 4 5
15. This is disgusting 1 2 3 4 5 I 2 3 4 5
16. I'm not as physically attractive as I used to be 1 2 3 4 5 I 2 3 4 5
17. I should not take the lead in sexual activity 1 2 3 4 5 I 2 3 4 5
18. He only cares about me when he wants sex 1 2 3 4 5 I 2 3 4 5
19. I'm not getting turned on 2 3 4 5 I 2 3 4 5
20. I'm not feeling physically attractive 1 2 3 4 5 I 2 3 4 5
21. These activities shouldn't be planned ahead of time 1 2 3 4 5 V 2 3 4 5
22. I can't feel anything 1 2 3 4 5 I 2 3 4 5
23. I don't want to get hurt emotionally 1 2 3 4 5 I 2 3 4 5
24. Why doesn't he kiss me? 1 2 3 4 5 2 3 4 5
25. My body turns him on 1 2 3 4 5 2 3 4 5
26. When will this be over? 1 2 3 4 5 2 3 4 5
27. If only he'd whisper something romantic in my ear 1 2 3 4 5 2 3 4 5
28. He only loves me if I'm good in bed 2 3 4 5 2 3 4 5
29. I should wait for him to make the first move 1 2 3 4 5 I 2 3 4 5
30. I am only doing this because he asked me to 2 3 4 5 I 2 3 4 5
31. I'm the happiest woman on earth 2 3 4 5 i 2 3 4 5
32. I have other more important matters to deal with 1 2 3 4 5 I 2 3 4 5
33. If I refuse to have sex, he will cheat on me 1 2 3 4 5 I 2 3 4 5