Journal of Sex & Marital Therapy, 39:436452, 2013

Copyright Taylor & Francis Group, LLC

ISSN: 0092-623X print / 1521-0715 online
DOI: 10.1080/0092623X.2012.665813

The Role of Trait-Affect, Depression, and

Anxiety in Women With Sexual Dysfunction:
A Pilot Study

CATIA OLIVEIRA and PEDRO J. NOBRE
Departamento de Ciencias da Educaca
o, Universidade de Aveiro,
Aveiro, Portugal

Despite the increasing number of studies, it is not yet clear how

emotions affect sexual response in women with and without sexual
problems. The aim of this study was to explore the relation among
trait-affect, depression, anxiety, and sexual functioning. Partic-
ipants were 237 women: 167 without sexual problems, 37 with
low levels of sexual functioning, and 17 with sexual dysfunction.
Participants completed the Positive and Negative Affect Schedule,
the Brief Symptom Inventory, the Beck Depression Inventory, and
the Female Sexual Function Index. Results showed that women with
sexual problems presented lower levels of positive trait-affect in com-
parison with women without sexual problems. Mediation analysis
indicated that depression mediated 44% of the total effect of posi-
tive trait-affect and 83% of the total effect of negative trait-affect on
sexual functioning. Moreover, anxiety (Brief Symptom Inventory
subscale) mediated 18% of the total effect of positive trait-affect on
sexual functioning and 61% of the total effect of negative trait-
affect on sexual functioning. These results may help explain the
high comorbidity among sexual dysfunction, depression, and anx-
iety, and raise the hypothesis that trait-affect may act as a common
vulnerability factor for these clinical conditions.

The authors thank G. Santos, Hospitais da Universidade de Coimbra, Portugal, for making
possible the collection of the clinical sample. They also thank A. Gomes, J. Almeida, P. Costa,
S. Vilarinho, L. Fonseca, J. Teixeira, P. Abrantes, for the suggestions and help in sample
collection. Last, they thank participants who volunteered to participate in the study.
Address correspondence to Catia Oliveira, Departamento de Educaca o, Universidade de
Aveiro, 3810-193 Aveiro, Portugal. E-mail: catioliveira@gmail.com

436
 Role of Trait-Affect, Depression, and Anxiety 437

Several studies have indicated a large overlap and comorbidity between

sexual dysfunction and other psychological disorders, particularly depression
and anxiety (Bodinger et al., 2002; Cyranowski et al., 2004; Degoratis &
Balon, 2009; Figueira, Possidente, Marques, & Hayes, 2001; Graham, Sanders,
Milhausen, & McBride, 2004; Kennedy, Dickens, Eisfeld, & Bagby, 1999;
Laurent & Simons, 2009; van Lankveld & Grotjohann, 2000). Although this
comorbidity has been widely recognized for decades in research and clinical
settings, little is known about its potential causes. One possible explanation
for this overlap is the role played by affect on sexual response and on
anxiety and depressive states (Clark, Beck, & Stewart, 1990; Laan, Everaerd,
Van Berto, & Rijs, 1995; ter Kuile, Both, & van Uden, 2010; Watson, Clark, &
Carey, 1988).
Several studies have tested the relation between state affect and sex-
ual response in men and women. Overall, findings have consistently shown
a significant effect of positive mood on sexual response. Women who re-
sponded with higher levels of sexual arousal during exposure to erotic films
showed greater levels of joy and lower rates of depression after the expo-
sure, regardless of the previous mood state (Laan et al., 1995). Also, women
reported higher levels of subjective sexual arousal and more positive affect
in response to an erotic film after a happy mood induction (ter Kuile et al.,
2010). Other studies showed that the presence of positive mood was strongly
related to feelings of pleasure, sexual interest, and engagement in differ-
ent sexual behaviors besides intercourse itself (Bancroft, 1989; Burleson,
Trevathan, & Todd, 2007; Warner & Bancroft, 1988).
Inversely, studies have indicated that the presence of negative mood re-
duced the probability of sexual intercourse on the same day and was related
to low desire, low sexual arousal, and low satisfaction with the sexual rela-
tionship (Blanchflower & Oswald, 2004; Cyranowski, Bromberger et al., 2004;
Fortenberry et al. 2005; Heiman, 2000; Heiman & Rowland, 1983; Kockott
& Pfeiffer, 1996). The presence of high levels of depressive symptoms was
associated with less sexual thoughts and orgasmic function and also with
general sexual response (Dunn, Croft, & Hackett, 1999; Cyranowski, Frank,
Cherry, Houck, & Kupfer, 2004; Kennedy et al., 1999). Moreover, women
with sexual dysfunction presented lower rates of pleasure and satisfaction
and more emotions of sadness, disappointment, guilt, and anger during
sexual activity, when compared with sexually healthy women (Nobre &
Pinto-Gouveia, 2006). Overall, these findings have reinforced that women
are more prone to express themselves sexually when they experience a state
of positive affect (Sanders, Werner, Backstrom, & Bancroft, 1983; Warner &
Bancroft, 1988).
Regarding the influence of anxiety on sexual function the evidence is
mixed (Althof et al., 2005). Some studies showed that the presence of anger
and worry led sexually healthy women to report a decrease in their levels of
sexual desire and arousal (J. G. Beck & Bozman, 1995; Dunn et al., 1999; Katz
438 C. Oliveira and P. J. Nobre

& Jardine, 1999; Lykins, Janssen, & Graham, 2006). Also, women with anxiety
disorders presented sexual problems involving the first phase of the sexual
response cycle, although the phases of excitement and orgasm seemed to be
unaffected (van Minnen & Kampman, 2000). However, experimental studies
conducted in women and men also suggested that anxiety had a neutral or a
facilitating effect on arousal response in both genders, probably because of
its direct effect on sympathetic activation (Barlow, 1986; J. G. Beck & Barlow,
1984). Laboratory studies (Elliot & ODonohue, 1997; Hoon, Wincze, & Hoon,
1977; Laan, Everaerd, Van Aanhold, & Rebel, 1993; Meston & Gorzalka,
1996; Palace & Gorzalka, 1990) showed that women with and without sexual
difficulties responded with higher sexual arousal during the view of an erotic
film, when it was preceded by an anxiety-type film, rather than by a neutral
film. The same pattern was found in men (Barlow, Sakheim, & Beck, 1983).
Clark and Watson (1991) proposed a tripartite model to understand the
nature and distinct features of anxiety and depression. The model comprises
negative affect, positive affect, and physiological arousal (associated with so-
matic tension, shortness of breath, dizziness, and dry mouth). Negative affect
was usually related to high distress and encompasses a variety of affective
states including anger, guilt, fear, worry, sadness, and disgust (Anderson &
Hope, 2008; Clark & Watson, 1991). Positive affect was generally related to
enthusiasm, activity, control, and compromise, incorporating the propensity
of the individual to maintain a positive view over time and across situations.
The absence of positive affect indicated loss of pleasure, hopelessness, apa-
thy, fatigue, lethargy, and psychomotor retardation (Aspinwall, 1998; Watson,
Pennebaker, & Folger, 1987).
Despite the accumulated knowledge on the association between state-
affect and sexual response and functioning, less is known regarding the role
of trait-affect.1 This is particularly important because trait-affect has been
widely studied and conceptualized as an important vulnerability factor for
depression and anxiety disorders, which are highly comorbid with sexual
dysfunction (L. A. Clark & Watson, 1991).
The present study was designed to assess the role of affect on womens
sexual functioning. Our main goal was to examine the relations among
trait-affect, depression, anxiety, and sexual functioning. Our theoretical as-
sumption is that trait-affect (specifically positive trait-affect) may have an
independent effect on sexual functioning, over and above depressive and
anxiety symptoms.
We expected that women with sexual dysfunction would present sig-
nificantly lower levels of positive trait-affect and higher levels of negative
trait-affect when compared with women without sexual dysfunction. We also
hypothesized that depression would partially mediate the relation between

1
The term trait-affect is used to differentiate it from state-affect.
 Role of Trait-Affect, Depression, and Anxiety 439

positive and negative trait-affect and sexual functioning, and that anxiety
symptoms would partially mediate the relation between negative trait-affect
and sexual functioning.

METHOD
Participants
Participants were 237 women: a clinical sample of 17 women with sexual
dysfunction and a community sample of 220 participants (convenience sam-
ple). The community sample was divided to create a group with no sexual
difficulties (control group) and a group with low levels of sexual function-
ing (subclinical group), using the cutoff point of 26.55 (Wiegel, Meston, &
Rosen, 2005) of the Female Sexual Function Index (Rosen et al., 2000). Thus,
women who obtained a score below the cutoff point (a total of 37) were
included in the subclinical group. Participants who were not sexually active
during the past 4 weeks before completing the questionnaire (a total of 16)
were excluded from the study (to avoid the inclusion of these women in the
subclinical group because of their low scores on the Female Sexual Function
Index).

Procedures
Participants from the Clinical Group were recruited from the Sexology Clin-
ics of Coimbras University Hospital and of S. Joao Hospital (Porto) be-
tween January and October 2007 and diagnosed with sexual dysfunction
using the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2000). A group of trained sex therapists initially con-
ducted a clinical evaluation using the Sexual Dysfunction Interview (Sbrocco,
Weisberg, & Barlow, 1992). After being diagnosed, the patients were ap-
proached by a member of the research team and invited to participate in the
study. Women who agreed to participate signed a consent form and com-
pleted the self-report measures, returning it in hand to a member of the team.
The response rate was 94% (proportion of the total number of approached
women who completed the measures).
Participants from the Community Group (convenience sample) were
recruited from central hospitals and small public community health cen-
ters from different regions of Portugal, between the months of April and
November 2007. A group of research students collected the sample in their
hometowns, particularly in the north and central regions of the country,
using nonrandom methods. Participants were contacted directly by the re-
search students and received instructions regarding the aim of the study.
Individuals who agreed to participate signed an informed consent form and
were instructed to complete the questionnaires in private and return them
440 C. Oliveira and P. J. Nobre

in hand to the researchers or by mail using a prepaid envelope. Participants

were not paid for participation. The study was approved by the Institutional
Review Board of Coimbras University Hospital. The response rate was ap-
proximately 65%.

Measures
POSITIVE AND NEGATIVE AFFECT SCHEDULEEXPANDED FORM
The Positive and Negative Affect ScheduleExpanded Form (Watson &
Clark, 1994) is a 60-item self-report questionnaire that assesses two ma-
jor emotional states: positive affect and negative affect; and 11 specific af-
fects: fear, sadness, guilt, hostility, shyness, fatigue, surprise, joviality, self-
assurance, attentiveness, and serenity. It allows the evaluation of the state-
affect (in the present moment, last days) or trait-affect (in general). Higher
scores indicate higher rates of positive and negative affect (minimum =
60; maximum = 300). Participants were asked to rate the list of emotions
with the specific instruction: Indicate to what extent you feel each of the
emotions presented, in general. Participants answered the questions using
a 5-point Likert-type scale ranging from 1 (very slightly or not at all) to 5
(extremely). This version is an expansion of the original version, the Positive
and Negative Affect Schedule (Watson, Clark, & Tellegen, 1988), with only
20 items and two scales (positive affect and negative affect). Psychomet-
ric studies indicated adequate levels of internal consistency (positive affect:
Cronbachs = .85; negative affect: Cronbachs = .88), and testretest relia-
bility (positive affect: r = .71; negative affect: r = .70; Watson & Clark, 1994).
Both subscales were also correlated (positive affect: r = .56; negative affect:
r = .35) to the Beck Depression Inventory (Watson & Clark, 1994). The Por-
tuguese version (Vilarinho & Nobre, 2010) also showed appropriate internal
consistency (positive affect: Cronbachs = .88; negative affect: Cronbachs
= .66) and test-retest reliability (positive affect: r = .76; negative affect:
r = .47).

BRIEF SYMPTOM INVENTORY

The Brief Symptom Inventory (Degoratis, 1982) is a 53-item questionnaire
that assesses the presence of psychopathological symptoms through nine
psychopathological dimensions (somatization, obsessive-compulsive, inter-
personal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid
ideation, and psychoticism) and three global indices (global severity index,
positive symptom total, and positive symptom distress index). The partici-
pant must rank each item on a 4-point Likert scale ranging from 0 (never)
to 4 (many times). Higher scores indicate lower psychological adjustment
(minimum = 53; maximum = 265).
 Role of Trait-Affect, Depression, and Anxiety 441

Psychometric studies indicated appropriate internal consistency for the

nine dimensions considered, with Cronbachs alpha ranging from .71 to .85
(Degoratis, 1993; Hayes, 1997; Kellet, Beail, Newman, & Frankish, 2003),
and for the Global Severity Index, with a Cronbachs alpha of .90 (Degoratis,
1993). Adequate testretest reliability was also found for the nine dimen-
sions (from r = .68 to r = .91) and for the three global subscales (Positive
Symptoms Distress Index: r = .87; Global Severity Index: r = .90; Degoratis,
1993). The Portuguese version (Canavarro, 1999) also presented adequate
internal consistency with Cronbachs alpha ranging from .62 to .80 for the
various dimensions, and testretest reliability (from r = .63 to r = .81).

BECK DEPRESSION INVENTORY

The Beck Depression Inventory (A. T. Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961) is a 21-item questionnaire. Each question has a number
of issues sorted by severity that allows the assessment of the depression
magnitude (nonexistence, low, moderate, and severe). Higher scores indicate
higher levels of depression (minimum = 0; maximum = 63).
Psychometric studies confirmed high internal consistency (Cronbachs
= .93), and significant convergent and discriminant validity (A. T. Beck,
Steer, Ball, & Ranieri, 1996; A. T. Beck, Steer, & Carbin, 1988). Studies in
Portugal indicated good psychometric properties of the Portuguese version
regarding reliability and validity (Vaz Serra & Pio Abreu, 1973).

FEMALE SEXUAL FUNCTION INDEX

The Female Sexual Function Index (Rosen et al., 2000) is a 19-item question-
naire that assesses several aspects of female sexual functioning. The measure
allows the calculation of specific indexes for each dimension (sexual inter-
est/desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and sexual
pain) as well as a sexual function index. Several authors underline some lim-
itations in the scoring procedures of this index, because it depends of how
sexually active a person is (Meyer-Bahlburg & Dolezal, 2007). Lower scores
indicate lower levels of sexual functioning (minimum = 2; maximum = 36).
Psychometric studies confirmed high levels of internal consistency
(Cronbachs = .86) and good temporal stability (correlations between
r = .79 and r = .86). Regarding discriminant validity, statistically signifi-
cant differences (p < .001) were found for all dimensions, between clinical
and control groups (Rosen et al., 2000). Studies in the Portuguese pop-
ulation confirmed the good psychometric characteristics of the Portuguese
version with a Cronbachs alpha of .97 for the Sexual Function Index (Nobre,
2002).
442 C. Oliveira and P. J. Nobre

Data Analysis
To analyze the relation between trait-affect and sexual functioning, we con-
ducted a correlation analysis between the two affect dimensions, assessed
by the Positive and Negative Affect Schedule (Watson et al., 1988) and the
Female Sexual Function Index dimensions (Rosen et al., 2000). We per-
formed a multiple regression analysis (enter method) using positive and
negative trait-affect as predictors and sexual functioning as criterion to ex-
plore the ability of trait-affect dimensions to predict sexual functioning in
women.
We also performed a multivariate analysis of covariance to study the
differences between women with and without sexual dysfunction regard-
ing both dimensions of trait-affect. The assumption of homogeneity of
variance-covariance matrices was met and the missing values were auto-
matically excluded. We used Bonferroni-corrected alpha levels for each
analysis.
Last, to test the mediational role of depression and anxiety on the re-
lation between trait-affect and sexual functioning, we conducted several
regression analyses according to Baron and Kennys (1986) procedure, for
testing mediational hypotheses. Specifically, we tested the mediational role
of depression (as measured by the Beck Depression Inventory total score)
and anxiety (as measured by the anxiety subscale of the Brief Symptom In-
ventory) on the relation between positive and negative trait-affect and sexual
functioning. The first three conditions for the test of mediation were met in all
the mediation analysis, and the Sobel (1982) test of mediation was conducted
for each one to determine whether partial mediation had occurred.

RESULTS
Sample Characteristics
The three groups (control group, subclinical group and clinical group)
showed statistically significant differences regarding age, F(2, 210) = 4.72,
p < .01, and educational level, 2 (2) = 24,92; p < .001. Participants from
the subclinical group were significantly older (M = 40.6 years, SD = 13.7)
in comparison with women from the control group (M = 34.2 years, SD =
10.5). Participants from the clinical group were less educated in comparison
with women from the subclinical and the control groups. The three groups
showed no differences regarding marital status, 2(8) = 6.69, p = .571.
The principal diagnoses assigned to women in the clinical group were
hypoactive sexual desire (47.1%), orgasmic disorder (17.6%), vaginismus
(11.8%), and sexual arousal disorder (5.9%). About 35.3% of the women
had other comorbid sexual problems.
The demographic characteristics are presented in Table 1.
 Role of Trait-Affect, Depression, and Anxiety 443

TABLE 1. Demographic Characteristics of the Control, Clinical, and Subclinical Groups

Control Clinical Subclinical

(n = 167) (n = 17) (n = 37)

Age (years)
M 34.2 36.5 40.6
Range 1858 2267 1972
SD 10.45 12.6 13.7
n % n % n %

Marital status
Single 54 33.3 4 26.7 8 21.6
Married 80 49.4 9 60.0 26 70.3
Divorced 11 6.8 1 6.7 1 2.7
Widowed 3 1.9 1 2.7
Living together 14 8.6 1 6.7 1 2.7
Educational level (years)
04 3 1.8 4 26.7 1 2.7
56 5 3.0 1 6.7 5 13.5
79 17 10.3 2 13.3 10 27.0
1012 31 18.8 3 20.0 8 21.6
1315 3 1.8 2 13.3 1 2.7
16 or more 106 64.2 3 20.0 12 32.4

Trait-Affect and Sexual Functioning

On correlation analyses positive trait-affect presented positive and statistically
significant correlations to the Female Sexual Function Index total score and to
most of the indexs dimensions, except for lubrication, pain, and vaginismus
(see Table 2). Women with higher positive affect presented higher levels
of sexual satisfaction, sexual desire, and sexual arousal. In turn, negative
trait-affect presented negative and statistically significant correlations only to
the Female Sexual Function Index total score and to the pain dimension.

TABLE 2. Correlations Between Trait-Affect and Sexual Functioning in a Community Sample

(N = 204)

Affect dimension

Female Sexual Function Index dimension Positive affect Negative affect

Desire .26 .16

Sexual arousal .27 .18
Lubrication .17 .17
Orgasm .19 .12
Satisfaction .23 .08
Pain .17 .20
Vaginismus .13 .12
Female Sexual Function Index total .28 .22
Note. With 196 degrees of freedom. Statistical significance using Bonferroni corrections.
p < .05. p < .01. p < .001.
444 C. Oliveira and P. J. Nobre

TABLE 3. Multiple Regression Analysis (Enter Method) for Trait-Affect as Predictor of Female
Sexual Functioning in a Community Sample (N = 198)

Predictor B SE t p

Positive affect 2.61 0.65 .27 4.00 .000
Negative affect 1.70 0.54 .21 3.14 .002
p < .05. p < .01. p < .001.

Women with higher negative affect presented higher levels of sexual pain
and lower levels of sexual functioning (Female Sexual Function Index total
score).
The results of the regression analysis (Table 3) showed that trait-affect
significantly predicted sexual functioning in women, F(2, 195) = 13.00, p <
.001, explaining 10.9% of the variance (adjusted R 2 = .11). The analysis of
the standardized regression coefficients showed that positive and negative
trait-affect were significant predictors of female sexual functioning.
In the multivariate analysis of covariance, sexual functioning was used
as independent variable (1 = control group, 2 = subclinical group, 3 =
clinical group) and the two trait-affect dimensions as dependent variables.
We included educational level, age, marital status, depression, and anxiety in
the analysis as covariates to control their effects on the dependent variables:
For educational level, Wilkss = 0.984, F(4, 196) = 1.56, p = .214; for age,
Wilkss = 0.997, F(4, 196) = .271, p = .763; for marital status, Wilkss =
0.999, F(4, 196) = .073, p = .930; for total Brief Symptom Inventory, Wilkss
= 0.841, F(4, 196) = 17.74, p < .001; for total Beck Depression Inventory,
Wilkss = 0.928, F(4, 196) = 7.30, p < .01. After we controlled for the effect
of these variables, the multivariate test was statistically significant: Wilkss
= 0.939, F(4, 196) = 3.00 p < .05.
The univariate tests (see Table 4) showed a statistically significant effect
on positive trait-affect. The post hoc comparisons indicated that women from
the clinical group presented significantly lower scores on positive trait-affect
(p < .01, 2 = .05) when compared with women in the control group.

TABLE 4. Trait-Affect as a Function of Sexual Functioning (Clinical/Subclinical/Control

Group), After Controlling for Effect of Age, Marital Status, Educational Level, Anxiety, and
Depression (N = 196)

Control Subclinical Clinical

(n = 150) (n = 33) (n = 13)

Affect dimension M SD M SD M SD F(4, 196) P 2

Positive affect 3.49a 0.04 3.28ab 0.09 3.08b 0.13 5.34 .006 .054
Negative affect 2.33 0.04 2.37 0.09 2.46 0.14 0.45 .636 .005
Note. Values adjusted for covariates. For each factor, adjusted means marked with different superscripts
differ significantly, according to Bonferroni test (p < .05).
p < .05. p < .01. p < .001.
 Role of Trait-Affect, Depression, and Anxiety 445

TABLE 5. Regression Analyses for Testing Depression as Mediator of the Relation Between
Positive Trait-Affect and Sexual Functioning in a Community Sample (N = 202)

Criterion Predictor F R2

Total BDI Positive affect 18.80 .08 .30
Total FSFI Positive affect 16.85 .07 .28
Total FSFI Positive affect 24.69 .19 .17
(a) Total BDI .37
Total BDI Negative affect 49.11 .19 .45
Total FSFI Negative affect 10.20 .04 .22
Total FSFI Negative affect 21.78 .17 .04
(b) Total BDI .41
Note. (a) Sobel value, t = 3.60, p < .001; percentage of total effect mediated = 44%; (b) Sobel value,
t = 4.75, p < .001; percentage of total effect mediated = 83%. BDI = Beck Depression Inventory;
FSFI = Female Sexual Function Index.
p < .05. p < .01. p < .001.

Trait-Affect, Depression, Anxiety, and Sexual Functioning

DEPRESSION AS MEDIATOR OF THE RELATION BETWEEN TRAIT-AFFECT
AND SEXUAL FUNCTIONING

Regarding the mediation of depression on the relation between positive

trait-affect and sexual dysfunction (Table 5), the inclusion of depression as
a mediator variable resulted in a significant increase in the overall R 2, F(1,
198) = 24.69, p < .001. Moreover, the previously significant relation between
positive-trait affect and sexual functioning was reduced after depression was
controlled for. The Sobel test was significant and indicated that about 44% of
the total effect of positive trait-affect on sexual functioning was mediated by
depression.
As for the mediation of depression on the relation between negative
trait-affect and sexual dysfunction, the inclusion of the mediator variable
resulted in a significant increase in the overall R 2, F(1, 200) = 21.78,
p < .001. The previously significant relation between the two variables was
reduced after depression was controlled. The Sobel test was significant and
indicated that about 83% of the total effect of negative trait-affect on sexual
functioning was mediated by depression.

ANXIETY AS MEDIATOR OF THE RELATION BETWEEN TRAIT-AFFECT

AND SEXUAL FUNCTIONING

Regarding the mediation of anxiety on the relation between positive trait-

affect and sexual dysfunction, the inclusion of anxiety as a mediator vari-
able resulted in a significant increase in the overall R 2, F(1, 197) = 14.18,
p < .001. The previously significant relation between positive trait-affect and
sexual functioning was reduced after anxiety was controlled. The Sobel test
446 C. Oliveira and P. J. Nobre

TABLE 6. Regression Analyses for Testing Anxiety as Mediator of the Relation Between
Negative Trait-Affect and Sexual Functioning in a Community Sample (N = 202)

Criterion Predictor F R2

Anxiety Positive affect 7.19 .03 .19

Total FSFI Positive affect 16.85 .07 .28
Total FSFI Positive affect 14.18 .12 .25
(a) Anxiety .21
Anxiety Negative affect 64.45 .24 .50
Total FSFI Negative affect 10.20 .04 .22
Total FSFI Negative affect 9.15 .08 .12
(b) Anxiety .22
Note. (a) Sobel value, t = 2.21, p < .05; percentage of total effect mediated = 18%; (b) Sobel value,
t = 3.54, p < .001; percentage of total effect mediated = 61%. FSFI = Female Sexual Function Index.
p < .05. p < .01. p < .001.

was significant and indicated that about 18% of the total effect of positive
trait-affect on sexual functioning was mediated by anxiety.
Last, the mediation of anxiety in the relation between negative trait-
affect and sexual functioning (Table 6) showed that the inclusion of anxiety
as a mediator variable resulted in an increase in the overall R 2, F(1, 199)
= 9.15, p < .001. The previously significant relation between negative-trait
affect and sexual functioning was reduced after anxiety was controlled. The
Sobel test was significant and indicated that about 61% of the total effect of
negative trait-affect on sexual functioning was mediated by anxiety.

DISCUSSION

This study examined the correlation between affect and womens sex-
ual functioning; specifically, we used a series of validated psychomet-
ric measures to analyze the correlations between positive and negative
trait-affect, depression, anxiety, and sexual dysfunction. Our main hypoth-
esis was that positive and negative trait-affect were associated with sexual
dysfunction, and that depression and anxiety would partially mediate this
relation explaining the high comorbidity among them.
Correlational analysis showed that negative and positive trait-affect were
associated and significantly predicted womens sexual functioning. However,
only positive trait-affect significantly differentiated women from clinical and
control groups, partially corroborating our hypothesis. These findings were
consistent with the current literature. The lack of positive affect seemed to
have a central and negative impact on sexual functioning (Adams, Haynes,
& Brayer, 1985; J. G. Beck & Barlow, 1986; Graham et al., 2004; Heiman,
1980; Laan et al., 1995; Meisler & Carey, 1991; Nobre & Pinto-Gouveia, 2006).
Higher levels of positive mood and energy were usually significantly associ-
ated with greater sexual interest and the presence of pleasure emotions and
 Role of Trait-Affect, Depression, and Anxiety 447

feelings (Blanchflower & Oswald, 2004; Elliot & ODonohue, 1997; Warner
& Bancroft, 1988), as well as with higher frequency of sexual intercourse
(Fortenberry et al., 2005; Sanders et al., 1983). The presence of negative
affect also seemed to be involved on sexual dysfunction in women (Brown,
Chorpita, & Barlow, 1998; Cyranowski, Frank et al., 2004; Nobre & Pinto-
Gouveia, 2006), although our findings were not so evident.
Results from the mediational analyses partially corroborated our hypoth-
esis. They showed that the relation between trait-affect and sexual function-
ing was mediated by depression and anxiety. Whereas the effect of positive
trait-affect on sexual functioning was partially mediated (44%) by depression
and anxiety (18%), the effect of negative trait-affect was partially mediated by
anxiety (61%) and almost completely mediated by depression (83%). These
results emphasized the possibility of a more specific and independent role of
the positive trait-affect on sexual functioning, when compared with negative
trait-affect.
It is still not clear how the absence of positive affect influences sexual
functioning. Nevertheless, studies showed that the existence of a specific
cognitive pattern in women with sexual dysfunction, similar to mood dis-
orders (Nobre & Pinto-Gouveia, 2009), may generate negative automatic
thoughts and limit the process of erotic stimuli promoting low positive affect
(Bancroft, 1989; Nobre & Pinto-Gouveia, 2003; Wiegel et al., 2005).

Conclusions and Future Research

Results of this study should be interpreted with some caution, since there
were several limitations that impair the generalization of the results. First,
the number of participants in the clinical group was small and presented di-
agnostic heterogeneity. Similarly, although we have controlled demographic
variables, depression, and anxiety, we did not control the use of medication,
the presence of psychiatric comorbidity, and chronic disease, which may
have contaminated the results because of its consequences on sexual and
emotional responses. The use of a nonrandom community sample and the
different conditions in which the questionnaires were completed among par-
ticipants from the control and subclinical groups (some done at home) and
the clinical group (done at the hospital) may also have altered the results,
limiting their generalization. Despite these limitations, results suggested that
positive and negative trait-affect were associated with sexual dysfunction and
that this relation was partially mediated by anxiety and depression. One pos-
sible explanation for these results is that positive and negative trait-affect act
as common vulnerability and etiological factors for emotional disorders (anx-
iety and depression) and sexual dysfunction in women. This could explain
the high comorbidity among these clinical presentations. Moreover, positive
trait-affect may play a more specific role in sexual dysfunction because its
448 C. Oliveira and P. J. Nobre

relation was only partially mediated by depression and anxiety, whereas

for negative affect the mediations were almost complete. These tentative
hypotheses should, however, be tested, using longitudinal or experimental
designs to clarify the predicted causal path. Future studies should also
address the role of ambivalent affect in depression, anxiety, and sexual func-
tion, in addition to positive and negative affect, and take into account the
menopausal status of women. Overall, our results draw attention to possible
new etiological factors that may contribute to a better comprehension of
sexual problems in women and also suggest new insights to psychosexual
therapy.

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