Arch Sex Behav DOI 10.1007/s10508-013-0191-0

ORIGINAL PAPER

Dissociation During Sex and Sexual Arousal in Women With and Without a History of Childhood Sexual Abuse Elizabeth R. Bird • Martin Seehuus • Jessica Clifton • Alessandra H. Rellini

Received: 25 October 2012 / Revised: 26 April 2013 / Accepted: 2 June 2013  Springer Science+Business Media New York 2013

Abstract Women with a history of childhood sexual abuse (CSA) experience dissociative symptoms and sexual difficulties with greater frequency than women without a history of CSA. Current models of sexual dysfunction for sexual abuse survivors suggest that dissociation may mediate the relationship between CSA and sexual arousal difficulties. Dissociation, however, is often conceptualized as a single construct in studies of CSA and not as separate domains as in the dissociation literature. In the present study, women with (CSA, N = 37) and without (NSA, N = 22) a history of CSA recruited from the community were asked to indicate the frequency and intensity of their experience in two dissociation subgroups, derealization and depersonalization, during sex with a partner and in their daily life. Findings showed that, in the NSA group, more depersonalization during sex with a partner was associated with lower sexual arousal functioning. However, for both the NSA and CSA groups, more derealization during sex was associated with higher sexual arousal functioning. No measure of dissociation was significantly associated with sexual responses in the laboratory. These findings highlight the importance of distinguishing between different forms of dissociation (i.e., derealization and depersonalization) in the study of sexual arousal functioning. In addition, the findings challenge the notion that dissociation is a main predictor of sexual arousal problems in survivors of CSA and suggest that a more nuanced relationship may exist. Keywords Sexual arousal
Dissociation
Women
Childhood sexual abuse

E. R. Bird
M. Seehuus
J. Clifton
A. H. Rellini (&) Department of Psychology, University of Vermont, John Dewey Hall, 2 Colchester Ave., Burlington, VT 05401, USA e-mail: [email protected]

Introduction Childhood Sexual Abuse and Sexual Arousal Childhood sexual abuse (CSA), defined as unwanted or forced sexual experiences during childhood or early adolescence, has been highlighted by the World Health Organization (2003) as a major public health issue that affects mostly women. Approximately 20 % of women in North America are sexually abused by the time they reach adulthood (Kendall-Tackett, Williams, & Finkelhor, 1993; Stoltenborgh, IJzendoorn, Euser, & Bakermans-Kranenburg, 2011). Survivors of CSA are at high risk for developing various psychological and behavioral problems in adulthood, such as post-traumatic stress disorder, borderline personality disorder, dissociation, alcohol problems, and suicidal ideation (for a review, see Hillberg, Hamilton-Giachritsis, & Dixon, 2011). One of the least studied correlates of CSA is sexual dysfunction. Among the different sexual dysfunctions, sexual arousal problems appear to be highly prevalent in this group of women (Lewis et al., 2010). The etiology of sexual arousal disorder in women with a history of CSA is complex and not well understood. Sexual arousal is a phase of the sexual cycle during which an individual experiences the heightening of physiological responses and subjective sensations of excitation (Masters & Johnson, 1970). Epidemiological studies have shown that between 49 and 84 % of women with a history of CSA report problems with sexual arousal (for a review, see Leonard & Follette, 2002). Also, women with a history of CSA are 1.73 times more likely to have problems with sexual arousal compared to women without a history of abuse (Laumann, Paik, & Rosen, 1999) and tend to show lower physiological sexual responses when measured in the laboratory (Gilmore et al., 2010; Rellini, Elinson, Janssen, & Meston, 2012; Rellini & Meston, 2006a; Schacht et al., 2007). It is noteworthy that, despite the higher prevalence of sexual

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problems in CSA survivors, not all women who experience abuse develop a sexual dysfunction, thus it is possible that some cognitive and emotional vulnerabilities that are characteristics of the individual may interact with the abuse to lead to a sexual dysfunction (Rellini & Meston, 2007; Staples, Rellini, & Roberts, 2012). Studies indicate that correlates of sexual responses in women with a history of CSA are different than those in women without a history of CSA. For example the association between affect and sexual stimuli is different in CSA survivors compared to women with no history of sexual abuse (Gilmore et al., 2010; Meston & Lorenz, 2012; Rellini et al., 2012; Rellini, Ing, & Meston, 2011; Schacht et al., 2007; Stephenson, Hughan, & Meston, 2012). It is possible that CSA is such a pervasive experience that it interacts with pivotal mechanisms of sexual arousal changing its basic patterns and responses. The relationship between dissociation and sexual arousal may be yet another aspect of sexuality that is modified by CSA. Specifically, clinical experiencesuggeststhat insomewomen,sexual situationsmaytrigger memories of the abuse (Leiblum & Rosen, 1989), which then lead to dissociation, conceptualized as an avoidance of the emotional distress caused by such memories (Rellini, 2008). While women with no history of sexual abuse may also dissociate during sex, their experience and the nature of their dissociation may be different from those of women with a history of sexual abuse. Dissociation Theoretical models of sexual arousal (e.g., Barlow, 1986) emphasize the importance of attention to sexually relevant stimuli. Distraction from the present moment and/or such sexually relevant stimuli may be caused by dissociation. Dissociation is broadly defined as ‘‘a disruption in the usually integrated functions of consciousness, memory, identity, and perceptions’’(American Psychiatric Association, 2000) and, to date, has rarely been empirically studied in a sexual context. Severity of dissociative symptoms is conceptualized on a continuum, ranging from daydreaming and fantasy-proneness to clinically incapacitating conditions, such as in the case of dissociative identity disorders (Putnam, 1997). Dissociation is not an experience reported only by trauma survivors. An epidemiological study reported that 5.8 % of women without a history of CSA reported high levels of daily dissociation (Mulder, Beautrais, Joyce, & Fergusson, 1998), although, dissociation is particularly common in individuals exposed to a traumatic event, with approximately 30 % of women with a history of CSA reporting severe daily dissociative symptoms (Maercker, Beauducel, & Schu¨tzwohl, 2000; Mulder et al., 1998; Sanders & Giolas, 1991; van der Kolk, 2003). Individuals who experienced sexual abuse often report experiencing their first dissociative symptoms during or immediately after the abuse, and these symptoms tend to persist in their daily life

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and throughout adulthood (Boysan, Goldsmith, C¸avus¸ , Kayri, & Keskin, 2009; Boysan et al., 2009; Johnson, Pike, & Chard, 2001; Sanders & Giolas, 1991). Two subgroups of symptoms, depersonalization and derealization, may be particularly related to sexual arousal functioning because they are characterized by shifts in attention and connection to one’s body and the present moment (Fleiss, 1975). Examples of depersonalization experiences are a sense of feeling disconnected from one’s body, watching oneself as an observer, or feeling like one’s body is unusually large or small. Examples of derealization experiences are feeling as if the external world is strange or unreal, or time is moving unexpectedly fast or slow (American Psychiatric Association, 2000; Bremner et al., 1998; Briere, Weathers, & Runtz, 2005). According to one study, dissociative symptoms occurred after upsetting memories in 45 % of cases, during states of anxiety or depression in 66 % of cases, or for no specific reason in 35 % of cases (Aderibigbe, Bloch, & Walker, 2001). While depersonalization generally occurs during high stress or depression, derealization is more likely to occur during dangerous situations or for no particular reason (Aderibigbe et al., 2001), suggesting that these two forms of dissociation are controlled by different mechanisms. Dissociation, being an alteration of conscious awareness of the present moment, can also be experienced positively. For example, orgasm creates‘‘an altered state of consciousness’’which is perceived as a positive experience (Davidson & Davidson, 1980; Meston, Hull, Levin, & Sipski, 2004). Indirect Evidence on Dissociation and Sexual Responses The perceived importance of dissociation in the sexuality of CSA survivors is reflected in the fact that many treatments for sexual dysfunction in CSA survivors focus on the reduction or elimination of dissociation during sexual activities. Dissociation could also negatively affect the sexuality of women without a history of CSA since dissociation is theorized to impact a woman’s awareness of sexual stimuli thereby leading to difficulties in becoming or remaining sexually aroused (see Barlow, 1986 for a discussion of attention to sexually-relevant stimuli and sexual arousal). However, to date, no research has been conducted to directly test if dissociation during sex occurs more frequently in women with a history of CSA compared to women without a history of abuse. In addition, no research has tested whether dissociation, either during sex or in general, is correlated with greater sexual arousal problems in women with a history of CSA. The literature on sexuality has not directly addressed dissociation during sexual activity; however, awareness of the present moment and a connection with one’s body are foci of theoretical and empirical studies that link distraction with low sexual arousal. For example, Masters and Johnson (1970) emphasized ‘‘spectatoring’’or the tendency for individuals to judge

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their sexual performance from a third person’s perspective as a key factor in sexual arousal problems. This detachment is problematic because it prevents the individual from fully experiencing and enjoying the sexual activity, and it moves the focus away from the sexual stimuli. In support of this theory, empirical evidence has demonstrated that spectatoring leads to lower physiological sexual arousal in men and sexually functional women (Meston, 2006; van Lankveld, van den Hout, & Schouten, 2004). Also, spectatoring compared to immersing in one’s experienced emotions is associated with lower subjective sexual arousal (SSA) functioning in men and women (Both, Laan, & Everaerd, 2011). Additionally, increased body-awareness leads to higher subjective mental sexual arousal and perceptions of physical sexual arousal in sexually dysfunctional women (Seal & Meston, 2007). Further support for the importance of derealization and depersonalization on sexual arousal comes from studies that manipulated awareness of the present moment by utilizing a therapeutic technique known as mindfulness (Brotto, Basson, & Luria, 2008; Brotto, Seal,& Rellini, 2012;Classenetal., 2011). Mindfulness Therapy evolved from Buddhist meditation and emphasizes nonjudgmental present-moment awareness (Hanh, 1976). Studies demonstrated that mindfulness can improve sexual arousal functioning (Brotto, Basson, & Luria, 2008a; Brotto, Krychman, & Jacobson, 2008b; Brotto et al., 2012) suggesting that increasing nonjudgmental awareness, and therefore reducing/preventing distraction during sexual activity, can improve sexual functioning.

Based on evidence from clinical outcomes studies showing that enhancing focus on the present moment during sex improved SSA in CSA survivors more than other modes of treatment (Brotto et al., 2008a, 2012), for Hypothesis 1 we expected that greater dissociative symptoms during partnered sexual activity would be related to more sexual arousal problems, while dissociative symptoms that occurred outside of partnered sexual activity would not. In Hypothesis 2, we predicted that depersonalization and derealization would have different effects on sexual arousal during partnered sexual activity, with depersonalization having a stronger negative influence. We based this hypothesis on evidence that awareness of one’s own body, as opposed to the surrounding environment, is important to sexual experiences (Seal & Meston, 2007). Hypothesis 3 combined Hypotheses 1 and 2 by predicting an interaction between CSA status and depersonalization as associated with sexual arousal during partnered sexual activity. Based on previous findings that dissociation is associated with trauma, specifically with a history of CSA (Boysan et al., 2009; Johnson et al., 2001; Sanders & Giolas, 1991), as well as empirical and theoretical support for differential correlates of sexual responses between women with and without a history of CSA (Gilmore et al., 2010; Meston & Lorenz, 2012, Rellini et al., 2012; Schacht et al., 2007), we anticipated that the effect of depersonalization on sexual arousal during partnered sexual activity would be different for the CSA and NSA groups, with depersonalization having a greater effect on the CSA group. Given that we anticipated in Hypothesis 2 that derealization would have less of an effect, we did not anticipate that a similar interaction with derealization would be found.

The Present Study The present study addressed two main gaps in the literature on dissociation and sexual function in CSA survivors. First, it considered two distinct and independent aspects of dissociation (derealization and depersonalization) separately. This differs from previous work that has often combined these constructs under the umbrella of dissociation. Second, this study measured dissociation during sexual activity separately from dissociation occurring during daily life. While dissociation during sex may have a direct effect on sexual response, an overall tendency to dissociate may provide greater information on trait characteristics and tendency of the individual to escape from the present moment in situations that are not engaging, and thus daily dissociation may need to be considered separately from dissociation specific during sex. Moreover, to provide a more comprehensive view of the effects of dissociation on sexual arousal, this study utilized a multi-method approach to the operationalization of sexual arousal. Included were self-reports of perceived ability to reach and maintain sexual arousal during sexual activities with a partner, and objective and subjective measures of sexual arousal to audio-visual sexual stimuli shown in a laboratory setting.

Method Participants Women with a history of CSA and women with no history of childhood abuse were recruited from the community. Participants, who could identify as more than one ethnicity, were 77.2 % Caucasian, 14.0 % Hispanic, 8.8 % Black, and 1.8 % ‘‘other.’’CSA was initially assessed during a phone screening and was defined as experiencing a forced or coerced sexual encounter where touching or penetration of the genitals happened before age 16 with someone at least 5 years older (adapted from Finkelhor, Hotaling, Lewis, & Smith, 1989). Several women in the CSA group also reported later revictimization (sexual abuse after age 16). Participants did not qualify for the NSA group if they reported a history of physical abuse or neglect during their childhood or if they reported sexual abuse at any point in their lives. A clinical interview conducted at the end of the study confirmed that participants were correctly assigned to CSA and NSA groups. For both the CSA and NSA groups, participants

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were between the ages of 25 and 35 years, fluent in English, and sexually active with a partner or partners in the previous 4 weeks. We excluded women under 25 years and over 35 years of age in order to focus on a group of women who had an opportunity to have sexual experiences and to increase homogeneity across sexual experience level. Additionally, we intended to avoid including women with menopausal symptoms and associated sexual dysfunction since our research questions were related to sexual difficulties associated with a history of CSA. Midlife isgenerallyconsideredover35 yearsofage(An&Cooney,2006) and research has shown that changes associated with menopause (i.e., changes in menstrual flow or cycle length) can occur in women during this time period (Mitchell, Woods, & Mariella, 2000). Of 188 women who were initially screened, 82 (43.6 %) did not qualify and 106 (56.4 %) met eligibility criteria. Of the 106 women who qualified, 9 (8.5 %) were not interested, 29 (27.4 %) did not show up for their appointments, and 3 (2.8 %) had technical problems with data collection. From the 82 women that were excluded, 18 (9.6 %) had exclusively a lesbian orientation, 9 (4.8 %) had health problems that affected sexuality, 9(4.8 %)hadnotparticipatedinsexualactivityinthelast4 weeks, 23 (12.2 %) were outside the age range, 7 (3.7 %) had a history of voluntary sexual experiences before the age of 16 with someone at least 5 years older, and 17 (9.0 %) had a history of sexual abuse during adulthood but not during childhood. If participants were taking medications known to affect sexual function (e.g., antidepressants), they were included in the study if they reported that the medication type and dosage had been stable for the prior 3 months, that they did not experience any decrease in sexual function from taking the medication, and thattheyhadnointenttochangetheirmedicationordosagebefore participation in the study. Seventeen (9.0 %) women reported a medication change in theprior 3 months and also reported changes in sexual function and thus were excluded. Please note that many participants were excluded from more than one reason so the numbers of excluded criteria are more than the number of excluded participants. Among the participants included in the study, 23 % reported not using any medication (including birth control, recreational substances, or vitamins). The remainder of participants reported use of oral contraceptives (17.8 %), recreational drugs such as marijuana (14.1 %), nutritional supplements (12.5 %), allergy medication (10.8 %), over the counter pain medication (8.9 %), antidepressants (7.2 %), and other medications (10.8 %). Some people used more than one of the substances listed above. Measures Questionnaires and Interviews Sexual functioning was measured using the Female Sexual Functioning Index (Rosen et al., 2000). All 19 items were

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administered; however, since the study focused on sexual arousal, only the four items comprising the sexual arousal subscale (FSFI-AR) were utilized for the analyses. Sample items include ‘‘Over the past 4 weeks, how often did you feel sexually aroused (‘‘turned on’’) during sexual activity or intercourse?’’and‘‘Over thepast 4 weeks, how would yourate your level ofsexual arousal (‘‘turn on’’) during sexual activity or intercourse?’’Answer choices vary depending on the question but generally range from ‘‘1’’(‘‘Almost never or never’ or‘‘Very low or none at all’’) to‘‘5’’ (‘‘Almost always or always’ or ‘Very high’’). A score of 6 on the arousal subscale indicates the highest level of sexual arousal functioning and a score of 1 indicates the lowest. A score of 0 indicates the individual has not engaged in sexual activities in the previous 4 weeks. Because of our eligibility criteria, none of our participants scored 0. The FSFI has shown adequate interitem reliability for sexually healthy women (Cronbach’s a = 0.82–0.92) and for women diagnosed with female sexual arousal disorder (Cronbach’s a = 0.89–0.95). Internal consistency (Cronbach’s a = 0.82 and higher) and test–retest reliability (r = .79–.86) of this scale tested in the past (Rosen et al., 2000) and current sample (full score Cronbach’s a = 0.91; arousal subscore Cronbach’s a = 0.85) were also in the acceptable range. General dissociative symptoms were assessed with the Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale (CAPS) (Blake et al., 1990). A trained interviewer administered the CAPS, a widely published standardized interview that assesses the 17 key symptoms of PTSD (APA, 2000). The last items ask about frequency and intensity of derealization (one item) and frequency and intensity of depersonalization (two items) (CAPS-Der and CAPS-Deper) symptoms and were used in the present study to assess daily symptoms of dissociation not necessarily related to sexual activities. The interview questions collect information about depersonalization, e.g.,‘‘Have there been times when you felt as if you were outside of your body, watching yourself as if you were another person?’’These questions are followed by other prompts designed to ensure that the responder correctly understands the question and to provide a clinician-based evaluation of intensity and frequency of the symptoms. Questions of frequency are rated by the interviewer on a scale from‘‘0’’(‘‘Never’’) to‘‘4’’(‘‘Daily or almost daily’’) and questions of intensity are rated by the interviewer on a scale from ‘‘0’’ (‘‘None’’) to ‘‘4’’ (‘‘Extreme’’). This interview has shown strong convergent validity with the Mississippi Scale for Combat-Related PTSD (Keane, Caddell, & Taylor, 1988), the MMPI-2 Keane’s PTSD subscale (Lyons & Keane, 1992), and the Standardized Clinical Interview, DSM-III (King, Leskin, King, & Weathers, 1998). The CAPS has also shown strong test–retest reliability, acceptable internal consistency in past studies (Cronbach’s a = 0.73–0.85; Blake et al., 1990) and in the current study (Cronbach’s a = 0.97), and good discriminate validity, diagnostic utility, and sensitivity to clinical change (for a review see, Weathers, Keane, & Davidson, 2001). The senior author (A.H.R.) was the trained

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interviewer for this study. In previous studies, the scores from the CAPS conducted by this interviewer showed high correlations (r = .87) with scores on another self-reported measure for PTSD. Dissociative symptoms during sexual activity with a partner were measured using a variation of the Clinician Administered Dissociative States Scale (CADSS; Bremner et al., 1998). The CADSS is a 27-item questionnaire consisting of three subscales (amnesia, depersonalization, and derealization). Given that derealization and depersonalization are the two aspects of dissociation that have theoretical support, only the derealization (CADSS-Der) and depersonalization (CADSS-Deper) were used in this study. The scale consists of 19 self-report and 8 observer-rated items which are measured on a 5-point scale from‘‘0’’(‘‘Not at all’’) to‘‘4’’(‘‘Extremely’’). In this study, participants were assessed using the self-report section and were instructed to think of a typical sexual activity with their identified partner. To our knowledge, this scale has not been previously adapted to a sexual context. Examples of derealization items (12 items total) are‘‘Do things seem to be unreal to you, as if you are in a dream?’’and‘‘Does it seem as if you are looking at the world through a fog, so that people and objects appear far away or unclear?’’Examples of depersonalization items (five items total) are‘‘Do you feel as if you are looking at things from outside your body?’’and‘‘Does your sense of your own body feel changed; for instance, does your own body feel unusually large orunusually small?’’The19self-report itemshaveshown acceptable internal consistency (Cronbach’s a = 0.94) and high interrater reliability (intraclass correlation coefficient = 0.99, p\.001) in previous studies (Bremner et al., 1998). In the current study, inter-item correlations were Cronbach’s as = 0.86, 0.72, and 0.80 for the Full Score and Depersonalization and Derealization domains, respectively. Severity of childhood abuse (i.e., physical, emotional, and sexual abuse) was measured utilizing the Childhood Trauma Questionnaire-Short Form (Bernstein & Fink, 1998). The 28 items ask participants to indicate how much each statement is true about the their childhood, with responses ranging from ‘‘1’’ (‘‘Never true’’) to‘‘5’’(‘‘Always true’’). The sexual abuse subscale (CTQ-Sex) and total score (CTQ-Total) were utilized to confirm that the two groups (CSA and NSA) differed in their experiences of childhood abuse. Sample items include‘‘When Iwasgrowingup,someonemolestedme.’’and‘‘WhenIwasgrowing up, I had the best family in the world.’’The CTQ has shown good internal consistency estimates in past research (Cronbach’s a = 0.79–0.95), and test–retest reliability (Chronbach’s a = 0.80–0.88) in previous studies (Bernstein & Fink, 1998). In the present study, the inter-item correlations were Cronbach’s as = 0.67 and 0.96 for the Full Scale and Sexual Abuse domain, respectively. Of note, the inter-item correlation for the Full Scale is lower than previously reported correlations.

Psychophysiological Assessment Physiological sexual arousal was measured using a vaginal photoplethysmograph (Sintchak & Geer, 1975), a device consisting of a clear acrylic, tampon-shaped probe that is inserted by the participant into her vagina. The device measures vaginal pulse amplitude (VPA), an indirect measure of changes in vaginal blood flow. A data acquisition unit Model MP100WS (BIOPAC System, Inc.) and a software program, AcqKnowledge version 3.7.3 (BIOPAC Systems, Inc.), were used for data capture and analysis. The VPA signal was sampled 80 times per second and the amplitude of each pulse wave was recorded in millivolts (mV). The average VPA was calculated during exposure to a non-sexual video and during a sexual video. The final outcome variable utilized for the study was VPA percentage change from the non-sexual to the sexual video (VPA%). SSA was assessed with the Arousometer, which consisted of a lever moved by the participant to indicate her level of sexual arousal during exposure to the videos (on a scale from 0 to 10). The same Biopac system used for photoplethysmography was used for the collection of continuous SSA data. This procedure has been used in prior studies to measure SSA during psychophysiological assessment and has shown adequate reliability and validity as shown by a significant correlation with questionnaire measures of mental sexual arousal, b = 0.01, t = 5.88, p\.006 (Rellini, McCall, Randall, & Meston, 2005; Rellini & Meston, 2006b). Other studies have also used similar procedures to measure continuous SSA (Laan, Everaerd, Van Aanhold, & Rebel, 1993; Laan, Everaerd, van der Velde, & Geer, 1995; Wincze, Hoon, & Hoon, 1977). The videos used for this study were comprised of a nonsexual video (time = 3 min) followed by an explicit sexual video showing a heterosexual couple engaging in sexual activities (masturbation, oral sex, and vaginal intercourse, time = 10 min). The excerpt of the sexual video was selected from videos produced and directed by women because past studies indicate that these videos are more successful at producing both physiological and subjective sexual responses in women (Laan, Everaerd, van Bellen, & Hanewald, 1994). Studies that used these stimuli with women with a history of CSA found a significant increase in both physiological and SSA in participants (Rellini & Meston, 2006a). Procedure Participants were recruited from the community using advertisements which explained that the study was on the sexual health of women with and without unwanted past sexual experiences. After a brief standardized phone interview for the assessment of inclusion and exclusion criteria, participants were invited for an individual laboratory visit. All visits were scheduled in

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Der, CAPS-Deper and CAPS-Der were also added in Step 2 to test the significance, direction and strength of their interactions.

the afternoon between day 5 and 10 of the participant’s menstrual cycle (calculated using the participant’s report of her first day of her last cycle). A female experimenter collected informed consent and then participants were left alone in a private room that was internally locked. After inserting the vaginal photoplethysmograph and completing a trial to help participants become familiar with the Arousometer, participants relaxed on a recliner chair for an adaptation period (time = 10 min). The video sequence was shown on a plasma TV positioned 6 feet in front of their chair. The TV monitor was controlled from the adjacent experimenter room. At the end of the sexual video, the participant completed the interview and all questionnaires. Each participant was compensated $30 and thoroughly debriefed before leaving.

Results Means of key variables were compared between the CSA and NSA groups using t tests (see Table 1). Confirming the division of participants into CSA and NSA groups, CTQ-Total was lower in the NSA group, M = 35.46, SD = 7.95, than in the CSA group, M = 66.57, SD = 21.48, t(59) = 6.81, p\.001. Similarly, CTQ-Sex was lower in the NSA group, M = 5.42, SD = 1.28, than in the CSA group, M = 16.38, SD = 7.01, t(59) = 7.55, p\.001. The CSA and NSA groups did not significantly differ in age, t(61) = -1.74. The CSA and NSA groups also significantly differed in FSFI-AR, t(61) = 2.45, p\.05, d = .63, with the CSA group reporting lower sexual arousal functioning. The CSA group reported significantly higher levels of CAPS-Deper, NSA: M = 0.18, SD = 0.59, CSA: M = 1.42, SD = 1.25, t(56) = 2.25, p\.05. The two groups did not significantly differ in CADSS-Deper, CADSS-Der, CAPS-Der, VPA%, or SSA. We tested for multicollinearity between dissociation variables by calculating the correlations (see Table 2) and the variance inflation factors (VIF). All VIFs were below 5, suggesting that multicollinearity was not an issue (O’Brien, 2007). Of note, the correlation between CADSS-Deper and CADSS-Der was high at .80 (see Table 2). Because results differed for these variables and because our VIFs were in the acceptable range,

Data Analytic Plan Descriptive information on differences in sexual functioning and dissociative symptoms between women with and without a history of CSA was assessed using t tests. In addition, three hierarchical linear regressions were conducted, one for each of the sexual outcomes, FSFI-AR, VPA% and SSA. The independent variables were mean-centered, and CSA history was dummy coded as -1 = NSA and 1 = CSA. In Step 1 of each two-step model, CSA status was added. In Step 2, the dissociation subscales of the CADSS (CADSS-Deper and CADSSDer) and the two subscales of the CAPS (CAPS-Deper and CAPS-Der) were added to the model to test their independent and additive main effects on the outcome. The four two-way interactions between CSA history and CADSS-Deper, CADSS-

Table 1 Means and SDs for severity of childhood trauma (CTQ), dissociation during sex with a partner (CADSS), daily dissociation symptoms (CAPS), and sexual responses (FSFI-AR, VPA%, SSA) by CSA status NSA M

CSA SD

N

M

d SD

N

Age (in years)

28.50a

4.61

24

30.77a

5.64

39

0.44

CTQ Full Score

35.46a

7.59

24

66.57b

21.48

37

1.93

CTQ Sexual Abuse

5.42a

1.28

24

16.38b

7.01

37

2.18

CADSS-Deper

1.68a

2.38

22

3.55a

4.55

38

0.52

CADSS-Der

2.77a

5.66

22

3.81a

6.46

37

0.17

CAPS-Deper

0.18a

0.59

22

1.42b

2.52

36

0.68

CAPS-Der

0.00a

0.00

22

0.44a

1.25

36

0.50

FSFI-AR

5.06a

1.03

24

4.42b

1.01

39

0.63

VPA%

40.59a

34.95

23

35.50a

33.47

34

0.15

SSA

71.73a

27.09

21

74.81a

28.94

30

0.11

Note: Means in the same row not sharing subscripts are significantly different at p\.05 CADSS-Deper Clinician Administered Dissociative States Scale Depersonalization factor, scores range from 0 to 20, CADSS-Der Clinician Administered Dissociative States Scale Derealization factor, scores range from 0 to 48, CAPS-Deper Clinician Administered PTSD Scale Depersonalization factor, scores range from 0 to 16, CAPS-Der Clinician Administered PTSD Scale Derealization factor, scores range from 0 to 8, CTQ Full Score Childhood Trauma Questionnaire Full Score, scores range from 25 to 125, CTQ Sexual Abuse Childhood Trauma Questionnaire Sexual Abuse factor, scores range from 5 to 25, FSFI-AR Female Sexual Functioning Index Arousal factor, scores range from 0 to 6, SSA Subjective Sexual Arousal in the laboratory, higher scores reflect greater subjective sexual arousal, VPA% Vaginal Pulse Amplitude Percent Change in the laboratory

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this high correlation should be noted for future research but is not of central concern in the current study. For the regression predicting FSFI-AR, in Step 1, CSA alone did not significantly predict FSFI-AR, F(1, 47) = 2.41 (see Table 3). This incongruence in results from the t test is most likely attributable to missing data and the use of pairwise deletion (N = 4). However, an analysis of effect sizes showed that the direction andmagnitude ofthetwo analyses are comparable. The t test showed an effect of r = .29 (r2 = .09) and the regression showed an effect of r2 = .05. In Step 2, with the addition of CADSS-Deper, CADSS-Der, CAPS-Deper, CAPS-Der, and thefourinteractionterms, the model significantlypredicted FSFIAR, F(8, 40) = 2.89, p\.05. Also in Step 2, CADSS-Der had a significant main effect on FSFI-AR, b = 0.69, t(48) = 3.21, p\.01, and the interaction between CADSS-Der and CSA was not significant, b = -0.16, t(48)\1, allowing for direct interpretation of the main effect. This relationship suggests that, regardless of CSA status, higher levels of derealization during sexual activity were associated with higher levels of sexual arousal during partnered sexual activity. While CADSS-Deper had a significant main effect on FSFIAR, b = -0.72, t(48) = 3.00, p\.01, CADSS-Deper was also part of a significant two-way interaction involving CSA, b = 0.65, t(48) = 2.76, p\.01, and the higher level interaction should be analyzed in preference to the lower level effect. A simple slopes analysis (Aiken & West, 1991) for the interaction between CSA and CADSS-Deper wasconducted, and the resulting graph is shown in Fig. 1. Amongst those women with a history of CSA, CADSS-Deper was not significantly associated with FSFIAR. For the NSA group, higher levels of CADSS-Deper were associated with lower levels of FSFI-AR. That is, for women without a history of CSA, increased depersonalization during sex wasassociated with lower sexual arousal, butforthe women with a history of CSA, there was no significant relationship between depersonalization during sex and sexual arousal. The other variables in Step 2 of the model predicting FSFIAR were not significant predictors in either main effect or interaction: CAPS-Deper,b = 0.27,t(48)\1,CAPS-Der,b = -0.23,

t(48) = 1.67, and their interaction terms, CSA 9 CAPS-Deper, b = 0.30,t(48)\1, and CSA 9 CAPS-Der,b = -0.36, t(48)\1. The regressions using the same independent variables to predict VPA% and SSA were not significant at either Step 1 or Step 2 (see Table 3). VPA% was not significantly predicted by Step 1, F(1, 47)\1, or Step 2, F(8, 40)\1. SSA was also not significantly predicted by Step 1, F(1, 47)\1, or Step 2, F(8, 40) = 1.84. Since the model itself was not a significant predictor of VPA% or SSA, the slopes of the individual independent variables making up the model were not assessed for significance or interpreted. Thus, the effects found above for sexual arousal during partnered activity were not observed in laboratory measures of sexual arousal (Table 3).

Discussion Group Differences In agreement with the view that intrusive thoughts and the inability to stay in the present moment are symptoms often reported by individuals with a history of trauma and CSA in particular (Maercker et al., 2000; Mulder et al., 1998; Sanders & Giolas,1991; van der Kolk,2003), participants in our study who reported a history of CSA indicated more depersonalization during their daily life than women in the NSA group. The tendency to move outside one’s body and feel detached from reality is usually experienced as outside one’s control and has been conceptualized as a defense mechanism to protect oneself from emotional distress (Chu & Dill, 1990; Putnam & Trickett, 1997; Sanders & Giolas, 1991). While depersonalization can be effective at reducing acute stress, in the long run it is more problematic. For example, lack of awareness of one’s body and sensations can reduce the ability to respond to potential threats in the environment. Indeed, scholars have proposed that dissociation (i.e., a lack of awareness) is one of the vulnerabilities explaining the high incidence of sexual revictimization in adult women with a history of CSA (Cloitre, Scarvalone, & Difede, 1997;

Table 2 Correlations between depersonalization and derealization variables (during sex: CADSS, and daily symptoms: CAPS) 1

2

3

4

1. CADSS-Deper 2. CADSS-Der

0.80**

3. CAPS-Deper

0.39**

0.16

4. CAPS-Der

0.24

0.21

0.20

CADSS-Deper Clinician Administered Dissociative States Scale Depersonalization factor, CADSS-Der Clinician Administered Dissociative States Scale Derealization factor, CAPS-Deper Clinician Administered PTSD Scale Depersonalization factor, CAPS-Der Clinician Administered PTSD Scale Derealization factor ** p\.01

Fig. 1 Simple slopes plot illustrating the relationship between depersonalization during sex (CADSS-Deper) and sexual arousal functioning (FSFI-AR) for CSA and NSA groups. Asterisks slope was significantly different than 0, p\.05

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Arch Sex Behav Table 3 Multistep regression models of CSA status and dissociation (during sex: CADSS, and daily symptoms: CAPS) as predictors of sexual responses (sexual arousal functioning: FSFI-AR, physiological sexual responses: VPA%, and subjective sexual arousal: SSA) Dependent variable

Step and predictor variable

FSFI-AR

Step 1 CSA

b

CSA

-0.14

CADSS-Deper

-0.72**

CAPS-Deper CAPS-Der CSA 9 CADSS-Deper

VPA%

-0.22

SSA

CADSS-Deper

-0.01 -0.05

CAPS-Deper

-0.05

CAPS-Der

-0.38

Step 1 CSA

CADSS-Deper CADSS-Der

.01

.01

.27

.26

0.49 -0.03 0.08 -0.07 0.56* -0.09 0.07

CAPS-Der

0.00 0.08

CSA 9 CADSS-Der

-0.15

CSA 9 CAPS-Deper

0.16

CSA 9 CAPS-Der

.05

0.27

CAPS-Deper CSA 9 CADSS-Deper

.07

-0.23

Step 2 CSA

.02

0.03

CADSS-Der

CSA 9 CAPS-Der

.02 -0.14

Step 2

CSA 9 CAPS-Deper

.32*

0.69**

CSA 9 CAPS-Der

CSA 9 CADSS-Der

.37*

0.28

Step 1

CSA 9 CADSS-Deper

.05

-0.22 -0.16 -0.30

CSA

.05

0.69**

CSA 9 CADSS-Der CSA 9 CAPS-Deper

CSA

DR2

-0.22

Step 2

CADSS-Der

r2

-0.13

CADSS-Deper Clinician Administered Dissociative States Scale Depersonalization factor, CADSS-Der Clinician Administered Dissociative States Scale Derealization factor, CAPS-Deper Clinician Administered PTSD Scale Depersonalization factor, CAPS-Der Clinician Administered PTSD Scale Derealization factor, CTQ Full Score Childhood Trauma Questionnaire Full Score, CTQ Sexual Abuse Childhood Trauma Questionnaire Sexual Abuse factor, FSFI-AR Female Sexual Functioning Index Arousal factor, SSA Subjective Sexual Arousal in the laboratory, VPA% Vaginal Pulse Amplitude Percent Change in the laboratory * p\.05; ** p\.01

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DePrince, 2005; Noll, Horowitz, Bonanno, Trickett, & Putnam, 2003). Consistent with our hypotheses, all effects were only seen in the analysis of dissociative symptoms that occurred during sexual activity (CADSS) and not when considering dissociative symptoms that occurred during daily life (CAPS). This expectation was based on theoretical understandings and empirical evidencesupportingtheimportanceofbody-awarenessandattention to sexual stimuli during sexual activity for sexual functioning (Barlow, 1986; Meston, 2006; Seal & Meston, 2007). Thus, dissociative symptoms occurring outside of sexual activity, theoretically, should not interrupt an individual’s ability to focus on sexual stimuli and her own body. In our study, we did not find evidence that women with a history of CSA experienced more dissociation during sex with a partner as compared to women with no history of abuse, although they did experience more dissociation in daily life. Multiple explanations can be offered for this finding. It is possible that a woman with a history of CSA experiences dissociation during sex only when with a relatively new partner or outside the contextof an emotionally significantrelationship.Women may feel a higherlevel ofsafety with an established or emotionally trusted partner and there may be less of a need to dissociate during sexual activity to escape from triggered memories. In our study, the majority of women were in a committed relationship and therefore more likely to know their partners well. However, without more detail on the length and intimacy of the relationships, this limitation cannot be disregarded. It is also plausible that the amount of dissociation of the CSA and the NSA groups may not differ in frequency (as measured by the CADSS) but we cannot determine whether they may have differed in intensity of dissociative symptoms or the etiology of dissociation. To provide an example, awomanwitha historyofCSA and awomanwithno history of abuse may both report experiencing dissociation during sex half of the times (similarfrequency). For the woman with a history of CSA, the dissociation may be triggered by nonsexual cues and she may even enter the sexual activity already in a dissociative state as suggested by the higher rates of daily dissociative symptoms found in our sample. Thus, there may be very little about the dissociative experience per se that is sexually-related. Conversely, for the woman with no history of abuse, the dissociation may be in response to negative emotions such as anxiety about being an inadequate sexual partner. Her fears of being disliked or abandoned by her partner may be the trigger that pushes her to dissociate. The CADSS is not able to capture either the nuances or the severity of the symptoms that may make these two experiences, although similar in frequency, essentially different. Our results on dissociation during sex may not be in agreement with a recently published study indicating that a longer duration (years) of sexual abuse and higher number of perpetrators were related to higher levels of dissociation during sex

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(Hansen, Brown, Tsatkin, Zelgowski, & Nightingale, 2012). This recent study used a new 15-item scale intended to measure dissociation during partnered sexual activity. It is not possible to directly compare our findings with this study because of the differences in participant population (i.e., all participants were HIV positive and some were not sexually active) and study design; (i.e., no control group). Regardless of these differences, both the findings from our study and from Hansen et al. point to a complex relationship between women with a history of CSA and dissociation during sexual activity and highlight the importance of further investigation into the characteristics of dissociation and sexual functioning. We did not observe a lower VPA or SSA in the CSA group as compared to the NSA group, which is consistent with previous studies that found no differences in SSA functioning in the laboratory (Gilmore et al., 2010; Rellini et al., 2012; Rellini & Meston, 2006a; Schacht et al., 2007). Results are inconsistent,however,withpreviousstudiesthatfounddifferencesinboth VPA between women with and without a history of sexual abuse (Gilmore et al., 2010; Meston & Lorenz, 2012; Rellini et al., 2012; Rellini & Meston, 2006a; Schacht et al., 2007). It is possible that, given the literature’s limited understanding of sexual arousal and its relationship to CSA, a number of moderators may affect the sexual responses of this group. For example, a negative relationship between VPA and abuse history may be visible only when additional factors are present such as exaggerated sympathetic nervous system activity (Rellini & Meston, 2006a). Also, CSA experiences vary in their nature and their effects on women. It is possible that the types of sexual abuse experienced by participants in this study may be significantly different from those experienced by individuals who participated in previous studies and this may have resulted in a different VPA response. Of note, not all previous research has found deficits in physiological sexual arousal (Rellini & Meston, 2011) in women with a history of CSA. More investigations need to be conducted before we can understand this phenomenon more clearly. Hypotheses 1 and 2: Dissociation During Sex and Sexual Arousal Functioning While dissociation is often assumed to be a major factor in the sexual arousal difficulties of women with a history of CSA, no empirical evidence has been published in support of this view. Hypothesis 1, which expected a negative relationship between dissociation (CADSS) and SSA (FSFI-AR) experienced during partnered sexual activity, was partially supported. The two components of dissociation during sexual activity—depersonalization and derealization—had main effects in opposite directions, with depersonalization associated with lower and derealization associated with higher sexual arousal functioning. This is consistent with Hypothesis 2, which predicted that depersonalization would have a stronger effect on partnered arousal. These results can be read as evidence that, in the bedroom, depersonalization

and derealization may have opposite relationships with sexual arousal functioning. It is feasible that while derealization may be the product of being fully engaged in the sexual experience to the point of losing track of time and place, on the other hand, detaching from one’s body and losing awareness of sensations (e.g., depersonalization) may be an indication of distancing from the experience. These two aspects of dissociation could be qualitatively different and our findings support this conceptualization. It is interesting to note that derealization during sex was positively associated with sexual arousalfunctioning for all women in the study, including the CSA group. Current mindfulness programs for sexual dysfunction help individuals focus on bodily sensations utilizing Mindfulness exercises that Linehan (1993) calls Observe and Describe. According to Linehan, observing is attending to emotions and events to allow one to experience the fullmomentwithawareness.Describingisapplyingverballabels to emotions and events where one learns not to take their thoughts as absolute truths. For example, Brotto (2011) taught women to observe and describe the sensations associated with experiencing the sight, smell, feel and taste of a raisin (Brotto, 2011). In addition to these two aspects of Mindfulness, Linehan also introduced the technique, ‘‘Participate,’’ in her Mindfulness training.‘‘Participate’’consists of immersing fully into an activity without analyzing the experience (Linehan, 1993). When a person is fully immersed in an activity, their sense of time, awareness of outside noises, and other stimuli becomes peripheral and can fade or be intensely muted. That derealization, or a change in perception of the outside world, was positively associated with sexual arousalfunctioning in our sample,mightsuggest that incorporating Participate mindfulness exercises into therapy may be particularly efficacious for engendering deep engagement in the sexual activity. Such engrossment and participatory attention may be useful beyond increasing presentmoment awareness such as during Observe and Describe exercises. The psychophysiological sexual responses in the laboratory were not associated with dissociative symptoms experienced during sex or during daily activities. It is possible that women do not experience dissociation during a psychophysiological assessment because the anxiety and fear that would be experienced during sexual activity with a partner is not activated while alone in front of a TV monitor where there are different, fewer, orno sexualexpectations placed ontheindividual. Anecdotally, we routinely ask women whether they are able to focus on the sexual videos during the psychophysiological assessment, and the great majority of women always answer positively. Since we expected little variance in their perceived distraction during the videos, we did not inquire about distraction during the psychophysiological assessment. However, more sophisticated and specific questions that tap into dissociation during the sexual psychophysiological assessment or objective measures of attention (e.g., eye tracking) may be able to provide greater insight into this phenomenon.

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Hypothesis 3: CSA History and Depersonalization Interaction on Sexual Arousal Hypothesis 3 predicted an interaction between CSA status and depersonalization (CADSS-Deper), with women in the CSA group showing a greater sensitivity to the effect of depersonalization on sexual arousal during partnered sexual activity (FSFIAR). This hypothesis was not supported. While there was a significant interaction between CSA and depersonalization, the simple slopes analysis showed a different picture than expected, with depersonalization having no statistically significant effect on the sexual arousal functioning of women in the CSA group. The NSA group, however, showed a significant negative relationship between depersonalization during sexual activity (CADSS-Deper) and sexual arousal functioning (FSFI-AR). These findings suggest that depersonalization symptoms may not have a direct and stable relationship with the sexual arousal functioning of CSA survivors. However, the significant, negative relationship between depersonalization and NSA was in the expected direction. Depersonalization, or thetendency to detach from one’sbody and physical sensations, has been identified by many scholars as a risk factor for sexual arousal problems during sex. Masters and Johnson (1970) and Barlow (1986) point to the importance of focusing on one’s sensations toincrease sexual arousal. These approaches are based on the assumption that distancing from sensations in the present moment causes a decrease in sexual arousal by reducing attention to sexually-relevant stimuli. However, both CSA and NSA groups reported similar levels of depersonalization during sexual activities but only the NSA group showed a significant and negative relationship between sexual arousal and depersonalization. This finding suggests that experiencing depersonalization during sex may not be sufficient to cause problems with sexual arousal.

Limitations and Conclusion A number of limitations need to be considered when generalizing these findings to the larger population. It is of note that the CAPS PTSD Scale used to measure daily dissociative symptoms is less extensive than the CADSS used to measure dissociation during sex with a partner. Only one item measuring derealization intensity and frequency and two items measuring depersonalization intensity and frequency were used. If depersonalization and derealization are indeed differentially related to sexual functioning, it is imperative for future studies to utilize a measure including the full range of symptoms characterizing each construct. In addition, the CADSS was not created to specifically measure dissociation during partnered sexual activity, and future research would benefit from the validation of a measure

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intended for this purpose. Indeed, such a measure (42 items) is currently being developed (Hansen et al., 2012). We did not include other variables such as co-occurring types of abuse or abuse severity. Even though the current study is blind to those important factors, we believe that, as a first step and the beginning of a line of research, this study contributes important information. Of note, the study did not differentiate between women with a history of CSA who experienced sexual revictimization during adulthood from those who were abused only during childhood. Previous studies (Cloitre et al.,1997; DePrince, 2005; Noll et al., 2003) have shown that women who experience revictimization during adulthood are different from those who experience sexual abuse only during childhood, therefore a larger study that focuses on CSA only versus CSA plus sexual revictimization during adulthood as well as other abuse types and severity of abuse may be able to provide more detailed information about the relationships between trauma, dissociation, and sexual arousal functioning. The relatively small sample size of this study should be considered when making inferences about the generalizability of the results. The sample was large enough to identify a medium effect; however, a smaller effect in VPA or SSA may have been lost. For this reason, a replication of these results will aid in making more solid inferences about dissociation, sexual responses, andsexual abuse. In addition, the small age range used limits the generalizability of the results. Although the use of a younger sample aided in avoiding certain confounding variables in the present study, much valuable information can be gleaned by sampling women over the age of 35 in future research. As in all studies using vaginal photoplethysmography, it is important to note that there may be differences between women who volunteered for the study and those who did not. Both men and women who volunteer for these studies tend to be more sexually experienced, exhibit less sexual guilt, and be more willing to disclose sexual information (Catania, McDermott, & Pollack, 1986; Plaud, Gaither, Hegstad, Rowan, & Devitt, 1999; Strassberg & Lowe, 1995; Wolchik, Spencer, & Lisi, 1983). Since information about individuals who do not volunteer for this study is not available, it is difficult to indicate what these differences might be. In conclusion, this study indicates that, when considering dissociation and sexual function, scholars and therapists should focus on changes in bodily perception and not necessarily changes in perception of the environment. Also, we should not assume that depersonalization is a main problem in the sexual arousal dysfunction of women with a history of CSA. Finally, independently from one’s history of abuse, helping women to fully immerse in the sexual experience may benefit the sexual arousal of the individual. Future studies on the causes of and intensity of depersonalization during sexual activities may lead to a clearer identification of its relationship with female sexual arousal functioning.

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