JOURNAL OF SEX & MARITAL THERAPY, 41(4), 427–439, 2015 C Taylor & Francis Group, LLC Copyright  ISSN: 0092-623X print / 1521-0715 online DOI: 10.1080/0092623X.2014.918066

Prevalence of Sexual Problems and Associated Distress Among Lesbian and Heterosexual Women Maria Manuela Peixoto and Pedro Nobre Faculdade de Psicologia e de Ciˆencias da Educac¸a˜ o, Universidade do Porto, Porto, Portugal

Prevalence studies on female sexual problems among heterosexual samples have been conducted extensively across different countries. However, relatively little is known regarding prevalence of sexual problems in lesbians. The present study aimed to assess and compare the frequency of selfperceived sexual problems and associated levels of distress in lesbians and heterosexual women. In all, 390 lesbians and 1,009 heterosexual women completed an online survey. The authors assessed the frequency of self-perceived sexual problems in lesbians and heterosexual women, over the past 6 months, as well as the associated levels of distress. Main results suggested that, after controlling for distress levels, sexual pain was the most frequent sexual problem reported by lesbians and heterosexual women. Also, when distress was considered a significant decrease on prevalence rates of sexual problems were found for both lesbians and heterosexual women. Current findings emphasize the role of associated levels of distress to self-perceived sexual problems in women, regardless of sexual orientation. In addition, results suggest that length of relationship play a major role on sexual problems. Overall, data indicated a relatively similar pattern in prevalence of sexual problems in lesbians and heterosexual women.

Over the past years, several prevalence studies suggested that female sexual problems are an important health concern with a negative effect on women’s quality of life and sexual satisfaction (Abdo, Oliveira, Moreira, & Fittipaldi, 2004; C ¸ ayan et al., 2004; Haavio-Mannila & Kontula, 1997; Ishak, Low, & Othman, 2010; Lau, Cheng, Wang, & Yang, 2006; Laumann, Paik, & Rosen, 1999; Oksuz & Malhan, 2006; Oniz, Keskinoglu, & Bezircioglu, 2007; Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Rosen & Bachmann, 2008; Sidi, Puteh, Abdullah, & Midin, 2007; Stulhofer, Gregurovic, Pikic, & Galic, 2005). However, most studies have been conducted with heterosexual samples. For that reason, little is known about prevalence of sexual problems in lesbians. In a review of prevalence studies on female sexual dysfunction, Hayes, Dennerstein, Bennett, and Fairley (2008) found that estimates varied across alternative instruments used to assess the different disorders. The range of time used to assess the sexual difficulties and the inclusion of distress levels were important variables in determining prevalence rates. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013), sexual symptoms should persist for at least 6 months and personal distress should Address correspondence to Maria Manuela Peixoto, Faculdade de Psicologia e de Ciˆencias da Educac¸a˜ o, Universidade do Porto, Rua Alfredo Allen, 4200-135 Porto, Portugal. E-mail: [email protected]

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be experienced. Previous studies have suggested that only 25 to 28% of sexual difficulties that occurred for 1 month persist after 6 months or more (Hayes, Bennett, Fairley, & Dennerstein, 2006). Regarding prevalence studies in heterosexual women, results showed, consistently, lower rates of sexual problems when levels of distress were considered (Bancroft, Loftus, & Long, 2003; Dennerstein, Guthrie, Hayes, DeRogatis, & Lehert, 2008; Hayes et al., 2008; Knoepp et al., 2010; Rosen et al., 2009; Shifren, Monz, Russo, Segreti, & Johannes, 2008; Witting et al., 2008). Some studies have compared levels of sexual functioning between lesbians and heterosexual women. In general, findings have indicated that lesbians tend to report higher levels of sexual functioning compared with heterosexuals (Beaber & Werner, 2009; Coleman, Hoon, & Hoon, 1983; Matthews, Hughes, & Tartaro, 2006). More specifically, lesbians reported better orgasmic function (Beaber & Werner, 2009; Coleman et al., 1983) as well as higher levels of sexual arousal (Beaber & Werner, 2009), and lower levels of sexual pain (Matthews et al., 2006) compared with heterosexual women. Regarding self-reported sexual problems, according to Lau, Kim, and Tsui (2006), 75.6% of women in same-sex relationships reported at least one sexual problem, and 44.9% felt extremely bothered as a result of sexual difficulties. Prevalence rates for specific sexual problems were contradictory. According to Lau, Kim, and Tsui (2006), lubrication difficulties (39.3%) represent the most frequent sexual problem, followed by lack of sexual desire (30.7%), orgasmic difficulties (24.7%), and sexual pain (23.6%). In a study conducted by Meana, Rakipi, Weeks, and Lykins (2006), 28% of lesbians reported difficulties in reaching orgasm, 15% experienced arousal difficulties, and 12% referred lack of sexual desire. Similar to studies with heterosexual samples, prevalence rates of sexual problems in nonheterosexual women when associated levels of distress were considered tend to be lower. According to Burri and colleagues (2012), prevalence estimates were 9.9% for lack of sexual desire, 8.4% for difficulties in reaching orgasm, 6.5 and 6.4% for arousal and lubrication difficulties, respectively, and 5.9% for sexual pain, when distress levels were taken into account. Overall, the majority of prevalence studies regarding sexual problems in women was conducted with heterosexual samples, did not assess associated levels of distress, and reported sexual problems over the past 4 weeks. Levels of distress related to the sexual problems should be considered when prevalence studies are conducted. Because of the constant evolution of the definitions of sexual problems, it may be important to assess frequency of sexual problems along with and separately from associated distress levels. Therefore, data from future studies can be compared with current data (Hayes, 2008). Recently, self-reported sexual problems among Portuguese women were assessed (Peixoto & Nobre, in press). Results suggested lack of sexual desire (25.4%) as the main sexual problem reported by women, over the past 4 weeks, followed by orgasmic (16.8%) and lubrication difficulties (12.9%), dyspareunia (9.8%), and vaginismus (6.6%). However, only heterosexual women were considered in this study. The present study aimed to assess and compare the frequency of self-perceived sexual problems and associated distress experienced by lesbians and heterosexual women in a Portuguese community sample. This is the first study that directly compares frequency of self-reported sexual problems among heterosexual women and lesbians while simultaneously considering the levels of associated distress.

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METHOD Participants and Procedures Participants were 1,563 women from the general population who completed an online survey about female sexual problems between May 2012 and May 2013. To recruit heterosexual women and lesbians, we considered different recruitment approaches. The online survey (www.limesurvey. org) was publicized on several Portuguese LGBT forums, websites, and social networks (focused recruitment). Also, an invitation by e-mail was sent via Portuguese universities mailing lists. Participants received an e-mail with a full explanation about the purpose of the study and the respective link to answer the survey. Initially, participants were invited to select the link according to their sexual orientation (lesbians or heterosexual women). Women who agreed to participate were invited to read an informed consent. After agreeing to the informed consent, participants were invited to answer several questions about sexual problems. No monetary compensation was given. To safeguard participants’ privacy and anonymity, the online survey was located at the University of Aveiro server, and IP addresses were not recorded. The study was approved by the University of Aveiro Ethics Committee. To control for potential inaccuracies made by participants when selecting the appropriate link according to their sexual orientation, or when answering to the sexual orientation scale, women who reported incongruent self-identified sexual orientation were excluded from the final sample. In addition, to control for confounding effects related to sexual activity incongruent to self-labeling sexual orientation, we excluded lesbians involved in mixed-sex relationship and heterosexual women involved in same-sex relationships over the past 6 months. Participants who selected the link for heterosexual women but scored 4 or less on the 7-point Likert-type scale of sexual orientation (n = 35) or who reported engaging in sexual activity with another woman in the preceding 6 months (n = 19) were excluded from the final sample. Also, women who selected the online survey for lesbians and scored 4 or above on the sexual orientation scale (n = 78) or who indicated sexual activity with a man in the preceding 6 months (n = 32) were also excluded. From the 1,399 eligible participants, 390 completed a version for lesbians and 1,009 completed a version for heterosexual women. No significant differences were found between lesbians and heterosexual women on age, t(1397) = 1.209, p = .227; marital status, χ 2(1) = 0.164, p = .685; and educational level, Z = 1.347, p = .053. However, heterosexual women (M = 3.98, SD = 4.68; range = 0–33 years) reported longer relationship duration compared with lesbians (M = 2.60, SD = 3.15; range = 0 to 25 years), t(1010) = –4.842, p < .001. Sociodemographic characteristics of the sample are shown in Table 1. Measures Sociodemographic Characteristics Sociodemographic characteristics were evaluated by several questions about personal information (age, education, marital status), and climacteric status (premenopausal, perimenopausal, and postmenopausal). Regarding sexual orientation, participants answered the question, “How would you define your sexual orientation?” according to a Likert-type scale ranging from 1 (exclusively homosexual) to 7 (exclusively heterosexual). Also, participants answered the question, “Over the

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TABLE 1 Sociodemographic Characteristics of the Sample (N = 1,399) Lesbians (n = 390)

Age (years) Marital status Single Married or living together Missing Educational level (years) 0–9 10–12 13 or more Data missing Climacteric Premenopausal Perimenopausal Postmenopausal Data missing Length of relationship (years)

Heterosexual women (n = 1,009)

M (SD)

Range

M (SD)

Range

26.26 (7.83) n

18–62 %

25.70 (7.75) n

18–62 %

319 67

81.8 17.2

822 184

81.5 18.2

4

1.0

3

0.3

14 144 230 2

3.6 36.9 59.0 0.5

5 324 678 2

0.5 32.1 67.2 0.2

321 17 7 45

82.3 4.4 1.8 11.5

925 14 12 58

91.7 1.4 1.2 5.7

M (SD) 2.60 (3.15)

Range 0–25

M (SD) 3.98 (4.68)

Range 0–33

past 6 months, how often had you engaged in sexual activity with a man?” (lesbian version) or “Over the past 6 months, how often had you engaged in sexual activity with a woman?” (heterosexual women version). We assessed length of relationship by asking, “If you are in a relationship with a partner, for how long does it last?” Self-Perceived Sexual Problems We developed a specific questionnaire to assess perceived sexual problems, namely orgasmic difficulties, lack of sexual desire, arousal difficulties, and sexual pain. To evaluate orgasmic difficulties, participants answered the question, “Over the past 6 months, have you experienced an absence of orgasm?” We assessed lack of sexual desire by asking, “Over the past 6 months, have you experienced absent or markedly reduced interest in sexual activity?” For arousal difficulties, participants answered the question, “Over the past 6 months, have you experienced absent or reduced sexual excitement or pleasure during sexual activity?” Participants answered using a 7-point Likert-type scale ranging from 1 (never) to 7 (always). For sexual pain, participants used a 7-point Likert-type scale ranging from 1 (no pain) to 7 (extreme pain) in response to the question, “How much pain do you feel during (attempted) penetration?” Participants could also select the option for 0 (no sexual activity). To assess distress levels, participants answered the question, “How would you classify the rate (degree) of associated distress?” using a 7-point

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Likert-type scale ranging from 1 (no distress) to 7 (extreme distress), after each sexual problem question.

Data Analysis We conducted frequency analyses to assess prevalence of self-perceived sexual problems in lesbians and heterosexual women, and we estimated 95% confidence intervals. Likewise, we conducted frequency analyses to assess distress levels of each sexual problem. For prevalence purposes, only participants who reported sexual activity over the preceding 6 months were included in the analysis. Lesbians and heterosexual women who reported experiencing sexual difficulties in 50% of the times or more (cutoff ≥ 4 in a 7 point Likert-type scale) were considered to present a sexual problem. In addition, self-reported levels of distress from moderate to extreme (cutoff ≥4 in a 7-point Likert-type scale) were considered as the threshold to classify sexual problems. To analyze the differences between frequency of self-perceived sexual problems, before and after controlling of associated levels of distress, in lesbians and heterosexual women, a chi-square analysis was conducted. To explore differences in the self-perceived sexual problems, between lesbians and heterosexuals, adjusted for length of relationship, we computed a multivariate logistic regression. Presence of self-perceived sexual problems was introduced as dependent variable (presence of sexual problem vs. absence of sexual problem), and group (lesbians vs. heterosexual women) and length of relationship were entered as independent variables.

RESULTS Frequency of Self-Perceived Sexual Problems in Lesbians and Heterosexual Women, Before Controlling for Levels of Distress Over the past 6 months, 7.7% (n = 30) and 8.5% (n = 33) of lesbians reported not having been engaged in sexual activity or attempted sexual penetration, respectively. For heterosexual women, 2.8% (n = 28) did not engage in sexual activity and 6.4% (n = 65) did not attempt sexual penetration. For prevalence purposes, women who did not engaged in sexual activity or attempted penetration over the past 6 months were excluded from the analysis. As Figure 1 indicates, regarding the prevalence of self-perceived sexual problems in lesbians, the most frequently reported difficulty was lack of sexual desire 21% (95% CI [16.96, 25.04]). In addition, 17.4% of the lesbians (95% CI [16.64, 21.16]) experienced sexual pain, 14.6% (95% CI [11.1, 18.1]) experienced difficulties in reaching orgasm, and 10.3% (95% CI [7.28, 13.32]) reported sexual arousal difficulties. Regarding the heterosexual sample, the most frequently reported sexual problems were difficulties in reaching orgasm with 25.8% (95% CI [23.1, 28.5]) followed by lack of sexual desire with, 24% (95% CI [21.37, 26.63]). In addition, 18.6% (95% CI [16.2, 21.0]) experienced sexual pain, and 17% (95% CI [14.68, 19.32]) referred sexual arousal difficulties, in 50% of the times or more, over the past 6 months.

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30,0% Lesbian women Heterosexual women 25,0%

Frequency

20,0%

15,0%

10,0%

5,0%

0,0%

Orgasmic difficulties

Lack of sexual desire

Arousal difficulties

Sexual pain

Self-perceived sexual problems

FIGURE 1 Frequency of self-perceived sexual problems in lesbians and heterosexual women (N = 1,399).

Distress Levels Associated With Self-Perceived Sexual Problems in Lesbians and Heterosexual Women Regarding associated distress levels to specific sexual problems, frequency analyze were conducted. Lesbians and heterosexual women, who experienced moderate to severe associated distress to the presence of a sexual problem (in 50% of the times or more), over the past 6 months, were considered. As shown in Table 2, results suggested that for lesbians, sexual pain was the problem with higher associated distress levels (56.5%), followed by arousal difficulties (55%), orgasmic difficulties (45.6%), and lack of sexual desire (32.1%). Regarding heterosexual women, sexual pain was also the sexual problem with higher associated distress levels (71.7%), followed TABLE 2 Distress Levels Experienced by Lesbians and Heterosexual Women With Sexual Problems Lesbians Sexual

problem1

Orgasmic difficulties Lack of sexual desire Arousal difficulties Sexual pain

Heterosexual women

n

%

n

%

26 26 22 35

45.6 32.1 55.0 56.5

116 95 90 129

44.6 39.3 52.3 71.7

Note. Participants who indicated not having sexual activity in the 6 months before completion of the questionnaire were excluded from the analysis. 1Answers for orgasmic difficulties, lack of sexual desire, arousal difficulties, and sexual pain scored 50% of the times or more.

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16,0%

Lesbian women Heterosexual women 14,0%

12,0%

Frequency

10,0%

8,0%

6,0%

4,0%

2,0%

0,0%

Orgasmic difficules

Lack of sexual desire

Arousal difficules

Sexual pain

Self-perceived sexual problems

FIGURE 2 Frequency of self-perceived sexual problems in lesbians and heterosexual women after controlling for distress levels experienced (N = 1,399).

by sexual arousal difficulties (52.3%), orgasmic difficulties (44.6%), and lack of sexual desire (39.3%).

Frequency of Sexual Problems in Lesbians and Heterosexual Women, After Controlling for Levels of Distress Considering distress levels as moderate to extreme, we computed frequency analyses to assess frequency of self-perceived sexual problems after controlling for experienced distress levels. As Figure 2 shows, for lesbians, the prevalence rates of sexual difficulties when considering the distress levels of moderate to extreme were 9.8% for sexual pain, 6.7% for orgasmic difficulties and lack of sexual desire, and 5.6% for sexual arousal difficulties. Regarding heterosexual women, the frequency rates were 13.3% for sexual pain, 11.5% for orgasmic difficulties, 9.8% for lack of sexual desire, and 8.9% for sexual arousal difficulties.

Differences in Frequency of Sexual Problems, Before and After Controlling for Levels of Distress, in Lesbians and Heterosexual Women To analyze the statistical differences between frequency of self-perceived sexual problems, before and after controlling for associated distress levels, we conducted chi-square analyses. As Table 3 shows, results suggested statistical significant differences for both lesbians and heterosexual women, in every single sexual problem.

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TABLE 3 Differences in Frequency of Sexual Problems in Lesbians and Heterosexual Women, Before and After Controlling for Levels of Distress Lesbians

Heterosexual women

Differences in Differences in sexual problems sexual problems before and after before and after Before Before After After controlling for controlling for controlling for controlling for controlling for controlling for distress (χ 2) distress (χ 2) distress (%)1 distress (%)1,2 Sexual problem distress (%)1 distress (%)1,2 Orgasmic difficulties Lack of sexual desire Arousal difficulties Sexual pain

14.6

6.7

162.74∗∗∗

25.8

11.5

375.63∗∗∗

21.0

6.7

106.27∗∗∗

24.0

9.8

332.39∗∗∗

10.3

5.6

204.01∗∗∗

17.0

8.9

480.86∗∗∗

17.4

9.8

195.45∗∗∗

18.6

13.3

681.21∗∗∗

Note. Participants who indicated not having sexual activity in the 6 months before completion of the questionnaire were excluded from the analysis. For each chi-square, df = 1. ∗∗∗ p < .001. 1Answers for orgasmic difficulties, lack of sexual desire, arousal difficulties, and sexual pain scored 50% of the times or more. 2Answer for distress levels scored from moderate to extreme levels.

Differences in Frequency of Sexual Problems Between Lesbians and Heterosexual Women We computed a multivariate logistic regression for each self-perceived sexual problems after controlling for associated levels of distress. Self-perceived sexual problems were introduced as dependent variables (1 = presence of sexual problem; 2 = no sexual problem). Group (1 = lesbians; 2 = heterosexuals) and length of relationship were introduced as independent variables. As Table 4 shows, before adjusted for length of relationship, heterosexual women reported TABLE 4 Statistics for Multivariate Logistic Regression With Sexual Problems as Dependent Variables Sexual problem1

Lesbians

Orgasmic difficulties

Lack of sexual desire

OR

OR

95% CI Reference

p

95% CI Reference

p

Arousal difficulties OR

95% CI Reference

p

Sexual pain OR

95% CI

p

Reference

Heterosexual women2 1.819 1.168, 2.831 .008 1.455 0.927, 2.283 .103 1.638 1.012, 2.652 .045 1.487 1.003, –2.203 .048 Heterosexual women3 1.771 0.947, 3.311 .073 1.674 0.882, 3.177 .115 1.109 0.561, 2.195 .766 1.790 0.962, –3.329 .066

Note. Participants who indicated not having sexual activity in the 6 months before completion of the questionnaire were excluded from the analysis. 1Answers for orgasmic difficulties, lack of sexual desire, arousal difficulties, and sexual pain scored 50% of the times or more. Answer for distress levels scored from moderate to extreme levels. 2Data for differences in sexual problems. 3Data for length of relationship-adjusted differences in sexual problems.

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higher probability of having orgasmic difficulties, OR = 1.819 (95% CI [1.168, 2.831]), p = .008; experiencing sexual arousal difficulties, OR = 1.638 (95% CI [1.012, 2.652]), p = .045; and reporting sexual pain, OR = 1.487 (95% CI [1.003, 2.203]), p = .048. No differences were found regarding lack of sexual desire, OR = 1.455 (95% CI [0.927, 2.283]), p = .103. After adjusting for length of relationship, results indicated no statistical differences between lesbians and heterosexual women, regarding the probability of reporting orgasmic difficulties, OR = 1.771 (95%, CI [0.947, 3.311]), p = .073; experiencing lack of sexual desire, OR = 1.674 (95% CI [0.882, 3.177]), p = .115; referring sexual arousal difficulties, OR = 1.109 (95% CI [0.561, 2.195]), p = .766; and reporting sexual pain, OR = 1.790 (95%, CI [0.962, 3.329]), p = .066.

DISCUSSION Female sexual dysfunctions are often conceptualized according to guidelines in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000, 2013). Although the text of the Diagnostic and Statistical Manual does not explicitly refer to sexual orientation specificities, the fifth edition appears more inclusive of lesbians given that no references were found regarding penile-vaginal penetration in its criteria (American Psychiatric Association, 2013). For that reason, more studies are needed about the specificity of sexual problems in lesbians to develop evidence-based diagnostic guidelines. Therefore, we aimed to assess the prevalence rates of self-perceived sexual problems in lesbians and heterosexual women, as well as the associated levels of distress. According to our findings, 7.7% and 8.5% of the lesbians and 2.8% and 6.4% of the heterosexual women, who participated in the online survey, did not engage in sexual activity or attempted vaginal penetration, respectively. Also, 26.2 and 32.6% of lesbians and heterosexual women, respectively, were not in an exclusive relationship. Current methods do not allow to conclude why those women did not engage in sexual activity and/or attempt vaginal penetration. It may be that women who did not engage in sexual activity may present with some sort of sexual difficulty. However, according to a recent study, sexual difficulties were not a reason that women did not engage in sexual activity over the past year (Mitchell et al., 2013). A possible explanation for higher rates of sexual abstinence in the previous 6 months among lesbians compared with heterosexual women may be due to higher sexual passivity or difficulties in initiating sexual activity, as referred in previous studies (Nichols, 2004; van Rosmalen-Nooijens, Vergeer, & Lagro-Janssen, 2008). Therefore, the different frequency of sexual activity may have impaired results regarding prevalence of sexual problems. Lack of sexual desire has been suggested as the most frequent sexual difficulty among heterosexual women (Abdo et al., 2004; C¸ayan, et al., 2004; Hassanin et al., 2010; Ishak et al., 2010; Oksuz & Malhan, 2006; Peixoto & Nobre, in press; Sidi et al., 2007). Current findings indicated lack of sexual desire as a significant sexual problem in both heterosexual women and lesbians, however, when associated levels of distress were considered, the estimated rates decreased significantly and desire was no longer the most frequent sexual problem. Nevertheless, young women mostly constituted the present sample, and aging has been associated with lower levels of sexual desire (Abdo et al., 2004; C ¸ ayan et al., 2004; Hassanin et al., 2010; Ishak et al., 2010; Oksuz & Malhan, 2006; Peixoto & Nobre, in press; Safarinejad, 2006; Sidi et al., 2007).

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Although sexual pain is a common sexual difficulty in older women with vaginal atrophy, the empirical literature has systematically shown that sexual pain is the most frequent sexual problem among younger women (Abdo et al., 2004; C ¸ ayan et al., 2004; Hassanin et al., 2010; Ishak et al., 2010; Oksuz & Malhan, 2006; Peixoto & Nobre, in press; Safarinejad, 2006; Sidi et al., 2007). Consistent with previous findings, our data indicated that, after controlling for associated levels of distress, sexual pain represents the most prevalent sexual problem on both samples. Previous research have highlighted the role of distress associated with sexual problems in heterosexual women (Bancroft et al., 2003; Dennerstein et al., 2008; Hayes et al., 2006; Hayes et al., 2008; Knoepp et al., 2010; Rosen et al., 2009; Shifren et al., 2008; Witting et al., 2008). Also, a similar pattern was found in lesbians (Burri et al., 2012; Lau, Kim, & Tsui, 2006). Consistently with previous studies, lower rates of sexual problems were found in lesbians and heterosexual women, when associated levels of distress were considered. Moreover, the present study compares, directly, frequency of sexual problems before and after controlling for associated levels of distress, in a sample of lesbians and heterosexual women. Our data suggested that only a percentage of women with self-perceived sexual problems experience significant associated levels of distress. This finding emphasizes the importance of assessing associated levels of distress during clinical assessment and diagnosis. In addition, a better understanding of the reasons why some women experience mild levels of distress while others report moderate to severe distress associated with sexual difficulties may help to improve health care programs. Regarding the role of relationship length, previous studies with heterosexual samples indicated a positive correlation with frequency of sexual problems, with women in longer relationships showing more sexual difficulties (Hassanin et al., 2010; Ishak et al., 2010; Sidi et al., 2007; Stulhofer et al., 2005). Consistent with these findings, no significant differences were found for frequency of sexual problems between lesbians and heterosexual women, after adjusting for length of relationship. In other words, the higher frequency of sexual problems reported by heterosexual women, in particular regarding arousal and orgasmic difficulties and sexual pain, was partially explained by the fact that they were engaged in longer relationships compared with lesbians. Nevertheless, findings show a trend for lesbians to report lower rates of orgasmic difficulties (p = .008 vs. p = .073) and sexual pain (p = .048 vs. p = .066) even after controlling for relationship length. Findings using the FSFI cutoff point have suggested that lesbians are less at risk of having a sexual dysfunction compared with heterosexual women (Breyer et al., 2010; Shindel et al., 2012). Also, previous findings have suggested that lesbians reported better orgasmic function, compared to heterosexuals (Beaber & Werner, 2009; Colemen et al., 1983). Current data suggest that lesbians reported fewer difficulties in reaching orgasm. A possible justification for current findings may be related to the different sexual stimulation observed in lesbians and heterosexual women. It is possible that lesbians engage in sexual activity and stimulation that facilitate reaching orgasm. As observed by Masters and Johnson (1979), lesbians focused longer time in preliminary sexual behavior when compared with heterosexuals. In regards to sexual stimulation, lesbians usually adopt an in-depth approach, stimulating their partner in a way that they would like being stimulated (Masters & Johnson, 1979). Regarding sexual pain, one possible explanation for this finding may be related to the sexual behavior repertory commonly presented by lesbians, which is not focused on vaginal penetration (Bailey, Farquhar, Owen, & Whittaker, 2003) along with the central meaning of vaginal penetration among heterosexual couples (Colson, Lemaire, Pinton, Hamidi, & Klein, 2006; Nobre & Pinto-Gouveia, 2006).

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The present study presented some limitations that should be acknowledged. First, we used a convenience sample, and the majority of the participants were young and well educated, which can impair the generalization of the findings to the general population. Also, the survey was conducted online, and only women with Internet access were able to participate. Regarding sample collection, different recruitment approaches were considered in order to recruit heterosexual and lesbians. Because of the difficulty in having access to lesbians, we used a focused recruitment with the help of LGBT associations. Nevertheless, no significant differences were found regarding sociodemographic characteristics with the exception of length of the relationship. In addition, women who did not engage in sexual activity in the previous 6 months were excluded from the statistical analyses. However, it was not possible to infer why those women did not engage in sexual activity. It is possible that those women were avoiding sexual activity to cope with current sexual problems. In that case, prevalence of sexual problems could be underestimated. Last, sexual problems assessed were self-perceived and no clinical diagnoses could be inferred. Despite limitations, the present study represents the first attempt to describe and compare the frequency of self-perceived sexual problems and associated levels of distress in sociodemographic matched samples of lesbians and heterosexual women. Moreover, both lesbians and heterosexual women reported significant lower rates of sexual problems in terms of associated levels of distress. Along with similarities, findings also suggested specificities on frequency of self-perceived sexual problems, according to sexual orientation. Overall, findings indicated that heterosexual women reported more sexual problems than did lesbians; however, when controlling for length of relationship, the differences lose their statistical significance. REFERENCES Abdo, C., Oliveira, W., Moreira, E., & Fittipaldi, J. (2004). Prevalence of sexual dysfunctions and correlated conditions in a sample of Brazilian women: Results of the Brazilian Study on Sexual Behavior (BSSB). International Journal of Impotence Research, 16, 160–166. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Bailey, J. V., Farquhar, C., Owen, C., & Whittaker, D. (2003). Sexual behavior of lesbians and bisexual women. Sexually Transmitted Infections, 79, 147–150. Bancroft, J., Loftus, J., & Long, J. S. (2003). Distress about sex: A national survey of women in heterosexual relationships. Archives of Sexual Behavior, 32, 193–208. Barlow, D. H., Cardozo, L. D., Francis, R. M., Griffin, M., Hart, D. M., Stephens, E., & Sturdee, D. W. (1997). Urogenital aging and its effect on sexual health in older British women. British Journal of Obstetrics and Gynaecology, 104, 87–91. Beaber, T., & Werner, P. (2009). The relationship between anxiety and sexual functioning in lesbians and heterosexual women. Journal of Homosexuality, 56, 639–654. doi:10.1080/00918360903005303 Breyer, B. N., Smith, J. F., Eisenberg, M. L., Ando, K. A., Rowen, T. S., & Shindel, A. W. (2010). The impact of sexual orientation on sexuality and sexual practices in North American medical students. Journal of Sexual Medicine, 7, 2391–2400. doi:10.1111/j.1743-6109.2010.01794.x Burri, A., Rahman, Q., Santtila, P., Jern, P., Spector, T., & Sandnabba, K. (2012). The relationship between same-sex experience, sexual distress, and female sexual dysfunction. Journal of Sexual Medicine, 9, 198–206. doi:10.1111/j. 1743-6109.2011.02538.x C¸ayan, S., Akbay, E., Bozlu, M., Canpolat, B., Acar, D., & Ulusoy, E. (2004). The prevalence of female sexual dysfunction and potential risk factors that may impair sexual function in Turkish women. Urologia Internationalis, 72, 52–57. doi:10.1159/000075273

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