Journal of Studieson Alcohol, Vol. 52, No. 5, 1991

Sexual Satisfaction

and Dissatisfaction

in the

Marital Relationshipsof Male AlcoholicsSeeking Marital Therapy* TIMOTHYJ. O'FARRELL,PH.D.,KEITH A. CHOQUETTE,PH.D,ANDGARYR. BIRCHLER,PH.D. t Veterans AffairsMedicalCenterandHarvardMedicalSchool,940 BelmontStreet,Brockton and WestRoxbury,Massachusetts 02401

ABSTRACT. Twenty-sixmarriedcoupleswith alcoholichusbands who soughtmaritaltherapywerecompared with two groupsof coupleswithoutalcohol-related problems,26 coupleswith maritalconflict (MC) and26 with no maritalconflict(NC), on a rangeof sexual satisfaction variables.As predicted, the alcoholicandMC couples did notdifferandbothof thesegroupsof couplesreportedlesssexual satisfaction thanthe NC couples. AlcoholicandMC couples,in

comparisonwith NC couples,reportedless frequentintercourse, morechangedesiredin intercourse frequency,greatermisperception aboutthe amountof changein sexfrequencydesiredby their mate andmoredisagreement aboutsex.In addition,the findingthatolder alcoholics had lessfrequentintercourse replicatedsimilarresultsby Jensen.Limitationsof the presentresearchand neededfuture researchare discussed.(J. Stud. Alcohol 52: 441-447, 1991)

ical ratherthanpsychosocial causeshavebeenemphasized 'NCONTROLLED REPORTS from clinical settings in a numberof countries (e.g., Sweden--Jensen, despiterepeatedmention in the literatureof the impor-

1979;WestGermany--Fahrner,1987) indicatethat many male alcoholicsexperienceserious sexual adjustment problems.Evidencefrom controlledstudies(e.g., Jensen, 1984; Whalley, 1978) revealsthat male alcoholicsshowa heightened prevalence of sexualadjustment problems when comparisonsamplesare investigated.The mostrecentresearchhas examinedboth physicaland psychosocial factors implicatedin the etiologyof theseproblems.For a comprehensive review, seeO'Farrell (1990). Giventhe documented negativephysicaleffectsof alcohol abuseon male sexualfunctioning(e.g., O'Farrell, 1990) and the marital conflictthat often accompanies alcoholism(e.g., O'Farrell and Birchler, 1987), it seems likely that both of these factorscontributeto male alcoholics'sexualadjustment problems.Unfortunately, the literature on male alcoholics'sexual adjustmentproblems has sufferedfrom a narrowness of perspective.Sexual dysfunction hasbeenemphasized to a greaterextentthan otheraspectsof sexualadjustment suchas sexualsatisfaction and dissatisfaction.Comparisongroupsgenerally havebeenlimitedto normal,nonalcoholic controls.Phys-

Received:July 5, 1989.Revision:December10, 1989. *This research wassupported by the Department of VeteransAffairs. Portionsof thisarticlewerepresented at the annualmeetingof theEastern PsychologicalAssociation,Boston,March 1989.

*Dr.Birchlet is associated withtheVA MedicalCenter, SanDiego, andthe Universityof CaliforniaMedicalSchool,SanDiego. 441

tanceof marital relationshipand other psychosocial factors (e.g., Wiseman, 1985). It seemsplausiblethat alcoholabuseandmaritalconflict affect differentaspectsof a couple'ssexualadjustment. Specifically,thephysicaleffectsof prolonged alcoholabuse may producesexualdysfunction,most frequentlyimpotence.The sexualdissatisfaction experienced by alcoholics may not be a uniqueconcomitant of alcoholism,however, but may be secondaryto the alcoholics'distressedmarital relationships. One way to investigatethesenotionsis to studya comparisongroup of nonalcoholiccoupleswith marital conflict (MC) in additionto the alcoholics.Only one such studyhas appearedto date. Burton and Kaplan (1968) interviewed16 couplesapplyingfor marriagecounselingin which the husbandhad beenmedicallydiagnosedas alcoholic or had a historyof seekingtreatmentfor excessive drinking and 16 nonalcoholiccouplesseekingmarriage counseling.Resultsshowedthat alcoholic and MC cou-

plesdid not differ on the proportionof subjectsreporting dissatisfaction with their sexualrelationships,while the MC coupleshad more disagreement over sexualmatters thandid the alcoholics.Unfortunately,Burtonand Kaplan (1968) did not report any statisticalanalysesand did not includea groupof coupleswith no marital conflict(NC) for comparison with the alcoholicandMC couples. The presentstudyof sexualsatisfactionand dissatisfaction in the marriagesof male alcoholicsextendedprior

442

JOURNAL

OF STUDIES

ON ALCOHOL

studiesby (1) includingreportsfrom both husbandsand wives and (2) usingcomparisongroupsof both MC and NC coupleswithout alcoholproblems.The presentstudy assessed two predictions.First, coupleswith a newly sober alcoholichusbandwho are seekingmarital therapy and MC nonalcoholic coupleswill not differ on levelsof sexual satisfaction. Second, both alcoholic and MC cou-

ples, by virtue of the marital conflictexperienced by these two groupsof problemcouples,will scorelowerthan NC coupleson measuresof sexualsatisfaction.Age also was examined in relation

to sexual satisfaction

since earlier

studies (Jensen, 1979, 1984) had found lower sex frequencyamongalcoholicsover age 40. Method

Subjects

Married couples(with each spouseunderage 60) who were living togetherand had beenmarried at least 1 year were eligible for the studyif they met the criteria for one of the threegroupsof couplesdescribedbelow.To ensure samplehomogeneity, only coupleswho were white were included.Thesecouplesparticipatedin a larger studyof alcoholics'maritalrelationships whichhasbeenpresented elsewhere(O'Farrell and Birchlet, 1987). Alcoholiccouples(ALC) seekingmarital therapy.These

couples were selectedfrom 73 consecutivecases who completedan initial evaluationfor marital therapy (betweenJuly 1978 and July 1980) during the first monthof their participationin the Counselingfor Alcoholics'Marriages(CALM) Projectat the VeteransAffairs (VA) Medical Centerin Brocktonand West Roxbury,Massachusetts. Presence of alcoholism

in the husband but not the wife

/ SEPTEMBER

1991

eitherspousein (1) responses to screening questions about occurrenceof or treatmentfor emotionalproblemsor (2) a careful review of the husband's record of medical treat-

ment by the VA. Questionable caseswere reviewedand additionalinformationwas gathereduntil diagnostic eligibility couldbe satisfactorily determined.Finally,noneof thesecouplessoughtsex therapyor presenteda sexual dysfunctionas their primary complaint. Coupleswith marital conflict (MC) withoutalcoholism problems.Thesecoupleswere selectedfrom 114consecutive caseswho completedan initial evaluationfor marital therapy(betweenNovember1977 and October1979)during the first month of their participationin the Family Mental Health programat the VA Medical Centerin San Diego, California.Thirty-sevenof these1!4 casesmetall of the following criteria. Presenceof marital conflict was indicated(1) by the coupleseekingan evaluationfor marital therapyand (2) by the fact that eachspousereceiveda score of less than 100 on the Marital AdjustmentTest (MAT) (Lockeand Wallace, 1959), indicatingmaritaldissatisfaction.

Absence of alcoholism

was documented

as

follows.The followingsourcesdid not mentionthat either spousehad a drinking problem or that either spouse's drinking contributedto relationshipproblems:the husband'smedicalrecordat the VA, each spouse'scomments

to therapistsduringthe initial evaluationandresponses to a Problem Areas Questionnaireon which each spouse listed the four most significantindividual and couple problemscurrentlybeingexperienced.In addition,neither spouserequesteda decreasein the partner'sdrinkingon the AC. Exclusionof coupleswith seriouspsychopathology was accomplished in the sameway as it was for the ALC couples.Finally, coupleswho soughtsex therapyor presenteda sexualdysfunctionas their primary complaint

was documented as follows. The husband was an alcoholic

were excluded.

as evidencedby requestingalcoholismtreatmentat the VA and by the MichiganAlcoholismScreeningTest (MAST, Selzer, 1971) (mean [_ SD] = 36.56 --- 7.38, range = 20-48). The husband'sdrinking had been a problemfor many years (mean = 10.89 _+ 8.14), had resulted in alcohol-related hospitalizations (mean = 3.84 --- 9.09)

Coupleswith no marital conflict(NC) withoutalcoholismproblems.Thesecoupleswereselectedfrom40 couples who in 1981 answeredadvertisements for happilymarried couplesplacedin a newspaperservingBrockton,Massachusettsand surroundingtowns,and who met the following criteria. Absenceof marital conflict was documented by both spouses receivinga scoregreaterthan 100 on the MAT and reportingthat they were happily married and had no historyof marital therapy.Absenceof alcoholism was documentedas follows. Both spousescompletedthe MAST aboutthe husband'sdrinkingand noneof the husbandsreceiveda scoreover three, indicatingthe absence of problemswith drinking (Selzer, 1971). Husbandsand wives denied that they or their spousehad a drinking problemor that drinkinghadcausedconflictin theirrelationship.Further,neither spouserequesteda decreasein the partner'sdrinking on the AC. Exclusionof couples with seriouspsychopathology was accomplished in the sameway as it was for the ALC coupleswith the excep-

and arrests(mean = 2.42 ___2.55), and had led to withdrawal symptomsin 92% (24/26) of the alcoholics.Both

spouses agreedin separateinterviewsthat the wife was not an alcoholicand that her drinkingwas not a problem in the marriage. Further,the husbanddid not requesta decreasein the wife's drinkingon the Areas of Change (AC) Questionnaire(Weiss and Birchlet, 1975). Exclusion of coupleswith seriouspsychopathology otherthan alcoholismwas accomplished in the followingways.Couples wereexcludedif a historyof hospitalization for emotional problemsor currentor past symptomsof a major mental disorder(i.e., schizophrenia, bipolar disorder,major depressionor otherpsychoticdisorder)were discovered for

O'FARRELL, CHOQUETTE AND BIRCHLER TABLE1. Demographic datafor threegroupsof couples Variable

ALC couples

MC couples

NC couples

15.12 + 10.64 1-33

15.22 - 10.84 2-35

15.50 -+ 8.71 4-34

41.85 + 9.85 28-58

43.00 +- 11.01 21-58

40.31 + 9.76 26-58

40.04 +- 10.59 19-58

39.92 +- 10.80 24-57

36.62 +- 8.64 23-54

13.35 + 2.00 11-17

14.40 +- 2.97 8-21

13.69 + 2.59 8-18

12.69 + 1.59 10-16

13.25 +- 2.02 10-17

13.50 +- 2.21 12-18

3.04 + 1.80 0-7

3.46 +- 1.58 0-6

2.46 +- 1.30 0-5

Years married

Mean (- SD) Range Age husband Mean (+ SD) Range Age wife Mean (+- SD) Range Education husband '•

Mean (+ SD) Range Education

443

was describedas an attemptto understand what kinds of problemsare experiencedby differenttypes of couples andhowcouplescommunicate abouttheirproblems.The NC couplescompletedthe same data collectionproceduresas did the two othergroupsof couples.In addition, both spousescompletedthe MAST aboutthe husband's drinkingto makesurethatneitherspousethoughtthe husbandhada drinkingproblem.Finally,a debriefingsession was conductedwith eachNC coupleto discussany reactions to the procedures. Measures

wife '•

Mean (+- SD) Range Number of children

Mean (- SD) Range

Note: ALC couplesare coupleswith an alcoholichusband.MC couples are coupleswith marital conflict with neitherspousean alcoholic.NC couplesare coupleswith no marital conflict with neitherspousean alcoholic.

'•Educationis yearsof schoolingcompleted. tions that the husbands did not have a VA medical record

for review. In addition, neither spousewas currentlyinvolvedin psychotherapy. Sampleselection.The final sampleof 26 ALC, 26 MC and 26 NC couplesdescribedin Table 1 was selectedfrom the 73 malealcoholicsandtheirwivesseekingmaritaltherapy,the 37 coupleswithoutalcoholproblemsseekingmarital therapyand the 40 coupleswith no marital conflict and without alcohol problems.Coupleswere selectedto producea final sampleof three groupsof couplesthat did not differ demographically,had equal n's per group and had the largestn possibleper group. These subjectsampleswere not selectedto be representative of alcoholicsor of the othertypesof couples.Our intentwas to selectdemographicallysimilar coupleswho varied systematically in their level of alcohol-relatedand marital problemsin orderto providea conceptuallyclear comparisonof levels of sexualsatisfactionacrossthe threegroupsof couples. Procedure

The ALC and MC couples completed the questionnaires that contained the information

about sexual satis-

factionas part of an initial evaluationfor marital therapy. ALC husbandstook a breath test to ensuretheir sobriety duringcompletionof the questionnaires, a commonpractice in researchand clinical alcoholismsettings.A meeting to discussthe informationobtainedand to plan the couple'scounselingconcludedthe evaluation. The NC coupleswho respondedto newspaperads for happilymarried couplesand met the criteria for participation completedinformed consentprocedures.The study

MichiganAlcoholismScreeningTest(MAST). The MAST (Selzer,1971), a widely usedinstrumentwhich has satisfactoryreliabilityand validity,was usedin part to define subjects'extentof alcoholproblems. Marital AdjustmentTest(MAT). The MAT (Locke and Wallace, 1959), a widely usedmeasurewith established reliabilityandvalidity,assessed the level of marital satisfaction. On the MAT each spouserates overall marriage happiness and degreeof agreementon sevenareas(e.g., finances,sex relations), and answerssix additionalquestions on marital

satisfaction.

Areas of Change Questionnaire(AC). The AC (Margolin et al., 1983;Weissand Birchler,1975) consistsof two parts that containidenticallistingsof 34 items reflectingspecificissuesfor maritalchange.On Part I each spouseindicateswhat partnerchangesare desiredin 34 commonmarital behaviorsand on Part II predictswhat changes'thepartnerwill request.The AC, designedto measure extent of unresolved conflict about desired rela-

tionship change, validly discriminatesdistressedfrom nondistressed couplesand showsgoodconcurrentvalidity as a measureof overallmarital adjustment(Birchleret al., 1975;Margolin et al., 1983). The AC itemspertainingto changedesiredin frequencyof sexualrelationswere used to derivetwo typesof indicesdescribedin moredetail below. In addition,the AC item regardingpossiblechanges desired in the spouse'sdrinking behavior was used to screenfor alcoholproblems. Indicesof sexualsatisfaction.Four indicesof sexualsatisfactionwere:MAT item on disagreement aboutsexrelations, two AC items on changedesiredin frequencyof sexualrelations,and frequencyof intercourse. Extent of disagreementover sexrelationswas measured with the MAT item which reads"State the approximate extent of agreementor disagreementbetween you and your mate on sex relations."Responses were coded: 1 = alwaysagree, 2 = almostalwaysagree, 3 = occasionally disagree,4 = frequentlydisagree,5 = almostalwaysdisagree, 6 = alwaysdisagree. Changedesiredin frequencyof sex relationswas the absolutevalueof the subject'sresponse to Item 13on Part

•.•.•.

JOURNAL

TABLE2.

OF STUDIES

ON ALCOHOL

/ SEPTEMBER

1991

Mean (+_ SD) scoresof threegroupsof couplesfor measures of sexualsatisfactionand resultsof ANOVA Alcoholic

Variable

Husband

Conflict

Wife

Husband

No conflict

Wife

2.85 +- 1.32 2.77 +- 1.39 3.85 +- 1.26 3.23 +- 1.14

Extentof disagreement

Husband 1.92 +- 0.74

Wife 1.96 +- 0.72

Groupby Group Spouse Spouse 17.02'

3.12

2.67

over sexual relationst'

Changedesiredin frequency

4.42 +--1.33 3.58 +--1.30 4.81 +--1.13 3.73 +--1.25 3.62 + 0.85 3.23 +--0.65

6.63* 22.57**

1.41

of intercourse c

Misperception aboutchange

0.88 +--1.11 0.96 +--0.96 1.23+--0.91 1.19+--1.30 0.31 +--0.47 0.61 + 0.85 8.75* 0.51

0.40

desiredby mate

in sexfrequency a Frequency of sexualintercourse e 4.46 +--2.00 4.38 +--2.23 3.96 +--1.89 4.31 +- 1.87 5.62 +--0.90 5.69 +--1.01

6.16'

1.12

1.28

Note:Higherscoresindicategreatervaluesfor eachof the variables. aF valuesare for effectsin group(ALC, MC, NC) by spouse(husbandvs. wife) ANOVAS.

t'Forextentof disagreement oversex,comparisons between groups showed: ALC = MC, ALC > NC, andMC > NC, aspredicted. CForchangedesiredin frequencyof intercourse, comparisons betweengroups,whichweredoneseparatelyfor husbands andwivesdueto the significant spouseeffect, showed:(1) ALCH = MCH, ALCH > NCH andMCH > NCH, as predicted;(2) ALCW = MCW = NCW.

aFormisperception aboutchange desired by matein sexfrequency, comparisons between groups showed: ALC = MC, ALC > NC andMC > NC, as predicted.

eForfrequency of intercourse, orthogonal contrasts of ALC with MC andof NC with the averageof the two problem-couple groupsshowed: ALC = MC and [ALC + MC] + 2 < NC which is consistent with predictions. * p < .05. p < .001.

I of the AC. This item reads "I want my partnerto have sexualrelationswith me" and the responseoptionsare: +3 = much more, +2 = more, + 1 = somewhat more,

threedemographically similargroupsof couplesand that ALC and MC couplessharedsimilar levels of marital problemsthat were not experienced by the NC couples.

0 = no changedesired,-1 = somewhatless, -2 = less, -3

= much less.

Groupdifferenceson sexualsatisfactionmeasures

Misperceptionaboutchangedesiredby mate in sexfrequencywas computedby taking the absolutevalue of the differencebetweenthe amountof changethe subjectbelieved his/her mate wanted (as indicatedby the subject's responseto Item 13 on Part II of the AC) and the mate's actualrating (from Item 13 of Part I of the AC). Frequencyof sexualintercoursewas measuredby how often the couple had sexual intercourse(1 = not at all, 2 = < once a month, 3 = once a month, 4 = onceevery two weeks, 5 = once a week, 6 = twice a week, 7 = 3

or 4 times a week, 8 = oncea day, 9 = > oncea day). Results

One-way ANOVAS revealedthat the three groupsof couples did not differ on any of the characteristics shownin Table 1. A one-wayANOVArevealedthat the threegroups of couplesdid differ on MAT scores(F = 71.65, 2/78 df, p < .001). Newman-Keuls showedthatboththe ALC and MC couples,who did not differ on the MAT, scoredlower on the MAT than did the NC couples.Scoreson the MAT for the threegroupsof coupleswere as follows:ALC-mean (-+ SD) = 84.33 --- 26.44, MC--mean = 71.18 --19.47 and NC--mean

= 127.08 --- 12.30. Note that both

ALC and MC couplesreceiveMAT scoresindicativeof serious marital conflict and the NC couples score well

intotheno-conflict rangeon theMAT.• Theseresults indicate that our sampleselectionsuccessfully produced

Table2 presentsresultsof the group(ALC, MC, NC) by spouse(husbandversuswife--a repeateddimension) ANOVAS conducted on the four sexual satisfaction

mea-

sures.The ANOVAS were followedby Newman-Keulscomparisonsfor each variable to determine which groups differed.

Extentof disagreement oversexrelations.As predicted ALC and MC did not differ, and both ALC and MC cou-

ples disagreedmore aboutsex than did the NC couples. The first row of Table 2 displaystheseresults. Changedesiredin frequencyof intercourse.Both group andspouseeffectsweresignificantwith husbands wanting more changethan wives did irrespectiveof type of couple. For wives, Newman-Keulscomparisons amonggroup meansindicatedno significantdifferences.However,husbands'resultsfollowedpredictions: ALC and MC did not differ, while both ALC and MC husbandsdesired more

changethandid NC husbands. The secondrow of Table2 displaystheseresults. Misperceptionabout change desired by mate in sex frequency.Resultsfollowedpredictions. ALC andMC did not differ while misperception was greaterin both ALC and MC couplesthan in the NC couples.Row three of Table2 displaystheseresults. Frequency of intercourse. Althoughthe ANOVAindicated that the threegroupsof couplesdiffered,Newman-Keuls comparisons failed to detectdifferencesbetweenany pair

O'FARRELL, CHOQUETTE AND BIRCHLER

445

[]NCI

NEVE•

I/DAY

FIGURE 1. Frequencyof intercoursefor three groups of couples. (ALC = coupleswith an alcoholichusband,MC = coupleswith marital conflict withoutalcoholproblems,NC = coupleswith no marital conflict withoutalcoholproblems.)