Substance Use & Misuse, Early Online:1–6, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.962054
ORIGINAL ARTICLE
Smoking is Unrelated to Female Sexual Function Rui Miguel Costa and Lu´ıs Peres
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ISPA—Instituto Universit´ario, Lisbon, Portugal male sexual function (Aslan, Beji, Gungor, Kadioglu, & Dikencik, 2008; Kim, Kim, Kim, Cho, & Jeon, 2011), a far greater majority does not (Abu Ali, Al Hajeri, Khader, Shegem, & Ajlouni, 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen, Gronbaek, Pedersen, Graugaard, & Frisch, 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey, Link, Rosen, Wiegel, & McKinlay, 2009; Moreira, Kim, Glasser, & Gingell, 2006; Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Safarinejad, 2006; Shaeer, Shaeer, & Shaeer, 2012), including studies with large representative samples (Christensen et al., 2011; Lutfey et al., 2009). There are even reports of enhanced sexual function among female smokers (Wallwiener et al., 2010). One limitation of these studies is that smoking status was assessed, but not the degree of nicotine dependence. Another limitation is that sexual activities were not differentiated: this is important, because many studies show that penile–vaginal intercourse (PVI) frequency and orgasm ability therefrom are more clearly associated with better sexual function than other sexual behaviors (Brody & Costa, 2009; Brody & Weiss, 2011a, 2011b; Costa, 2012; Das, Parish, & Laumann, 2009; Gerressu, Mercer, Graham, Wellings, & Johnson, 2008; Lau, Cheng, Wang, & Yang, 2006; Nowosielski, Wrobel, Sioma-Markowska, & Poreba, 2013; Nutter & Condron, 1983; Shaeer et al., 2012; Tao & Brody, 2011; Weiss & Brody, 2009). In fact, PVI is more consistently associated with better physical and mental health than other sexual behaviors (Brody, 2010), which even makes this limitation more glaring. The present study aims at overcoming these limitations. Thus, we tested the hypothesis that smoking status is associated with poorer female sexual function during PVI. We also examined if nicotine dependence rather than smoking status is related to poorer female sexual function.
Background. Previous research shows that smoking status is unrelated to female sexual difficulties. However, degree of nicotine dependence has not been measured, and the assessment of sexual functioning has not specified penile–vaginal intercourse (henceforth, intercourse), which is more clearly impaired by sexual difficulties than other sexual behaviors. Objectives. To test if smoking status is associated with poorer female sexual function during intercourse, and if nicotine dependence rather than smoking status is related to poorer female sexual function. Methods. During 2012, 129 Portuguese community women reported their smoking ¨ Test for Nicostatus, and completed the Fagerstrom tine Dependence, the Female Sexual Function Index (FSFI), and an adaptation of the FSFI to assess sexual functioning specifically during intercourse, as well as the desire thereof. Results. Smokers reported higher desire for intercourse and were more likely to have actually engaged in it in the past 4 weeks. Among the coitally active women in the preceding 4 weeks, nicotine dependence correlated with lower desire for intercourse. Smoking status and nicotine dependence were unrelated to arousal, lubrication, orgasm, satisfaction, pain. Conclusions. The findings are consistent with many studies that fail to demonstrate an increased risk of sexual difficulties among female smokers. However, nicotine dependence, rather than smoking status per se, might be associated with lower libido. The results suggest the possibility of an inverse U-shaped relationship between smoking and libido with a moderate use of tobacco being associated with higher sexual desire. Keywords
Nicotine, female sexual function
INTRODUCTION
Smoking is a risk factor for erectile dysfunction (Cao et al., 2013), and it is often assumed that it also increases the risk of female sexual difficulties. However, empirical evidence does not support this notion. Although some studies show a link between being smoker and poorer fe-
METHODS Participants
After giving informed consent, 145 community women responded to a paper-and-pencil questionnaire, advertised
Address correspondence to Rui Miguel Costa, ISPA—Instituto Universit´ario, Lisbon, Portugal; E-mail: [email protected]
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TABLE 1. Descriptive statistics
Age (years) Smokers FTND FSFI With an ongoing relationship Relationship duration (months) Occupation University student Employed Unemployed Marital status Single Married Divorced Widow Education Less than high school High school University degree Income Less than 5.000 euros 5.000–12.000 euros 12.000–18.000 euros 18.000–24.000 euros More than 24.000 euros
Total sample (N = 129) Mean (SD) or% (N)
Coitally active subsample (N = 91) Mean (SD) or% (N)
29.38 (8.84) 39.5 (51) 2.57 (1.95) – 65.1 (84) 76.07 (77.97)1
31.71 (7.78) 47.3 (43) 2.53 (1.91) 30.59 (4.81) 85.7 (78) 78.59 (79.11)2
34.9 (45) 62.8 (81) 2.3 (3)
20.9 (19) 75.8 (69) 3.3 (3)
57.4 (74) 34.1 (44) 7.8 (10) 0.8 (1)
46.2 (42) 47.3 (43) 6.6 (6) 0.0 (0)
5.5 (7) 49.7 (64) 44.9 (58)
5.5 (5) 38.5 (35) 56.1 (51)
39.5 (51) 27.1 (35) 14.0 (18) 10.9 (14) 8.5 (11)
26.4 (24) 29.7 (27) 18.7 (17) 14.3 (13) 11.0 (10)
FTND = Fagerstr¨om Test for Nicotine Dependence. FSFI = Female Sexual Function Index. 1 Median = 37.00. 2 Median = 39.50.
as a study on female sexuality. The study complied with the Helsinki Declaration; all respondents were informed of their anonymity and confidentiality of the data, as well as of their right to discontinue participation at any moment. The final sample had 129 women after exclusion of nine taking antidepressants and eight menopausal. Descriptive statistics are displayed in Table 1. Measures
Tobacco dependence was measured with a validated Portuguese version (Ferreira, Quintal, Lopes, & Taveira, 2009) of the Fagerstr¨om Test for Nicotine Dependence (Fagerstrom, 1978). This instrument has six questions on daily smoking habits; higher scores indicate greater tobacco dependence. Female sexual function was assessed by a validated Portuguese version (Pechorro, Diniz, Almeida, & Vieira, 2009) of the Female Sexual Function Index (FSFI) (Rosen et al., 2000), which assesses six dimensions of functioning in the past 4 weeks: desire, arousal, lubrication, orgasm, satisfaction and pain. Lower scores indicate poorer sexual functioning. Further, we adapted the FSFI questions in a way that respondents reported their desire for PVI, as well their
arousal, lubrication, and orgasm ability specifically during PVI. Satisfaction and pain dimensions were not modified because the FSFI pain dimension already focuses on coital pain, and the satisfaction dimension focuses on a general sense of satisfaction with sexual life and relationships. Cronbach’s alpha for this adaptation of the FSFI among the coitally active women was .86. RESULTS
Smokers were more likely to have had PVI in the past 4 weeks than nonsmokers (χ 2 = 7.70, p = .006), but smokers were not more likely to have a regular partner (χ 2 = 2.05, p = .15). Among the smokers, occurrence of PVI in the preceding 4 weeks was unrelated to nicotine dependence (r = −.04, p = .78). Being a smoker was related to higher desire for PVI (r = .23, p = .008), but unrelated to unspecified desire, as measured by the FSFI (r = .13, p = .13). Among the smokers, nicotine dependence was marginally and inversely correlated with desire for PVI (r = −.26, p = .068), but uncorrelated with unspecified desire (r = −.21, p = .13). Table 2 displays correlations of smoking status and nicotine dependence with dimensions of female sexual function among the women who were coitally active in the past 4 weeks. There was only one significant correlation: nicotine dependence was inversely correlated with desire for PVI. Among the coitally active women, smoking status was unrelated to risk of sexual dysfunction as defined by the FSFI cut-off score of less than 26.55 (Wiegel, Meston, & Rosen, 2005): χ 2 = 1.81, p = .18. Among the coitally active smokers, risk of sexual dysfunction was unrelated to nicotine dependence: t = .82, p = .42. DISCUSSION
The present findings are consistent with a large body of literature revealing that, for women, smoking is not related to increased risk of sexual problems or dysfunctions (Abu Ali et al., 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen et al., 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey et al., 2009; Moreira et al., 2006; Ponholzer et al., 2005; Safarinejad, 2006; Shaeer et al., 2012; Wallwiener et al., 2010). If anything, the present study showed that being a smoker was related to higher desire for PVI and actual occurrence thereof; this is congruent with other findings of enhanced sexual function among female smokers (Wallwiener et al., 2010), which were interpreted as some female smokers being less inhibited in their appreciation of pleasures in general (Wallwiener et al., 2010). Other factors might account for moderate smokers having more PVI and desire thereof. Nicotine is a monoamine oxidase inhibitor (Fowler, Logan, Wang, & Volkow, 2003), and although extroversion and sensation seeking have been associated with smoking initiation, the findings regarding the relationships of extroversion
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TABLE 2. Pearson’s product-moment correlations of smoking status and nicotine dependence with dimensions of female sexual function among those with PVI in the past 4 weeks
Desire for PVI Arousal during PVI Lubrication during PVI Orgasm during PVI FSFI desire FSFI arousal FSFI lubrication FSFI orgasm FSFI satisfaction FSFI pain FSFI total score
Coitally active subgroup (N = 91) Smoking status (0 = nonsmoker, 1 = smoker) r (p)
Coitally active smoker subgroup (N = 43) Nicotine dependence (Fagerstr¨om Test) r (p)
−.015 (.87) .001 (.99) −.059 (.58) .16 (.12) −.11 (.32) −.092 (.39) −.099 (.35) .045 (.67) −.036 (.74) .032 (.77) −.052 (.63)
−.33 (.033) −.065 (.68) −.12 (.46) .059 (.58) −.16 (.12) −.11 (.49) −.13 (.40) .10 (.51) −.063 (.69) −.13 (.40) −.10 (.51)
PVI = penile-vaginal intercourse. FSFI = Female Sexual Function Index.
and sensation seeking with tobacco dependence are rather mixed (Carton, Jouvent, & Widlocher, 1994b; Kendler et al., 1999; MacKillop & Kahler, 2009; Munafo, Zetteler, & Clark, 2007; Wilkinson & Abraham, 2004); these findings might be explained by extroverts and sensation seekers being often moderate smokers. Of note, for women, number of lifetime sexual partners was associated with increased probability of ever having smoked (Matos et al., 2004), which is congruent with extraversion and sensation seeking being higher in smokers. However, studies on female sexual function and tobacco smoking typically did not measure degree of nicotine dependence, which led us to put the hypothesis that nicotine dependence, rather than smoking status per se, is related to sexual difficulties. There was some confirmation for this hypothesis; it was found that, among the coitally active smokers, greater nicotine dependence is related to lower desire for, and actual absence of, PVI. This, together with the finding that smokers have higher desire for PVI, raise the possibility of a curvilinear relationship between smoking and sexual function, in which both nonsmokers and more addicted smokers are at greater risk of at least lower desire. Notably, a study with a large sample of men with erectile dysfunction showed that the participants perceived the female sexual partners who were smokers as having less sexual desire than those who did not smoke (Corona et al., 2010), but again this study did not measure nicotine dependence. One reason why women’s sexual function might be more protected against noxious effects of tobacco than men’s is women’s higher levels of estradiol. It is likely that endothelial dysfunction disturbs the genital blood flow supporting female sexual performance (Aversa et al., 2013; Musicki et al., 2009), but animal models suggest that estradiol protects against nicotine-induced endothelial dysfunction (El-Seweidy, Mohamed, Asker, & Atteia, 2012). Future research might examine the role of different motivations for smoking in sexual functioning. Sexual
impairments are associated with coping with stressors by avoiding the awareness of emotional conflict, as well as with the impaired emotional awareness that ensues (Brody & Costa, 2008; Costa & Brody, 2010; Leonard, Iverson, & Follette, 2008; Madioni & Mammana, 2001; Scimeca et al., 2013). Given that smoking tobacco can be used for coping with negative affect by avoiding the awareness of stressors and associated problems (Carton, Jouvent, & Widlocher, 1994a), some persons might have tobacco-induced sexual problems, at least in part because of noxious effects of impaired emotional awareness on sexual function. Relatedly, in a study with daily smokers, neuroticism correlated with more use of maladaptive coping strategies (as by avoiding the awareness of the problems) and less use of adaptive coping strategies by taking effective actions to solve the problems (FriedmanWheeler, Haaga, Gunthert, Ahrens, & McIntosh, 2008). This seems particularly worth noting, because nicotine dependence has been related to high levels of neuroticism either as a main effect (Kendler et al., 1999; Talati et al., 2013) or in interaction with genes (Ellis et al., 2011; Lerman et al., 2000) and social environments (Kleinjan et al., 2012). These findings raise the possibility that many of the symptoms that smokers attribute to their addiction may be better explained by pre-existing neuroticism, which can also be a more important and deeper cause of impaired sexual function than the addiction or the nicotine effects per se. One limitation of the present study is the relatively small convenience sample. However, the null findings are not likely to have been caused by low statistical power, as the coefficients of the negative correlations between sexual function and smoking status were of small size, and our results are consistent with an empirically demonstrated lack of relationship between smoking status and sexual difficulties among women of a variety of countries (Abu Ali et al., 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen et al., 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey et al., 2009; Moreira et al., 2006;
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Ponholzer et al., 2005; Safarinejad, 2006; Shaeer et al., 2012; Wallwiener et al., 2010). Future investigation might continue to address the role of abuse of nicotine in female sexual dysfunction, as differentiated from more moderate use. Declaration of Interest
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.
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THE AUTHORS Rui Miguel Costa was awarded his PhD by the University of the West of Scotland in 2011, and is now postdoctoral researcher at ISPA—Instituto Universit´ario. His research interests are focused on psychophysiological and psychological factors in sexual behaviors, and altered states of consciousness.
Lu´ıs Peres was awarded his Masters degree in Psychobiology at ISPA—Instituto Universit´ario.
GLOSSARY
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Tao, P., & Brody, S. (2011). Sexual behavior predictors of satisfaction in a Chinese sample. Journal of Sexual Medicine, 8, 455–460. doi: 410.1111/j.1743-6109.2010.02129.x. Wallwiener, C. W., Wallwiener, L. M., Seeger, H., Muck, A. O., Bitzer, J., & Wallwiener, M. (2010). Prevalence of sexual dysfunction and impact of contraception in female German medical students. Journal of Sexual Medicine, 7, 2139–2148. doi: 2110.1111/j.1743-6109.2010.01742.x. Weiss, P., & Brody, S. (2009). Female sexual arousal disorder with and without a distress criterion: Prevalence and correlates in a representative Czech sample. Journal of Sexual Medicine, 6, 3385–3394. doi: 3310.1111/j.1743-6109.2009. 01498.x. Wiegel, M., Meston, C., & Rosen, R. (2005). The female sexual function index (FSFI): Cross-validation and development of clinical cutoff scores. Journal of Sex & Marital Therapy, 31, 1–20. doi: 10.1080/00926230590475206. Wilkinson, D., & Abraham, C. (2004). Constructing an integrated model of the antecedents of adolescent smoking. British Journal of Health Psychology, 9, 315–333. 10.1348/ 1359107041557075.
ORIGINAL ARTICLE
Smoking is Unrelated to Female Sexual Function Rui Miguel Costa and Lu´ıs Peres
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ISPA—Instituto Universit´ario, Lisbon, Portugal male sexual function (Aslan, Beji, Gungor, Kadioglu, & Dikencik, 2008; Kim, Kim, Kim, Cho, & Jeon, 2011), a far greater majority does not (Abu Ali, Al Hajeri, Khader, Shegem, & Ajlouni, 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen, Gronbaek, Pedersen, Graugaard, & Frisch, 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey, Link, Rosen, Wiegel, & McKinlay, 2009; Moreira, Kim, Glasser, & Gingell, 2006; Ponholzer, Roehlich, Racz, Temml, & Madersbacher, 2005; Safarinejad, 2006; Shaeer, Shaeer, & Shaeer, 2012), including studies with large representative samples (Christensen et al., 2011; Lutfey et al., 2009). There are even reports of enhanced sexual function among female smokers (Wallwiener et al., 2010). One limitation of these studies is that smoking status was assessed, but not the degree of nicotine dependence. Another limitation is that sexual activities were not differentiated: this is important, because many studies show that penile–vaginal intercourse (PVI) frequency and orgasm ability therefrom are more clearly associated with better sexual function than other sexual behaviors (Brody & Costa, 2009; Brody & Weiss, 2011a, 2011b; Costa, 2012; Das, Parish, & Laumann, 2009; Gerressu, Mercer, Graham, Wellings, & Johnson, 2008; Lau, Cheng, Wang, & Yang, 2006; Nowosielski, Wrobel, Sioma-Markowska, & Poreba, 2013; Nutter & Condron, 1983; Shaeer et al., 2012; Tao & Brody, 2011; Weiss & Brody, 2009). In fact, PVI is more consistently associated with better physical and mental health than other sexual behaviors (Brody, 2010), which even makes this limitation more glaring. The present study aims at overcoming these limitations. Thus, we tested the hypothesis that smoking status is associated with poorer female sexual function during PVI. We also examined if nicotine dependence rather than smoking status is related to poorer female sexual function.
Background. Previous research shows that smoking status is unrelated to female sexual difficulties. However, degree of nicotine dependence has not been measured, and the assessment of sexual functioning has not specified penile–vaginal intercourse (henceforth, intercourse), which is more clearly impaired by sexual difficulties than other sexual behaviors. Objectives. To test if smoking status is associated with poorer female sexual function during intercourse, and if nicotine dependence rather than smoking status is related to poorer female sexual function. Methods. During 2012, 129 Portuguese community women reported their smoking ¨ Test for Nicostatus, and completed the Fagerstrom tine Dependence, the Female Sexual Function Index (FSFI), and an adaptation of the FSFI to assess sexual functioning specifically during intercourse, as well as the desire thereof. Results. Smokers reported higher desire for intercourse and were more likely to have actually engaged in it in the past 4 weeks. Among the coitally active women in the preceding 4 weeks, nicotine dependence correlated with lower desire for intercourse. Smoking status and nicotine dependence were unrelated to arousal, lubrication, orgasm, satisfaction, pain. Conclusions. The findings are consistent with many studies that fail to demonstrate an increased risk of sexual difficulties among female smokers. However, nicotine dependence, rather than smoking status per se, might be associated with lower libido. The results suggest the possibility of an inverse U-shaped relationship between smoking and libido with a moderate use of tobacco being associated with higher sexual desire. Keywords
Nicotine, female sexual function
INTRODUCTION
Smoking is a risk factor for erectile dysfunction (Cao et al., 2013), and it is often assumed that it also increases the risk of female sexual difficulties. However, empirical evidence does not support this notion. Although some studies show a link between being smoker and poorer fe-
METHODS Participants
After giving informed consent, 145 community women responded to a paper-and-pencil questionnaire, advertised
Address correspondence to Rui Miguel Costa, ISPA—Instituto Universit´ario, Lisbon, Portugal; E-mail: [email protected]
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TABLE 1. Descriptive statistics
Age (years) Smokers FTND FSFI With an ongoing relationship Relationship duration (months) Occupation University student Employed Unemployed Marital status Single Married Divorced Widow Education Less than high school High school University degree Income Less than 5.000 euros 5.000–12.000 euros 12.000–18.000 euros 18.000–24.000 euros More than 24.000 euros
Total sample (N = 129) Mean (SD) or% (N)
Coitally active subsample (N = 91) Mean (SD) or% (N)
29.38 (8.84) 39.5 (51) 2.57 (1.95) – 65.1 (84) 76.07 (77.97)1
31.71 (7.78) 47.3 (43) 2.53 (1.91) 30.59 (4.81) 85.7 (78) 78.59 (79.11)2
34.9 (45) 62.8 (81) 2.3 (3)
20.9 (19) 75.8 (69) 3.3 (3)
57.4 (74) 34.1 (44) 7.8 (10) 0.8 (1)
46.2 (42) 47.3 (43) 6.6 (6) 0.0 (0)
5.5 (7) 49.7 (64) 44.9 (58)
5.5 (5) 38.5 (35) 56.1 (51)
39.5 (51) 27.1 (35) 14.0 (18) 10.9 (14) 8.5 (11)
26.4 (24) 29.7 (27) 18.7 (17) 14.3 (13) 11.0 (10)
FTND = Fagerstr¨om Test for Nicotine Dependence. FSFI = Female Sexual Function Index. 1 Median = 37.00. 2 Median = 39.50.
as a study on female sexuality. The study complied with the Helsinki Declaration; all respondents were informed of their anonymity and confidentiality of the data, as well as of their right to discontinue participation at any moment. The final sample had 129 women after exclusion of nine taking antidepressants and eight menopausal. Descriptive statistics are displayed in Table 1. Measures
Tobacco dependence was measured with a validated Portuguese version (Ferreira, Quintal, Lopes, & Taveira, 2009) of the Fagerstr¨om Test for Nicotine Dependence (Fagerstrom, 1978). This instrument has six questions on daily smoking habits; higher scores indicate greater tobacco dependence. Female sexual function was assessed by a validated Portuguese version (Pechorro, Diniz, Almeida, & Vieira, 2009) of the Female Sexual Function Index (FSFI) (Rosen et al., 2000), which assesses six dimensions of functioning in the past 4 weeks: desire, arousal, lubrication, orgasm, satisfaction and pain. Lower scores indicate poorer sexual functioning. Further, we adapted the FSFI questions in a way that respondents reported their desire for PVI, as well their
arousal, lubrication, and orgasm ability specifically during PVI. Satisfaction and pain dimensions were not modified because the FSFI pain dimension already focuses on coital pain, and the satisfaction dimension focuses on a general sense of satisfaction with sexual life and relationships. Cronbach’s alpha for this adaptation of the FSFI among the coitally active women was .86. RESULTS
Smokers were more likely to have had PVI in the past 4 weeks than nonsmokers (χ 2 = 7.70, p = .006), but smokers were not more likely to have a regular partner (χ 2 = 2.05, p = .15). Among the smokers, occurrence of PVI in the preceding 4 weeks was unrelated to nicotine dependence (r = −.04, p = .78). Being a smoker was related to higher desire for PVI (r = .23, p = .008), but unrelated to unspecified desire, as measured by the FSFI (r = .13, p = .13). Among the smokers, nicotine dependence was marginally and inversely correlated with desire for PVI (r = −.26, p = .068), but uncorrelated with unspecified desire (r = −.21, p = .13). Table 2 displays correlations of smoking status and nicotine dependence with dimensions of female sexual function among the women who were coitally active in the past 4 weeks. There was only one significant correlation: nicotine dependence was inversely correlated with desire for PVI. Among the coitally active women, smoking status was unrelated to risk of sexual dysfunction as defined by the FSFI cut-off score of less than 26.55 (Wiegel, Meston, & Rosen, 2005): χ 2 = 1.81, p = .18. Among the coitally active smokers, risk of sexual dysfunction was unrelated to nicotine dependence: t = .82, p = .42. DISCUSSION
The present findings are consistent with a large body of literature revealing that, for women, smoking is not related to increased risk of sexual problems or dysfunctions (Abu Ali et al., 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen et al., 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey et al., 2009; Moreira et al., 2006; Ponholzer et al., 2005; Safarinejad, 2006; Shaeer et al., 2012; Wallwiener et al., 2010). If anything, the present study showed that being a smoker was related to higher desire for PVI and actual occurrence thereof; this is congruent with other findings of enhanced sexual function among female smokers (Wallwiener et al., 2010), which were interpreted as some female smokers being less inhibited in their appreciation of pleasures in general (Wallwiener et al., 2010). Other factors might account for moderate smokers having more PVI and desire thereof. Nicotine is a monoamine oxidase inhibitor (Fowler, Logan, Wang, & Volkow, 2003), and although extroversion and sensation seeking have been associated with smoking initiation, the findings regarding the relationships of extroversion
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TABLE 2. Pearson’s product-moment correlations of smoking status and nicotine dependence with dimensions of female sexual function among those with PVI in the past 4 weeks
Desire for PVI Arousal during PVI Lubrication during PVI Orgasm during PVI FSFI desire FSFI arousal FSFI lubrication FSFI orgasm FSFI satisfaction FSFI pain FSFI total score
Coitally active subgroup (N = 91) Smoking status (0 = nonsmoker, 1 = smoker) r (p)
Coitally active smoker subgroup (N = 43) Nicotine dependence (Fagerstr¨om Test) r (p)
−.015 (.87) .001 (.99) −.059 (.58) .16 (.12) −.11 (.32) −.092 (.39) −.099 (.35) .045 (.67) −.036 (.74) .032 (.77) −.052 (.63)
−.33 (.033) −.065 (.68) −.12 (.46) .059 (.58) −.16 (.12) −.11 (.49) −.13 (.40) .10 (.51) −.063 (.69) −.13 (.40) −.10 (.51)
PVI = penile-vaginal intercourse. FSFI = Female Sexual Function Index.
and sensation seeking with tobacco dependence are rather mixed (Carton, Jouvent, & Widlocher, 1994b; Kendler et al., 1999; MacKillop & Kahler, 2009; Munafo, Zetteler, & Clark, 2007; Wilkinson & Abraham, 2004); these findings might be explained by extroverts and sensation seekers being often moderate smokers. Of note, for women, number of lifetime sexual partners was associated with increased probability of ever having smoked (Matos et al., 2004), which is congruent with extraversion and sensation seeking being higher in smokers. However, studies on female sexual function and tobacco smoking typically did not measure degree of nicotine dependence, which led us to put the hypothesis that nicotine dependence, rather than smoking status per se, is related to sexual difficulties. There was some confirmation for this hypothesis; it was found that, among the coitally active smokers, greater nicotine dependence is related to lower desire for, and actual absence of, PVI. This, together with the finding that smokers have higher desire for PVI, raise the possibility of a curvilinear relationship between smoking and sexual function, in which both nonsmokers and more addicted smokers are at greater risk of at least lower desire. Notably, a study with a large sample of men with erectile dysfunction showed that the participants perceived the female sexual partners who were smokers as having less sexual desire than those who did not smoke (Corona et al., 2010), but again this study did not measure nicotine dependence. One reason why women’s sexual function might be more protected against noxious effects of tobacco than men’s is women’s higher levels of estradiol. It is likely that endothelial dysfunction disturbs the genital blood flow supporting female sexual performance (Aversa et al., 2013; Musicki et al., 2009), but animal models suggest that estradiol protects against nicotine-induced endothelial dysfunction (El-Seweidy, Mohamed, Asker, & Atteia, 2012). Future research might examine the role of different motivations for smoking in sexual functioning. Sexual
impairments are associated with coping with stressors by avoiding the awareness of emotional conflict, as well as with the impaired emotional awareness that ensues (Brody & Costa, 2008; Costa & Brody, 2010; Leonard, Iverson, & Follette, 2008; Madioni & Mammana, 2001; Scimeca et al., 2013). Given that smoking tobacco can be used for coping with negative affect by avoiding the awareness of stressors and associated problems (Carton, Jouvent, & Widlocher, 1994a), some persons might have tobacco-induced sexual problems, at least in part because of noxious effects of impaired emotional awareness on sexual function. Relatedly, in a study with daily smokers, neuroticism correlated with more use of maladaptive coping strategies (as by avoiding the awareness of the problems) and less use of adaptive coping strategies by taking effective actions to solve the problems (FriedmanWheeler, Haaga, Gunthert, Ahrens, & McIntosh, 2008). This seems particularly worth noting, because nicotine dependence has been related to high levels of neuroticism either as a main effect (Kendler et al., 1999; Talati et al., 2013) or in interaction with genes (Ellis et al., 2011; Lerman et al., 2000) and social environments (Kleinjan et al., 2012). These findings raise the possibility that many of the symptoms that smokers attribute to their addiction may be better explained by pre-existing neuroticism, which can also be a more important and deeper cause of impaired sexual function than the addiction or the nicotine effects per se. One limitation of the present study is the relatively small convenience sample. However, the null findings are not likely to have been caused by low statistical power, as the coefficients of the negative correlations between sexual function and smoking status were of small size, and our results are consistent with an empirically demonstrated lack of relationship between smoking status and sexual difficulties among women of a variety of countries (Abu Ali et al., 2008; Amidu et al., 2010; Cayan et al., 2004; Christensen et al., 2011; Esposito et al., 2007; Esposito et al., 2010; Lutfey et al., 2009; Moreira et al., 2006;
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Ponholzer et al., 2005; Safarinejad, 2006; Shaeer et al., 2012; Wallwiener et al., 2010). Future investigation might continue to address the role of abuse of nicotine in female sexual dysfunction, as differentiated from more moderate use. Declaration of Interest
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.
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THE AUTHORS Rui Miguel Costa was awarded his PhD by the University of the West of Scotland in 2011, and is now postdoctoral researcher at ISPA—Instituto Universit´ario. His research interests are focused on psychophysiological and psychological factors in sexual behaviors, and altered states of consciousness.
Lu´ıs Peres was awarded his Masters degree in Psychobiology at ISPA—Instituto Universit´ario.
GLOSSARY
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