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Relational Intimacy and Sexual Frequency: A Correlation or a Cause? A Clinical Study of

Heterosexual Married Women.

MARTA PARKANYI WITHEROW

Watershed Counseling Associates, PLLC, Jackson, MS, USA

Reformed Theological Seminary, Jackson, MS, USA

SHAMBHAVI CHANDRAIAH

Department of Psychiatry and Human Behavior, University of Mississippi Medical Center,

Jackson, MS, USA

SAMANTHA R. SEALS

Center of Biostatistics and Bioinformatics, University of Mississippi Medical Center, Jackson,

MS, USA

ANTAL BUGAN

University of Debrecen, Medical and Health Science Centre, Department of Behavioral

Sciences, Hungary

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Address correspondence to Marti Witherow, LPC, LMFT, CST, Watershed Counseling

Associates, 1635 Lelia Drive, Jackson, MS 39216, USA. Email:

[email protected]

Researchers and practitioners have noted the importance of using clinical samples in sex

therapy research. Authors of this study investigated the relationship between perceived levels of

marital intimacy, sexual frequency and sexual functioning among heterosexual married women.

A clinical sample of 68 women completed the Couples Satisfaction Index (CSI), The Miller

Social Intimacy Test (MSI), the Sexual Satisfaction Scale for Women (SSS-W), The Inclusion of

the Other in the Self Scale (IOS) and The Female Sexual Functioning Index (FSFI-6). Data

analyses revealed that marital intimacy acted as a predictor in univariate relationships on

sexual frequency and sexual functioning but did not act as a mediator on sexual frequency and

sexual functioning. Overall, these findings may further the discussion in the treatment of

relational intimacy, sexual desire discrepancy and female sexual dysfunction.

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In clinical practice it is often relational conflict surrounding sexual desire and frequency that

prompts couples to seek treatment. In terms of theoretical conceptualizations regarding relational

context this presenting problem could potentially be approached in several ways. Surprisingly,

little empirical evidence has been offered to substantiate these theories in the context of marriage

and there is still a dearth of research evidence supporting these theories, especially in a format

applicable to clinical practice (Balon & Wise, 2011; Brotto, Bitzer, Laan, Leiblum & Luria,

2010; Ferreira, Narciso & Novo, 2012; Rosen & Bachmann, 2008; Sims & Meana, 2010).

A limited number of studies have focused on sexual frequency in heterosexual couples. The most

commonly proposed psychological factors are relational intimacy, psychotropic medications,

anxiety, religious convictions and body image (Basson, 2008; Bancroft, Loftus & Long, 2003; de

la Rubia, 2011; Rados, Vranes & Sunjic, 2014). Smith et al. (2011) found that desired frequency

of sex seems to be a major factor in overall relationship satisfaction even after adjusting for

education, language, age and beliefs about the importance of an active sex life. A limited

number of research studies have established that overall sexual satisfaction is strongly and

positively predicted by coital satisfaction and by frequency of orgasm and intercourse (Haavio-

Mannila & Kontula, 1997; Willoughby, Farero & Busby, 2014). McNulty, Wenner and Fisher

(2014) studied early-stage marriages and whether initial marital and sexual satisfaction predicted

changes in sexual frequency. They found that sexual but not marital satisfaction were positively

associated with frequency of sex and initial levels of partner marital satisfaction were negatively

associated with changes in both frequency of sex and own sexual satisfaction (McNulty et al,

2014).

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Willoughby, Farero & Busby (2014) report that gender differences do exist in how sexual

frequency influences individual perceptions of the relationship. They have found that husbands

are more likely to report larger discrepancies between desired and actual sexual frequency than

their wives but women’s sexual satisfaction may not be negatively impacted by lower sexual

frequency.

When examining the greater context in which sexual frequency takes place in long-term

relationships studies have indicated that there are sexual and non-sexual motivations for women

to engage in sexual activity, among these emotional intimacy and increased well-being are

positive rewards that women pursue through sex in their relationships (Mark, Fortenberry,

Sanders & Reece, 2014; Maserejian et al., 2010; Murray, Milhausen & Sutherland, 2014).

Interestingly, when examined within the context of marriage, Sims & Meana (2011) concluded

that certain aspects of intimacy and closeness might act as “generic sexual pitfalls” contributing

to the decline of sexual desire within marriage. Ferreira, Fraenkel, Narciso and Novo (2014)

found that sexual desire within marriage and long-term relationships needs both an intimate

emotional connection and self-integrity. (Philliphson and Hartmann (2009) expanded on some

previous studies on whether it is the quality of the sexual performance or the relational tone of

the marriage that determined sexual satisfaction. They concluded that satisfaction from sexual

coitus is “relational” and that the feeling of closeness to one’s partner is essential for sexual

satisfaction. There is some anecdotal evidence that as individual and marital functioning

improves so does sexual frequency but Leiblum (2010) cautions therapists from making

increasing sexual frequency the target of therapy. She states that arrangements about sexual

frequency or passion are foremost matters of relational negotiation and that at times despite an

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overall relationship change the partners’ level of sexual desire may still remain discrepant and

their frequency low (Leiblum, 2010, p. 208).

The current study investigates the relationship between perceived levels of marital intimacy- that

is the interpersonal interconnectedness in the areas of couple satisfaction, sexual satisfaction,

feelings and behaviors of closeness as well as sexual dysfunction and sexual frequency

(specifically coital frequency). We hypothesize that relational intimacy serves as predictor of

sexual frequency in the presence of sexual functioning (FSFI-6 variables) in married

relationships. Further, we hypothesize that relational intimacy will have a mediating factor on

sexual frequency in the presence of sexual functioning.

METHOD

Participants and Procedure

This study was conducted according to institutional standards and approved by the Institutional

Review Board of the University of Mississippi Medical Center (UMMC). A total of 68 women

have completed a battery of questionnaires anonymously either online or via a mail-in packet of

questionnaires. Response rate was 41% for both online and mail-in combined. Participants for

this study were recruited from two sites to provide heterogeneity of the overall combined sample:

a local private practice marriage and family therapy clinic, (first author) and 2 UMMC general

psychiatry clinics of the second author, namely a psychiatric teaching clinic and a private

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practice clinic. In order to qualify for this study, participants had to be heterosexual women

currently living in married relationships and enrolled as patients in one of the above mentioned

facilities, irrespective of their presenting problem or diagnosis. Out of 68 respondents 49 were

patients enrolled at the marriage and family therapy clinic and 19 were enrolled at the UMMC

general psychiatric clinics. In the sample 81% of the participants were Caucasian (Non-

Hispanic), 13% were African-American, 1.5 % Asian-American and 4.5 % did not indicate their

race. There was a significant difference between the two samples regarding age and length of

marriage, namely the mean age of participants at the marriage and family therapy clinic was 41

years and 50 years at the UMMC clinics (p=0.0012). Mean length of marriage at the marriage

and family therapy clinic was 13 years and 21 years at the UMMC clinics (p=0.0182). There

was no financial incentive offered for participating in this study.

45 of the participants had scored 19 or less on the FSFI-6, which is the clinical cut-off score to

have Female Sexual Dysfunction (FSD) (Isidori et al., 2010).

MEASURES

SEXUAL SATISFACTION AND DISTRESS

The Sexual Satisfaction Scale for Women (SSS-W) is made up of 30 items assessing five unique

domains of sexual satisfaction and has demonstrated high reliability and validity (Meston &

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Trapnell, 2005). The Sexual Satisfaction Scale for Women includes subscales assessing overall

satisfaction with one’s sex life as well as personal and relational sexual distress regarding sexual

problems in a relationship. The present study used all five subscales of the SSS-W. Each

subscale consists of six items that are reverse coded and summed so that higher scores indicate

less distress (higher well-being). Scores for each subscale range from 6 (very high distress) to 30

(no distress). When summed, the SSS-W ranges from 30 to 150. The Cronbach’s alpha was 0.90

for the current sample.

IOS (INCLUSION OF THE OTHER IN THE SELF SCALE)

The Inclusion of the Other in the Self (IOS) Scale has been demonstrated to be an excellent

psychometric tool to measure level of closeness in a relationship as well as has substantive

suitability as a measure since it can be completed rapidly and yet is not particularly susceptible to

social desirability response set effects. The IOS scale has been used in other research studies to

depict interconnectedness (Aron, Aron & Smollan, 1992). The IOS Scale consists of seven

pictures of circles depicting perceived levels closeness in a relationship. In the current study each

picture was assigned a number from 1-7 in a Likert scale-like fashion with 1 indicating the

lowest level of intimacy and 7 indicating the highest level of intimacy.

THE MILLER SOCIAL INTIMACY SCALE

Miller Social Intimacy Scale (MSIS), is a 17-item measure of the maximum level of intimacy

currently experienced, that was developed using both married and unmarried non-clinical as well

as a married clinical sample. It has good internal validity and test-retest reliability. The MSIS

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was also proven to be a good measure for married clinical samples. During its development the

mean MSIS score for the married students was significantly greater than that for the distressed

married clinic sample, which points to heterogeneity in the level of intimacy experienced by

married persons (Miller & Lefcourt, 1982). The Cronbach’s alpha was 0.95 for the current

sample.

THE COUPLES’ SATISFACTION INDEX

The Couples’ Satisfaction Index (CSI) is a 32-item scale constructed using item response theory

to measure relationship satisfaction. These authors have developed a 16- and a 4-item version of

it as well. Compared to some other relationship satisfaction scales it has greater power for

detecting differences in levels of satisfaction; as well it has demonstrated strong convergent

validity with other measures of satisfaction and has an excellent construct validity (Funk &

Rogge, 2007). The present study used the 16-item version of the CSI. Scores for the 16-item

scale range from 0 (no satisfaction) to 76 (very high satisfaction). The Cronbach’s alpha was

0.98 for the current sample.

THE FEMALE SEXUAL FUNCTION INDEX (FSFI-6)

The Female Sexual Satisfaction Index-6 (FSFI-6) is a six-question abridged version of the

Female Sexual Function Index-19. The FSFI-6 showed good internal consistency, reliability and

consistency and is a valuable tool to test for Female Sexual Dysfunction (FSD). A score of 19 or

less indicates the possibility of FSD present (Isidori et al., 2010). The Cronbach’s alpha was 0.80

for the current sample.

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COUNT VARIABLE OF SEXUAL (COITAL) FREQUENCY

We also added an additional question “Please indicate the number of times you have had sexual

intercourse with your spouse in the last month” at the end of the battery of questionnaires in

order to obtain a measure of sexual frequency.

PERCEIVED LEVEL OF INTIMACY

We measured perceived levels of intimacy in a marriage by taking a sum of the standardized

results of the SSSW-30, IOS, MSIS-17, and CSI-16 scores for each participant. We used

negative binomial regression to analyze correlations between the scales and found that all were

greater than 0.4, with the lowest correlation being between the IOS and SSS-W (r=0.44) and the

highest being between CSI and MSIS (r=0.77). Further, all scales were positively associated

with frequency of sex (all p<0.0007) and the sum of the standardized scales was positively

correlated with frequency of sex (p<0.0001).

STATISTICAL ANALYSIS

Patient characteristics, including FSFI-6 responses, are described using the mean, median and

standard deviation. Pearson correlations were used to examine simple correlations between FSFI

domains. Frequency of sexual intercourse is modeled using negative binomial regression.

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Mediation is examined using Baron and Kenny’s method (Baron & Kenny, 1986). Data were

analyzed with SAS software, version 9.4 (SAS Institute, Cary, NC) and graphs were produced

using Microsoft Excel 2013.

RESULTS

All research questions examined sexual frequency as an outcome. For all results we have

adjusted for clinic type (Clinic 1 or Clinic 2). The first hypothesis explored how marital

intimacy and the FSFI-6 domains serve as individual predictors of frequency of sex. As a basic

analysis, we examined the Pearson correlations. There is a moderate correlation between sexual

frequency and the FSFI-6 domains (r>0.4, p<0.05), the exception being pain (r=0.1, p=0.2708).

Further, intimacy is moderately correlated with sexual frequency, similar to the FSFI-6 domains

(r=0.6, p<0.0001).

To further explore the individual, unadjusted relationships between the FSFI-6 domains and

sexual frequency, we applied negative binomial regression. With the exception of pain, all of the

FSFI-6 variables significantly predicted frequency of sex (p<0.05). Given the Pearson

correlation results for pain (r=0.1), this is not surprising. For the five significant domains, as the

participant’s response increases, the expected frequency also increases.

Intimacy significantly predicted sexual frequency (p<0.0001) with each one-unit increase

of intimacy resulting in a 22% increase in sexual frequency. All of the FSFI-6 variables, with

the exception of pain, significantly predicted frequency of sex. In the case of sexual desire for

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every one-unit increase on the FSFI-6 there was a 50%increase in the expected sexual frequency.

Table 1 demonstrates how the multiplicative effect works. In order to make it more practical for

clinicians to interpret this table we have rounded up the values and included only integers to

show expected frequency of intercourse based on this sample.

Table 1 Frequency Based on FSFI-6 Domain responses

In order to test for correlation between perceived levels of “interpersonal

interconnectedness” within the dyad and sexual frequency, we modeled sexual frequency and

answers given by participants only on the IOS Scale. We found that the IOS Scale significantly

predicts sexual frequency (p=0.0007), and as IOS scale responses increase by 1 unit, sexual

frequency increases by 30%. Figure 1 illustrates expected frequencies against observed

frequencies.

We explored intimacy as a predictor after adjusting for multiple covariates in the model.

The first model examines intimacy as a predictor of sexual frequency after adjusting for the

FSFI-6 domains, excluding “Satisfaction” since it is not a physiological response. The second

model adjusts for both FSFI-6 domains as well as age of participant, length of marriage and

clinic location. The results indicate that intimacy is the only significant predictor of sexual

frequency and both age of participant and years of marriage did not significantly predict sexual

frequency. Results are presented in Table 2.

Our second hypothesis explored the extent to which marital intimacy serves as a

mediator between sexual functioning and sexual frequency. To answer this question, we follow

steps laid out by Baron and Kenny (Baron & Kenny, 1986). First, we modeled intimacy as the

dependent variable, and next we modeled the full model (adjusting for age and length of

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marriage. As a result we can conclude that intimacy is not a mediator for arousal. We did not

detect mediation between sexual functioning and sexual frequency; regression results are omitted

for brevity.

DISCUSSION

The present study explored the relationship between perceived levels of marital intimacy and

sexual frequency. In particular we examined the ways in which marital intimacy and the FSFI-6

variables predict sexual frequency among heterosexual married women both before and after

controlling for other variables such as age and years of marriage. In unison with our first and

second hypothesis we have found that higher marital intimacy scores significantly predict sexual

frequency as well each FSFI-6 variable (excluding satisfaction) significantly predicts sexual

frequency. This finding suggests that marital intimacy is an important factor in sexual

frequency. Age was not found to be a significant predictor of sexual frequency. This might be

because the current sample was a clinical sample and included a relatively high percentage of

women who met the criteria for sexual dysfunction regardless of their age. Another possible

reason might be that older women have more sexual experience and have already worked

through some sexual difficulties that their younger counterparts have not. This might also

explain why length of marriage did not end up being a significant predictor in sexual frequency.

Although the authors do not currently know of a research study which would explore this

correlation, anecdotal evidence suggests that older women and women who have been married

longer have a better grasp on their sexual function and they are more likely to have integrated

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sexuality into their relationships and life stories than younger women. Lastly, our analytic

method measured whether intimacy is a predictor in sexual frequency and not the reason for it.

Contrary to our hypothesis, marital intimacy was not found to be a mediator of the FSFI-

6 variables and sexual frequency. Based on this finding we speculate that sexual frequency is a

matter of relational negotiation and in a sense a “choice” or a “mutual agreement” instead of a

causal effect of intimacy levels within the marriage. This observation is particularly apparent

when observing the correlation between the IOS Scale and sexual frequency. We are

highlighting this in particular since it is a unique pictorial scale and can be easily used to

measure “interpersonal interconnectedness” in a marriage. A woman might score as high as a 7

on the scale and have very low to no sexual frequency reported. On the other hand she might

score very low on the IOS Scale yet indicate a high frequency. Although McNulty et al (2014)

measured the correlation of marital satisfaction and change of sexual frequency, which are

different constructs than what we measured, their finding indicated a similarly surprising result.

Again, our finding could be the result of the current sample being a clinical sample with the

majority of participants meeting the criteria for sexual dysfunction.

Interestingly, none of the FSFI-6 variables mediate the relationship between intimacy and

frequency. This might come as a surprise as one might expect variables such as “pain” to be

significant mediator. In general, this finding diverges from the findings of Desrosiers et al

(2008) on painful intercourse, possibly because their sample size was homogenous to vulvar pain

and thus may not be generalizable to our sample or the entire population. To explain our finding

we again have to rely on some anecdotal evidence from clinical experience which suggests that

women have a tendency to “tough it out” and still engage in sexual activity despite the presence

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of unpleasant side effects such as pain, for the sake of relational benefits. This finding might be

significant in the sense that it supports recent sexual desire models that take multiple relational

factors into consideration.

These findings suggest that enhancing marital intimacy and facilitating healthy relational

negotiation should be considered important factors in sex therapy however it might not

necessarily translate into an increase in sexual frequency. Sexual frequency appears to be

correlated with but not caused by perceived levels of relational closeness. The authors believe

that the field would greatly benefit from further research in this subject.

Additionally, the FSFI-6 is an easy-to-use quick assessment tool that can alert clinicians

about the possible presence of female sexual dysfunction when a patient scores 19 or less

prompting further inquiry into the marital intimacy in the relationship.

In regards to future directions, authors believe that this current study should be replicated

on different clinical populations such as married men or women in long-term dating relationships

in order to gain more knowledge about the relationship between intimacy and sexual frequency

in committed relationships, especially measuring differentiation, interpersonal

interconnectedness and marital satisfaction as they relate to sexual frequency, relational

negotiation and sexual desire discrepancy within a marriage.

A limitation of the study was that using only a sample of clinical participants may have biased

the sample since it limited our opportunity to recruit a larger representation from a variety of age

groups or ethnic backgrounds. However by recruiting from two different clinical sites (an

academic medical center and community private practice) it did provide some heterogeneity in

the target sample studied since our aim was to provide more research on clinical populations.

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While it would have been useful to look for differences even within these 2 subsamples our

overall sample size was not large enough to permit this.

ACKNOWLEDGMENTS

Authors wish to thank Michael Systma, Ph.D. for his valuable comments and insights into the

clinical applications of this research study and Marta Berka, Ph.D. for her helpful suggestions in

editing this article.

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Table 1
Expected Frequency Based on FSFI Domain Response*
E[Frequency]
Response Desire Arousal Lubrication Orgasm Pain Satisfaction
0 2 1 1 1 3 2
1 3 2 2 2 3 3
2 5 3 2 3 4 4
3 8 4 4 4 5 6
4 12 7 5 5 6 10
5 -- 11 8 7 -- --
* rounded values

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Table 2
Multivariable Negative Binomial Regression Results
Model 1: Model 2:
No Adjustors* M1 + Adjustors
Predictor Estimat p value Estimate p value
e
Desire 1.07 0.7020 1.04 0.8385
Arousal 0.80 0.2569 0.80 0.2355
Lubrication 1.29 0.0237 1.22 0.0820
Orgasm 1.19 0.1182 1.23 0.0687
Pain 1.03 0.8361 1.06 0.7061
Intimacy 1.22 0.0006 1.25 0.0002
Clinic Type 0.61 0.0818 0.75 0.3304
Age 0.97 0.0827
Length of Marriage 1.00 0.8035
*without adjusting for age and the length of marriage

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25 Observed Expected

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Sexual Frequency

15

10

0
0 1 2 3 4 5 6 7 8
Perceived Intimacy

Figure 1: Graph of Perceived Intimacy based on the IOS Scale and Sexual Frequency

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