BIBLIOTHERAPY INTERVENTIONS FOR FEMALE LOW SEXUAL DESIRE: EROTIC FICTION VS. SELF HELP By MEENAKSHI PALANIAPPAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2014
Â© 2014 Meenakshi Palaniappan
To Mama and Appa
4 ACKNOWLEDGMENTS I thank my advisor, Laurie Mintz; my thesis committee; my cohort, my lab mates, as well as my friends and family who have provided me with emotional, technical and professional support and encouragement throughout thi s process.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 6 LIST OF FIGURES ................................ ................................ ................................ .......... 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 10 2 METHODS ................................ ................................ ................................ .............. 15 Participants ................................ ................................ ................................ ............. 15 Measures ................................ ................................ ................................ ................ 15 Procedures ................................ ................................ ................................ ............. 16 Interventions ................................ ................................ ................................ ........... 19 3 RESULTS ................................ ................................ ................................ ............... 25 Preliminary Analyses ................................ ................................ .............................. 25 Short Term Efficacy of Interventions ................................ ................................ ....... 26 Longer Term Efficacy of the Interventions ................................ .............................. 28 Self Help Group ................................ ................................ ................................ 28 Erotic Fiction Group ................................ ................................ .......................... 29 4 DISCUSSION ................................ ................................ ................................ ......... 38 LIST OF REFERENCES ................................ ................................ ............................... 46 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 49
6 LIST OF TABLES Table page 2 1 Participant demographics ................................ ................................ ................... 22 3 1 Mean, standard deviations, and short term time effects on dependent variables ................................ ................................ ................................ ............. 30 3 2 Summary table for the long term effects of time on dependent variables in the self help group ................................ ................................ ................................ .... 31 3 3 Summary table for the long term effects of time on dependent variables in the erotic fiction group ................................ ................................ .............................. 32
7 LIST OF FIGURES Figure page 2 1 Participant flow chart ................................ ................................ .......................... 24 3 1 Short term time effects for FSFI total ................................ ................................ .. 33 3 2 Short term time effects for FSFI desire ................................ ............................... 34 3 3 Longer term time effects on FSFI total ................................ ............................... 35 3 4 Longer term time effects on FSFI desire ................................ ............................ 36 3 5 Longer term time effects on FSFI satisfaction ................................ .................... 37
8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science BIBLIOTHERAPY INTERVENTIONS FOR FEMALE LOW SEXUAL DESIRE: EROTIC FICTION VS. SELF HELP By Meenakshi Palaniappan August 2014 Chair: Laurie Mintz Major: Psychology Low sexual desire is the number one complaint that women bring to their health care practit ioners (Basson, 2007). Limited research demonstrates that written materials (i.e., bibliotherapy ) increase sexual desire in women (Hubin, 2011; Mintz, Balzer, Zhao & Bush , 2012). The aim of this study was to further the literature by conducting a comparati ve study on the efficacy of two types of written materials when read by women struggling with low sexual desire: self help versus erotic fiction. Thirty five women across the two conditions (self help and erotic fiction) completed the Female Sexua l Functio n Index (FSFI, Rosen et al., 2000) and the Hurlburt Index of Sexual Desire (HISD, Apt & Hurlburt, 1992) at two time points (pre intervention, and post intervention), with a subset of 27 women also completing a six week follow up. Results demonstrated that participants reading both types of books made statistically significant gains on the two measures of desire (HISD and FSFI desire subscale), as well as on measures of arousal, lubrication, satisfaction, orgasm, pain reduction, and overall sexual functionin g. Further, in both reading conditions, those participating in a six week follow up maintained their gains in desire, satisfaction, pain reduction, and overall sexual functioning. This is the first study in 20 years to evaluate the efficacy of erotic ficti on,
9 and these findings are discussed within the context of treatment options for low sexual desire in women. Additionally, implications for future research are discussed .
10 CHAPTER 1 INTRODUCTION The bestselling book 50 Shades of Grey (James, 2011) has ofte n been called a in the popular press. Although these sources may be pseudo scientific, decades and research conduct ed over 20 years ago found that reading erotic material increases sexual arousal and sexual drive in a representative sample of women from the United States (Schmidt, Sigusch, & Scafer, 1973). Hubin, Sutter & Reynaert (2011) state that when treating women with a significant number of clinicians include exercises designed to stimulate the erotic imagination especially by is a dearth of empiri cal research on the efficacy of reading erotica in assisting women struggling with low sexual desire. Examining treatment options for women distressed by low sexual desire is particularly pressing, in that research finds that 25% to 37% of women between th e ages of 30 to 59 will experience low sexual desire at some point in their lives ( West et al. , 2008). Indeed, low sexual desire is the most common sexual complaint that women bring to their healthcare practitioners (Basson, 2007). Additionally, experienci ng low sexual desire is linked to a decrease in marital satisfaction and diminished overall quality of life ( Brotto, Basson, & Luria, 2008 ). Despite the high prevalence of low sexual desire among women and its associated psychological issues, there is curr ently no standard treatment available (Ullery, Millner & Willingham, 2002). Low sexual desire has been described as one of the most difficult sexual issues to treat (Basson, 2007).
11 To date, there have only been a handful of studies providing evidence for t he efficacy of treatments for low sexual desire. The face to face treatment that appears to be most promising is a short term (i.e., three session) m indfulness based group psychoeducational intervention ( Brotto et al., 2008 ). Despite the efficacy reported for this intervention, a significant downside is accessibility. Specifically, it requires the presence of clinicians trained in this specific protocol. Additionally, treatments for sexual dysfunctions are often not covered by insurance companies ( Westheim er, 2007) , further limiting the accessibility of such a treatment for the majority of women. One affordable and accessible psychological treatment for sexual dysfunction that has been reviewed in research is bibliotherapy, defined as the reading of writt en material (Hubin et al., 2011; van Lankveld, 2009). It is important to note that there is a lack of clarity in terms of just what type of written material constitutes bibliotherapy. While some authors define bibliotherapy solely as psychological interven tions consisting of techniques and skills (van Lankveld, 2009), such as self help books, others provide a broader definition of bibliotherapy including informational sources such as encyclopedias and imaginative sources su ch as fictional books (Hubin et al ., 2011). Prior research has suggested that both erotic fiction (Coles & Shamp, 1984; Mosher & Greenberg, 1969, Schmidt, Sigusch, & Scafer, 1973) and self help books (Mint z et al, 2011) have a therapeutic effect on female low sexual desire. Therefore, for purposes of this study, both types of books will be classified as bibliotherapy. In other words, for the p urposes of this study, Hubin utilized to delineate written materials with a potential the rapeutic benefit to readers,
12 while the terms self help book and erotic fiction will be used to more specifically discuss the two types of bibliotherapy that are the focus of this study. Recent research has suggested that self help books may be a viable and promising treatment for sexual dysfunction, with multiple studies supporting its efficacy for orgasmic and pain dysfunctions (Hubin et al., 2011, van Lanekveld, 2009). Indeed, due to existing empirical evidence, some consider self help books to occupy a c entral position in the treatment of sexual dysfunctions (van Lankeveld, 2009). Despite this, until recently, there were no studies examining self help books for low sexual desire. This lack of readily accessible treatments for low sexual desire and prior r esearch finding that self help is efficacious for other sexual disorders (van Lankveld, 2009) led Mintz and colleagues (2012) to be the first to examine the efficacy of a self help book for increasing sexual desire among women. This study recruited a tota l of 45 female participants in two groups: an intervention group who read the self help book A Tired and a waitlist control group. After six weeks of reading the book, compared to the control group, participants in the inter vention group showed statistically significant gains in sexual desire, sexual arousal, sexual satisfaction and overall sexual functioning. Further, some of the participants from the intervention group were tested six weeks after finishing the self help boo k, and it was found that they maintained their gains in sexual desire and overall sexual functioning. While the book that Mintz and colleagues studied was a traditional self help book written from a psycho educational and cognitive behavioral perspective, Hubin et al. (2011) discuss the usefulness of a range of reading options for women with sexual problems, including both self help books and erotic literature. Prior research has found
13 that reading erotica increases sexual stimulation and sexual fantasy am ong women (Mosher & Greenberg, 1969) a a socially acceptable form of pornography that is not recognized as such either by those who read them or m easuring sex differences in reading erotic literature reported that women show greater gains in sexual desire than men after rea ding erotic fiction (Schmidt et al., 1973). It is important to note that the limited literature on the effect of reading erotic fiction on female sexual functioning is more than 20 years old. There is a striking lack of current functioning. In summary, while low sexual desire is a common proble m among women, and while recent clinical writings advocate reading erotic fiction as a treatment strategy (Hubin et al . , 2011), it appears that there has been no research in the last 20 years to validate this recommendation. Additionally, while bibliothera py is an oft used and empirically validated treatment for sexual dysfunctions in general, there is only one recent study on the efficacy of bibliotherapy for low sexual desire (Mintz et al., 2009). This study will thus examine whether women reading erotic fiction and self help will both make gains over time in sexual desire, overall sexual functioning and other aspects of sexual functioning (arousal, lubrication, satisfaction, orgasm, and pain) and if one group will make significantly greater gains than the other group. A second question is if these gains will be maintained over time within each group (i.e., Will gains in the self help book group be maintained?; Will gains in the erotic fiction group be maintained?). B ased on recently conducted research (Min tz et al., 2012) demonstrating the efficacy of self -
14 help both immediately after reading and at six week follow up, dated research finding that erotic literature increases sexual desire in women (Coles & Shamp, 1984; Mosher & Greenberg, 1969), and the findi ng that non violent erotic online pornography produces only short is hypothesized that both types of bibliotherapy will result in increases in sexual functioning immediately upon reading, b ut that only the self help will result in maintenance of gains. It is hoped that this study will assist clinicians in choosing reading materials to assist their clients suffering from low sexual desire.
15 CHAPTER 2 METHODS Participants Forty seven adults, recruited across three data collection waves, completed the pre test measures and were assigned to either the self help or erotic fiction group, with 20 being assigned to former and 27 being assigned to the latter. Nineteen of the 20 participants i n the self help group completed the post test measure (attrition rate = 5%) and 16 of the 27 participants in the erotic fiction group competed the post test measures (attrition rate = 40%). Thus, there were a total of 35 participants who completed both pre and post test assessments and who were included in the final sample. Additionally, of the 35 participants in the two groups who completed the post test measure, 27 completed the follow up measure six weeks later, with 16 participants in the self help gro up and 11 participants in the ero tic fiction group. See Figure 2 1 for the flow of participants through the study. Table 2 1 presents demographic characteristics for the final sample (i.e., the 35 participants who completed post test measures). Measures The Female Sexual Function Index (FSFI; Rosen et al., 2000) is a widely used, 19 item scale that was used to measure sexual desire, as well as five additional domains or subscales of female sexual functioning, specifically arousal, lubrication, orgasm, sat isfaction, and pain. The domain score ranges are: Desire 1.2 6; Arousal 0 6; Lubrication 0 6; Orgasm 0 6; Satisfaction: 8 6; and Pain 0 6. Additionally, the six domain scores are added to obtain a Total score which represents overall sexual fun ctioning and can range from 2 36, with a higher score indicating greater sexual often did you feel
16 satisfied have you been wi Rosen et al. (2009) report good ( r = .88) two to four week test retest reliability for the total scale and individual domains (r = .79 .86), as well as very good internal consistency for both the total scale ( = .97) and the individual domains ( =.89 .96). In this study, the internal consistency ( ) for the pretest, posttest and follow up respectively was as follows: FSFI total ( = .94, .96, .96); desire ( = .73, .87, .92); arousal ( = .94, .95, .82); lubrication ( = .9 7, .95, .97); orgasm ( = .94, .97, .95); satisfaction ( = .72, .68, .77); and pain ( = .97, .97, .97). The Hurlbert Index of Sexual Desire (HISD; Apt & Hurlbert, 1992) was used as a second measure of sexual desire. This 25 item self report measure asse sses an cognitive componen ts. Total scale scores range from zero to 100, with individual items rated on a five point Likert type scale, ranging from 0 (all of the tim e) to 4 (never). I think my good intern al consistency ( = .86), test retest reliability ( r = .86), and concurrent, construct and discriminant validity. The internal consistency in this study was = .76 at pretest, = .80 at posttest, and = .93 at follow up Procedures A priori power analysis revealed that 40 participants would be needed to obtain a medium effect size at a power of .80. Because of this, as well as projected intervention group attrition rates of 30% 35% found in other bibliotherapy studies (e.g., Floyd,
17 S cogin, McKendree Smith, Floyd, & Rokke, 2004; Malouff, Noble, Schutte, & Bhullar, 2010), a sample size of 55 was sought. Specifi cally, once campus Institutional Review Board (IRB) approval was obtained, advertisements were distributed through local flyers, radio, social media, and e mail listservs for universities and sexuality related interest groups. The advertisements sought heterosexual, married women who felt satisfied with their marriages but bothered by their low sex drive. Challenges in recruiting w omen who fit the inclusion criteria led to collection of data in three waves . Across all three waves, interested individuals responded via phone or email to the recruitment advertisements, and were provided with additional information regarding the study i ncluding being sent the informed consent to examine. Participants then indicated willingness to partake in the study and 51 participants indicated such willingness. These 51 participants were then sent a link to the informed consent and the pre test survey . Following the completion of the pre test surveys, participants also completed a separate identification (ID) survey where they were asked for their name, e mail and mailing address, as well as if they would like to receive a paper or an electronic versio n of the book. Following completion of the pre test measure, ID survey and book preference question, participants were assigned to either the self help or erotic fiction condition. Specifically, d uring the first two data waves, those completing the pre tes t survey were randomly assigned to either the erotic fiction or the self help book group. During the third wave of the study, a majority of participants were assigned to the erotic fiction condition as the data from the first two waves demonstrated that mo re participants from the erotic fiction group than the self help group were completing posttest measures. At the end of the third wave of data collection, there were 27 participants in the erotic
18 fiction group and 20 in the self help group. Participants in each condition were then mailed or e mailed either the self help book or the erotic fiction book with an accompanying letter, which provided detailed instructions for reading the book. Three weeks after mailing the books, an email was sent to participants reminding them that they had three more weeks to read the book. Approximately six weeks after the estimated date of arrival of the books, participants in both conditions were sent a link to the posttest survey. Participants were also asked a question abou t what page of the book they had read to, and those in the self help group were asked a question about what percentage of the exercises they had completed. Fifty eight percent of self help group participants and 81% of erotic fiction group participants rep orted completing the book in full. The average page number reached for those who did not complete the book was 192 of 237 pages in the self help group, and 144 of 219 pages in the erotic fiction group. On average, participants in the self help group report ed completing 45% of the exercises in the book. Participants were also reminded, as per the informed consent, that in six weeks they would receive a final set of follow up questionnaires. Six weeks later, participants were sent a final email with a link to the follow up survey, and were asked if they had completed the book at follow the book at post test. Among the participants who had not completed the self help book at post test, 92% reported completing the book by foll ow up, with one participant reporting that she had read three fourths of the book. Among the participants who had not completed the erotic fiction book at post test, 100% reported completing the book at follow up.
19 Upon filling out the final survey set, al l participants were be fully debriefed and provided with additional resources and referrals in the community for sexual concerns. Across all survey administrations, participants not responding within five days were emailed up to three reminders, each space d five days apart. In addition to receiving copies of the books, as an additional incentive, participants who completed the posttest were offered a $5 Starbucks gift card, and participants who completed the follow up survey were offered a second $5 Starbuc ks gift card. Interventions (Mintz, 2009) is a 237 page self help book designed as a treatment for heterosexual women experiencing low sexual desire. This book was chosen due to prior research on its efficacy (Mintz et al. , 2012) as well as positive scholarly reviews (Buehler, 2011; Sanchez, 2010). The book contains three the physical and emotional benefits of sex. The second fou ndational chapter details the multitude of reasons for low sexual desire, highlighting stress as a major cause and citing research (Bodenmann, Lederman, Blattner, & Galluzzo, 2006; Consumer Reports National Research Center, 2009) identifying a large propor tion of heterosexual women who report that they are satisfied with their relationships and enjoy sex once it is underway, but for whom chronic stress has led to diminished or nonexistent desire. Following the foundational chapters are six chapters, each co ntaining one step in a six step psycho educational and cognitive behavioral treatment program. In the first step, Thoughts , the author uses cognitive techniques to promote positive thoughts about sexuality and instructs readers on mindfulness practices to be used during sexual encounters. The focus of the Talk step is on healthy general and sexual communication
20 strategies. The Time step addresses goal setting and time management. The Touch step affectionate and non goal directed erotic touching. The Spice step provides suggestions to add Tryst step introduces the idea of scheduling sexual encounters, challenges the myth of spontaneous sex, and provides information on the additional information (i.e., finding a t herapist, resources for other sexual and psychological concerns). Passion: Erotic Romance for Women (Bussel, 2010 ) is a 219 page collection of fictional erotic short stories. This book was chosen through the following procedure: First, a post was made to the listserv for the American Association for Sex Counselors, Educators, and Therapists (AASECT) describing the st udy and asking for recommendations for erotic books. The most mentioned and recommended three books were then examined by the researcher and an expert in female sexuality. Passion: Erotic Romance for Women was then chosen due to its length and target audie nce being most similar to The 20 short stories in this book were produced by well known writers of female erotica who have been published in a variety of other collections, as well as won awards for their writing. T he content and nature of these stories were judged to hold appeal to women in long term relationships looking to rekindle romance and passion in their sex life. The tagline on c relationship between the characters in each story is well developed, while also fully exploring the explicit sexual and erotic relationship. The plots of each story, the
21 locations of sexual encounters and the actual sexual acts vary greatly among the sto ries in the book. However, all the stories in the book are based on heterosexual couples, with an overarching theme of passionate seduction.
22 Table 2 1: Participant d emographics Final Sample ( N = 35) Self Help Group ( N = 19) Erotic Fiction Group ( N = 16) M (or N ) SD (or %) M (or N ) SD (or %) M (or N ) SD (or %) Age 40.83 7.76 40.58 8.42 41.13 7.17 Race/Ethnicity White/European American 33 94% 19 100% 14 87.50% Black/African American 2 6% 0 0% 2 12.50% Education Some College 4 11.40% 2 10.50% 2 12.50% Associates Degree 2 5.70% 2 10.50% 3 31.30% Bachelor's Degree 6 17.10% 3 15.80% 2 18.80% Some Graduate /Profession Training 4 11.40% 2 10.50% 5 12.50% Master's Degree 12 34.30% 7 36.80% 3 31.30% Doctoral Degree 5 14.30% 2 10.50% 1 18.80% Advanced Professional Degree 2 5.70% 1 5.30% 1 6.30% Income 15,000 25,000 1 3% 1 5.30% 0 0% 25,000 50,000 2 5.70% 1 5.30% 1 6.30% 50,000 75,000 10 28.60% 6 31.60% 4 25% 75,000 100,000 6 17.10% 2 10.50% 4 25% > 100,000 16 45.70% 9 47.40% 7 43.80% Religion Christinaity 22 62.90% 10 52.60% 12 75% Judaism 1 2.90% 1 5.30% 0 9% Buddhist 1 2.90% 0 0% 1 6.30% Non Religious 6 17.10% 5 26.30% 1 6.30% Agnostic 3 8.60% 2 10.50% 1 6.30%
23 Table 2 1. Continued. Final Sample ( N = 35) Self Help Group ( N = 19) Erotic Fiction Group ( N = 16) M (or N ) SD (or %) M (or N ) SD (or %) M (or N ) SD (or %) Other 2 5.70% 1 5.30% 1 6.30% Marriage Length 11.45 7.56 9.46 7.13 13.81 7.58 Children Currently Living at Home 24 69% 11 58% 13 81% Note. Of the 35 participants in the final sample, 19 (54%) were in the self help group and 16 (46%) were in the erotic fiction group.
24 Figure 2 1: Participant flow c hart
25 CHAPTER 3 RESULTS Preliminary Analyses First, the data was screened in order to assess for missing data, outliers and assumptions of normality. No missing data or outliers were detected. However, the FSFI pain subscale was transformed to correct for the negative skewness (Â±3 SD) displayed at al l three time points (pretest, posttest, and fol low up). One way analyses of variance (ANOVAs) were conducted to test whether there were differences in demographic or pretest outcome variables between: a) those who completed only the pretest and those who c ompleted both the pretest and posttest; and b) those who completed the measures at the first, second and third time point and those who completed measures at the first and second time points only. In the overall sample, as well as in the self help and erot ic fiction conditions, no differences were found. ANOVAs were also used to test whether there were differences in demographic or pretest outcome variables between the three different waves of data collected, and no significant differences were found. Simil arly, ANOVAs were used to test whether there were differences in demographic or pretest outcome variables between the self help and erotic fiction group, and no significant differences were found for any variables except the FSFI Desire subscale. Specifica lly, individuals in the self help group indicated lower levels of desire at pretest (M = 1.73, SD = 0.59) than did participants in the erotic fiction group (M = 2.28, SD = 0.76), F (1, 34) = 2.634, p = 0.023. Thus, the analysis for the FSFI Desire subscale was adjusted to reflect pre group differences (i.e., use of an ANCOVA rather than an ANOVA).
26 Short Term Efficacy of Interventions Although a common strategy is to conduct an omnibus multivariance analysis of variance F test followed with univariate analys es, many statisticians recommend separate univariate F tests on each outcome variable, with a Bonferroni correction used (Enders, 2003; Huberty & Morris, 1989; Jaccard & Guilamo Ramos, 2002). Additionally, multiple univariate tests are recommended in explo ratory studies in which new treatments are being investigated (Huberty & Morris, 1989); because this is the first study in over 20 years examining erotic fiction as well as only the second study examining self help for low sexual desire, ANOVAs were consid ered especially appropriate. We thus conducted repeated measures ANOVAs using pre and posttest scores on the dependent measures (FSFI Desire, FSFI Satisfaction, FSFI Lubrication, FSFI Arousal, FSFI Orgasm, FSFI Pain, FSFI Total, HISD). As noted earlier, f or the FSFI Desire subscale, due to pre test differences between the groups, an ANCOVA was conducted. To protect against the effects of inflated Type I error with running multiple analyses, we used the Holm (1979) modified Bonferroni method; the traditiona l Bonferroni method ( /k ) often has low statistical power, whereas the Holm approach is more powerful and adequately maintains experiment wise error rates (Jaccard & Guilamo Ramos, 2002). To examine comparative changes over time (pre to posttest) and acro ss groups (self help vs erotic fiction), the ANOVA or ANCOVA Group X Time interaction was examined. Additionally, because changes over time (pre to posttest) within each group were also of interest, main effects for time were also examined. Also, due to t he problems associated with null hypothesis significance testing when interpreting social science data (see Ferguson 2009 for further discussion), effect sizes are presented for all variables. Specifically,
27 d ) is r eported (Ferguson, 2009; Sink & Stroh, 2006), along with interpretations (i.e., .2 = small, .5 = medium, and .8 = large). These ANOVA and ANCOVA results are described below and presented in Table 3 2. ANOVA results for the FSFI Total revealed no interactio n effect. However, there was a significant time effect, F (1, 34) = 24.22, p = 0.00 (see Figure 3 2). In the self help group, FSFI Total scores increased from 15.44 at pretest to 19.90 at posttest. The effect c fiction group, FSFI Total scores 1.00 (large). Neither measure of desire (FSFI Desire and HISD) showed a significant interaction effects , but both displayed significan t effects of time. Due to pre test differences between groups on the FSFI Desire Subscale, an ANCOVA was conducted. Post test scores on the FSFI Desire Subscale was the dependent variable, group membership (Erotic Fiction, Self Help) was the independent va riable, and FSFI Desire Subscale pre test scores was the covariate. There was a significant effect of time for FSFI Desire, F (1, 34) = 11.95, p = 0.002 (see Figure 3 3). In the self help group, the pretest score increased from 1.73 to 2.87 at posttest. The d was 1.37 (large). In the erotic fiction group, the pretest score increased from 2.28 to 3.67 at posttest. The d was 1.68 (large). Likewise, for HISD, there was a significant effect of time, F (1, 34) = 12.13, p = 0.001. In self help group , the pretest score increased from 36.52 to d was 0.49 (small). In the erotic fiction group, the pretest d was 0.55 (medium).
28 None of the remaining FSFI subscales (i.e. Satisfaction, Arousal, Orgasm, Pain or Lubrication) evidenced significant interaction effects, but all displayed significant effects of time. In all, both groups evidenced significant improvements in functioning over time. In the self help group, the FSFI Satisfaction displayed a large effect size d ), while all remaining effects were in the small range. In the erotic fiction group, effect sizes were large for Satisfaction, medium for Arousal and Orgasm, and small for Pain and Lubrication. The results of these ANOVAS, including means, standard deviations, F d , and alpha levels, can be found in Table 3 2. Longer Term Efficacy of the Interventions To determine the longer term efficacy (i.e. six week follow up) of each type of bibliotherapy intervention, we conducted repeated measures ANOVAs comparing week follow up, with th e Holm (1979) modified Bonferroni method used . Because the aim was to determine if each intervention resulted in maintenance of gains, rather than to compare maintenance across interventions, these analyses were conducted separately for each group. The per centage of variance explained ( p 2 ) is reported as a measure of effect size (Ferguson, 2009; Sink & Stroh, 2006), along with interpretations (i.e., p 2 , .01 = small, .06 = medium, and .14 = large; Sink & Stroh, 2006). Self Help Group Significant time effec ts were found for the FSFI Total, F (1, 15) = 7.73, p = 0.005, p 2 = 0.525 (large) (see Figure 3 4) . Post hoc analyses indicated that pretest and posttest scores differed significantly and that pretest and follow up scores differed significantly, but the posttest scores and follow up scores did not differ significantly, indicating that gains were mainta ined at follow up. Similarly, significant results were
29 found for FSFI Desire: F (1, 15) = 16.35, p = 0.00, p 2 = 0.7 (large) (see Figure 3 5) ; FSFI Satisfaction, F (1, 15) = 7.60, p = 0.006, p 2 = 0.521 (large) (see Figure 3 6); and FSFI Pain, F (1, 15) = 19.79, p = 0.00, p 2 = 0.73 (large) . For all, post hoc analyses indicated that pretest and posttest scores differed significantly, and pretest and follow up scores differed significantly. However, the posttest and follow up scores did not differ significa ntly, again indicating that the gains made at posttest were maintained at follow up. See Table 3 3 for details. Erotic Fiction Group Significant time effects were found for FSFI Total, F (1, 10) = 10.93, p = 0.004; p 2 = 0.708 (large) (see F igure 3 4); F SFI Desire, F (1, 10) = 8.29, p = 0.009, p 2 = 0.648 (large) (see Figure 3 5) ; FSFI Satisfaction, F (1, 10) = 10.37, p = 0.005, p 2 = 0.697 (large) (see F igure 3 6) ; and FSFI Pain, F (1, 10) = 12.20, p = 0.001, p 2 = 0.793 (large) . For all the measures, post hoc analyses indicated that pretest and posttest scores differed significantly, and pretest and follow up scores differed significantly, but that posttest and follow up scores did not differ significantly. As in the self help group, these r esults indicated that the gains made at posttest were maintained at follow up. See Table 3 4 for details.
30 Table 3 1 . Mean, standard deviations, and short term time effects on dependent v ariables Self Help Group Erotic Fiction Group Pre Test Post Test Pre Test Post Test Measure M SD M SD M SD M SD F (1,34) p d HISD*** 36.52 9.08 41.68 11.95 39.50 6.95 43.87 9.04 12.13 0.001 0.49/0.55 Desire** 1.73 0.59 2.87 1.05 2.28 0.76 3.67 0.90 11.95 0.002 1.37/1.68 Arousal** 2.46 1.32 3.22 1.81 3.16 1.58 3.90 1.40 8.34 0.007 0.47/0.50 Lub* 3.07 1.84 3.74 2.00 4.21 1.67 4.80 1.46 4.46 0.042 0.35/0.38 Sat*** 2.88 0.84 3.75 1.21 2.75 0.54 4.22 1.01 38.65 0.000 0.85/1.90 Orgasm** 2.71 1.84 3.47 2.05 3.07 1.52 4.22 1.83 10.77 0.002 0.40/0.69 Pain*** 2.56 1.53 2.88 1.52 2.82 1.52 3.22 1.40 70.42 0.000 0.21/0.27 FSFI*** Total 15.44 6.57 19.90 8.52 18.32 5.33 24.05 6.17 24.22 0.000 0.60/1.00 Note. N = 35 for analyses. The first listed Cohen s d is for the self help group posttest effect size and the second is for the erotic fiction group posttest effect size. All dependent variables were analyzed using repeated measures ANOVAs, except an ANCOVA was used for FSFI Desire. For all measures, high er scores indicate higher levels of sexual functioning. HISD = Hurlburt Index of Sexual Desire (range = 0 100); Desire = Female Sexual Functioning Index Desire subscale (range = 1.2 6); Arousal = Female Sexual Functioning Index Arousal subscale (range = 0 6); Lub = Female Sexual Functioning Index Lubrication subscale (range = 0 6); Orgasm = Female Sexual Functioning Index Orgasm subscale (range = 0 6); Sat = Female Sexual Functioning Index Satisfaction subscale (range = 0 6); Pain = Female Sexual Functio ning Index Pain subscale (range = 0 6). Total = Female Sexual Functioning Index Total Score (range = 2 36). * p p p
31 Table 3 2 . Summary table for the long term effects of time on dependent variables in the self help g roup M e asure Pretest Posttest 6 Week Follow Up 95% Confidence Intervals M SD M SD M SD Pre to post Post to Follow up Pre to Follow up HISD 3 6.5 9.88 42.62 12.81 40.50 17.05 [ 10.30, 1.95] [ 2.04,6.29] [ 9.61,1.61] Desire*** 1.83 0.60 3.00 1.09 3.11 1.10 [ 1.65, 0.68]*** [ 0.50, 0.28] [ 1.76, 0.80]*** Arousal 2.41 1.25 3.50 1.50 2.71 1.29 [ 1.98, 0.20] [0.10, 1.48] [ 1.14, 0.54] Lub 3.00 1.66 4.08 1.60 4.21 1.88 [ 2.10, 0.08] [ 0.73, 0.47] [ 2.40, 0.04] Sat** 2.80 0.77 3.75 1.22 4.00 1.40 [ 1.57, 0.33]** [ 0.98, 0.48] [ 1.93, 0.47]** Orgasm 2.62 1.67 3.75 1.72 3.75 1.88 [ 2.14, 0.11] [ 0.96, 0.96] [ 2.13, 0.13] Pain*** 2.57 1.48 3.17 1.22 4.67 2.04 [ 1.05, 0.15]*** [ 2.09, 0.92] [ 2.81, 1.40]*** FSFI Total** 15.25 6.01 21.26 7.11 22.47 7.91 [ 9.48, 2.54]** [ 3.93,1.52] [ 11.19, 3.25]*** Note. N = 16 for analyses. For all measures, higher scores indicate higher levels of sexual functioning. Significance levels next to scale name pertain to repeated measures ANOVAs; significance levels next to confidence intervals pertain to pairwise comparisons. HISD = Hurlburt Index of Sexual Desire (range = 0 100); Desire = Female Sexual Functioning Index Desire subscale (range = 1.2 6); Arousal = Female Sexual Functioning Index Arousal subscale (range = 0 6); Lub = Female Sexual Functioning Index Lubrication subscale (range = 0 6); Org = Female Sexual Functioning Index Orgasm subscale (range = 0 6); Sat = Female Sexual Functioning Index Satisfaction subscale (range = 0 6); Pain = Female Sexual Functioning Index Pain subscale (range = 0 6). Total = Female Sexu al Functioning Index Total Score (range = 2 36). * p p p
32 Table 3 3 . Summary table for the long term effects of time on dependent variables in the erotic fiction g roup Pretest Posttest Follow Up 95% Confidence Intervals Measure M SD M SD M SD Pre to post Post to Follow up Pre to Follow up HISD 37.00 4.81 40.72 8.24 41.45 12.67 [ 9.449, 2.045] [ 6.333, 4.878] [ 12.831, 3.922] Desire** 2.12 0.67 3.32 0.82 3.16 1.31 [ 1.824, 0.576]** [ 0.489, 0.816] [ 1.844, 0.228]* Arousal 3.30 1.75 3.76 1.64 2.70 1.39 [ 1.277, 0.349] [0.424, 1.703] [ 0.433, 1.643] Lub 4.22 1.80 4.69 1.70 4.17 2.21 [ 0.968, 0.041] [ 0.622, 1.659] [ 1.210, 1.319] Sat** 2.69 0.56 3.96 1.03 3.56 1.36 [ 1.916, 0.584]** [ 0.033, 0.833] [ 1.721, 0.024]* Orgasm 2.90 1.70 4.03 2.05 3.89 2.30 [ 1.866, 0.388] [ 0.818, 1.109] [ 1.916, 0.048] Pain*** 2.40 1.66 3.16 1.58 4.65 2.34 [ 1.565, 0.038]*** [ 2.953, 0.028] [ 3.269, 1.240]** FSFI Total** 17.65 6.02 22.95 7.12 22.14 9.81 [ 7.685, 2.897]*** [ 3.144, 4.744] [ 9.005, 0.023]* Note. N = 11 for analyses. For all measures, higher scores indicate higher levels of sexual functioning. Significance levels next to scale name pertain to repeated measures ANOVAs; significance levels next to confidence intervals pertain to pairwise comparisons. HISD = Hurlburt Index of Sexual Desire (range = 0 100); Desire = Female Sexual Functioning Index Desire subscale (range = 1.2 6); Arousal = Female Sexual Functioning Index Arousal subscale (range = 0 6); Lub = Female Sexual Functioning Index Lubrication subscale (range = 0 6); Org = Female Sexual Functioning Index Orgasm subscale (range = 0 6); Sat = Female Sexual Functioning Index Satisfaction subscale (range = 0 6); Pain = Female Sexual Functioning Index Pain subscale (range = 0 6). Total = Female Sexu al Functioning Index Total Score (range = 2 36). * p p p
33 Figure 3 1 . Short term time e ffects for FSFI t otal 0 5 10 15 20 25 30 Pre Test Post Test Self-Help Erotic Fiction
34 Figure 3 2 . Short term time effects for FSFI d esire 0 0.5 1 1.5 2 2.5 3 3.5 4 Pre Test Post Test Self-Help Erotic Fiction
35 Figure 3 3 . Longer term time effects on FSFI t otal 0 5 10 15 20 25 Pre Test Post Test Follow-Up Self-Help Erotic Fiction
36 Figure 3 4 . Longer term time effects on FSFI d esire 0 0.5 1 1.5 2 2.5 3 3.5 Pre Test Post Test Follow Up Self-Help Erotic Fiction
37 Figure 3 5 . Longer term time effects on FSFI s atisfaction 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Pre Test Post Test Follow Up Self-Help Erotic Fiction
38 CHAPTER 4 DISCUSSION As far as the authors of this study could determine, this is the first study in approximately 20 y ears to evaluate the effects of erotic fiction on female sexual functioning. Further, it is also the first study to compare the efficacy of erotic fiction and self help for alleviating low sexual desire among women. In line with predictions made at the out set of the study, women in both conditions (i.e., those who read the erotic fiction book and the self help book) experienced significant improvement in sexual desire (across two measures), sexual satisfaction, sexual arousal, lubrication, orgasm, pain redu ction, and overall sexual functioning from the baseline to post intervention, with no statistically significant differences between them but with effect sizes generally in the small range for the self help book group and generally in the medium to large ra nge in the erotic fiction book group. Additionally, contrary to our prediction that these gains would be maintained only in the self help group at the six week follow up, both groups maintained their gains on the same measures and for all, the effect sizes were in the same range (i.e., large). Specifically, in both groups, gains were maintained on one measure of sexual desire, as well as on measures of sexual satisfaction, reduction in sexual pain, and overall sexual functioning. In short, both books result ed in the same pattern of change across time. The similar efficacy of the two books in increasing sexual desire and sexual functioning from baseline to post intervention deserves exploration, particularly given that one was written as a treatment and the other was not. Specifically, the self help book was written as an intervention for women with low sexual desire, and it incorporated psychological principles and techniques, while the erotic fiction book was
39 written from an entertainment rather than a treatment perspective. One explanation for the equi valency of two books written from diverse perspectives is that both books functioning. For instance, the self help book might promote sexual functioning via psychological techniques such as cognitive behavioral methods and mindfulness, or by encouraging women to engage in honest communication with their partners, whereas the erotic fiction book might improve sexual functioning by providing written models of passionate sex, and encouraging participants to fantasize about sex. In sum, both books may be effective, but through different mechanisms of change. Another explanation for the equivalency of the two books is that there is a construct that cuts across both. Specificall y, perhaps both books (i.e., the self help book, which offered women guidance, validation and normalization regarding sexual dysfunction and the erotic fantasies about sex) provided women a feeling of empowerment and control. Richgels gender role socialization and the systematic control of her sexuality by the dominant ve, other researchers analyzing the ). It is therefore possible that both books were efficacious because they provide messages that encouraged women to embrace their sexual desires and pleasures. In this way, each book might have empowered women, and provided a feeling of being in control of
40 Another explanation for the equivalent changes in both groups is the simple act pharmacological treatments for female sexual dysfunction have shown that women in the placebo condition often improve significant ly in their sexual functioning. This finding, which mirrors findings of randomized controlled placebo tr ials for other conditio ns (e.g., irritable bowel syndrome, and chronic lower back pain ), has led some to speculate that a placebo may actually spur physical changes through a mind body interaction ( Kaptchuk et al, 2008; Marchand e. al., 1993; Meston, 2004) . In the present study, it is possible that simply participating in this study, and reading a book, provided the women with a sense that they were doing something to enhance their sexual well being. This, in turn, might have been sufficient to improve their sexual functioning. F uture research conducted with a qualitative methodology could help to more clearly ascertain the mechanism of change across both books, and to determine if their equivalency is due to distinct mechanisms of change, an active change mechanism that cuts acro ss both, or the placebo effect. Nevertheless, while this study did not find statistical differences in the change across both groups from pre to post test and also found a similar pattern of maintenance of gains at follow up, other results in this study point to some possible differences between the two books. First, there was a striking difference between the attrition rates in the two groups. In the self help group, attrition from pre to posttest was 5%, and attrition from posttest to follow up was 16 %. In the erotic fiction group, attrition from pre to posttest was 40%, whereas attrition from posttest to follow up was 32%.
41 Second, the erotic fiction book resulted in larger effect sizes for all the dependent measures at post test. Taking these two fin dings together, it is possible that participants had a stronger reaction (either positive or negative) to the erotic fiction book as compared to the self help book. To explain, the ability of the erotic fiction book to assist al desire may have been perceived as lesser by those in the erotic fiction group as compared to those in the self help book. Participants in the erotic fiction group may have dropped out of the study because they were disappointed to not receive the self h elp book and perceived the erotic fiction book to have lesser face value to help with their problem. Alternatively, they may have begun reading the book and found it was not helping with their desire problem; in fact, the one participant in the erotic fic tion group who gave a reason for dropping out at post test said just this. Thus, it may be that erotic fiction is helpful only for only a small subset of women , but for these women, it is extremely helpful. This would explain the higher effect sizes found for the women who read the erotic fiction book as compared to the self help book, and is an explanation that is also bolstered by the greater percentage of women in the erotic fiction condition than in the self help condition who reported finishing the ent ire book. quite useful. Also potentially informative is an examination of the maintenance of gains in the erotic fiction group. It is not surprising that many of the ga ins made by the group who read the self help book (i.e, ) were maintained at follow up, given that this effect was found in a prior study testing the efficacy of the book (Mintz et al. 2012). However, it is important to note that contrary to
42 the hypothesis, those reading the erotic fiction book evidenced similar long term effects. The initial hypothesis that women in the erotic fiction group would not maintain gains was based on past research findings that women expose d to non violent sexually explicit visual materials evidence only short term increases in sexual desire and established sexual practices (Brown, Amoroso & Ware, 1976; Fisher & Kohut, 2013, Fisher & Davis, 2007 ; Schmidt & Sigusch, 1970). However , it is impo rtant to consider both differences between reading a book and watching a video, as well as differences in the methodology of these past studies compared to the present study. In the past studies, participants watched sexually explicit visual stimuli in a c ontrolled experimental space, while in the present study participants read sexually explicit fiction at their imagination and development of fantasy to a greater extent than viewing sexually explicit material. Research comparing the effects of different types of media on imagination found that watching television, which seems similar to watching videos, contributed to a more passive mental process ( Carnegie Commission, 1979). On the other hand, listening to radio media may be more similar to reading fiction in terms of argues stimulated by a medium varies as a function of the mental effort invested i (Greenfield, Farrar & Beagles Roos, 1986). Therefore, it is possible that the mental investment utilized in reading erotic fiction allowed participants to learn skills to activate their imagination and engage in fantasy that could then be accessed fo r a longer duration even after finishing the book. Also, the fact that participants in the present study were able to read and engage with the erotic material in a setting where they
43 naturally would choose to engage in sexual thoughts or behavior (i.e., at home rather than in a laboratory) may also be responsible for the longer term maintenance of gains than has been found for women watching sexually explicit media in a laboratory condition. Although this study adds to the limited research on bibliotherap y, and more specifically on erotic fiction as a treatment for low sexual desire, there were some methodological concerns. First, although statistical significance and medium to large effect sizes were found in a majority of the outcome measures, the sample size of the study was small ( N = 35 at post test and N = 27 at follow up), as is the case with m ost bibliotherapy studies (Van Lankveld, 2009). Indeed, while a study with a large sample would be predicted to yield the same time effects (i.e., changes with in both groups after reading the book), it may be that such a study would also yield statistically significant interaction effects indicating that one type of book outperforms the other, a notion supported by comparing the effect sizes across the groups at post test. Second, the lack of diversity within the sample limits the generalizability of this study. For instance, most of the participants in the present study identified as White, Christian, highly educated, and reported high income levels. A study wit h a more diverse sample is sorely needed. Finally, both the self help book and the erotic fiction book only cater to heterosexual married couples, thus limiting their clinical utility with same sex individuals. A study with lesbian women suffering from low sexual desire is needed, using self help written for this or a more inclusive population and erotic fiction written from a lesbian perspective.
44 Other avenues for additional research include a replication study, using different self help and erotic fiction books. Additionally, research on erotic fiction as bibliotherapy for other types of sexual dysfunctions could be conducted . The results found for longer term improvement in pain and short term improvement in lubrication suggest that erotic fiction might a lso be helpful for female sexual pain and arousal concerns. Research could also explore the use of erotic fiction with couples instead of individuals. Finally, future research could also investigate the comparative efficacy of female centric visual pornogr aphy and erotic fiction for enhancing sexual desire. Despite its limitations, the results of this study provide evidence that clinicians may consider recommending either one or both of the books (self help and erotic fiction) used in this study with heter osexual female clients with low sexual desire. These books could be especially useful to women who are unable to afford face to face counseling for low sexual desire. Clinicians may also choose to recommend this book in the early stages of treatment or as a supplement to ongoing face to face counseling (Norcross, 2006). As noted by Mintz (2012) , bibliotheraputic interventions with evidence of efficacy can be used by clinicians before treatment begins, during counseling, or after termination of counseling in order to serve as an ongoing resource. Nevertheless, given the high dropout rate in the erotic fiction group, clinicians should closely monitor client reactions to the written materials. This study has broader implicati ons beyond the efficacy of the two books studied here. First, this study contributes to the debate regarding the definition of bibliotherapy, b y providing support for the more inclusive definition of bibliotherapy (Hubin et al ., 2011) that includes both self help and imaginative sources (e.g., fictional books). In the
45 present study, the erotic fiction book was shown to be just as effective as the self help book, rebutting the claim of some researchers that only self help books can be c onsidered bibliotherapy (van Lankveld, 2009). Second, this study adds to the limited literature on the efficacy of bibliotherapy, which has the ability to provide treatment to larger populations in a non stigmatizing modality Thi rd, this study contributes to the understudied area of treatments for low sexual desire, providing those who suffer with two easily accessible and potentially effective remedies. It is hoped that this study will serve as a starting point for more current r esearch on the efficacy of all types of bibliotheraputic interventions for low sexual desire in wom en.
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49 BIOGRAPHICAL SKETCH Meenakshi Palaniappan received her undergraduate degree in Psychology from the University of San Francisco, California. She is currently pursuing her PhD in Counseling Psychology at the University of Florida, and is involved in teaching and clinical work.