Abstract
Objectives
The purpose of this study was to describe associations between relationship status, anxiety, and sexual function and satisfaction in lesbian, gay, and bisexual (LGB) adults.
Methods
Linear regression determined associations between sexual function, relationship characteristics and anxiety in 979 LGB participants.
Results
Relationship status was not related to sexual interest in gay men. Partnered relationship status was associated with higher sexual satisfaction for gay men, lesbians, and bisexual women. Anxiety symptoms were negatively associated with sexual interest, satisfaction, and orgasm pleasure for gay men but not associated with sexual outcomes in lesbian women.
Conclusion
Using a nationally representative sample of LGB adults, differences were found in factors related to sexual function and satisfaction by gender and sexual orientation.
Keywords: Sexual function, sexual health, lesbian, gay, bisexual
Sexual function and satisfaction have rarely been explored in lesbian, gay, and bisexual (LGB) populations (Björkenstam et al., 2020; Calvillo et al., 2020). Sexual health is an under-recognized component of health and quality of life (World Health Organization, 2006). A systematic review of sexual satisfaction concluded that sexual satisfaction is a key factor in overall wellbeing (del Mar Sánchez-Fuentes et al., 2014). Yet only 1% of the studies included in the review focused on samples of individuals in same-sex relationships, and only 13% focused on mixed sexual orientation samples; 35% did not report the sexual orientation of participants.
Interest in sexual activity, sexual satisfaction, and orgasm pleasure are key components of sexual function, which, in turn, is an important part of health, wellbeing, and quality of life (Flynn et al., 2016). Diagnosis and treatment of sexual dysfunction, such as lack of libido, sexual distress, or orgasm disorders, can lead to improvements in sexual quality of life and relationships (Reese et al., 2018; Rosen et al., 2004; Symonds et al., 2005). Thus, knowledge of sexual function and satisfaction in LGB people, and the factors influencing sexual (dys)function and satisfaction, are both theoretically and practically meaningful. Models of sexual function and satisfaction, primarily based on heterosexual relationships, often include relationship factors (e.g., relationship satisfaction) and psychological factors (e.g., anxiety) (Althof et al., 2005; Calvillo et al., 2020). Associations of relationship factors, psychological factors, and sexual function and satisfaction have yet to be thoroughly explored in sexual minority people.
Although the associations of relationship satisfaction and sexual satisfaction have been explored more extensively (Calvillo et al., 2020; Fleishman et al., 2019), relationship status (e.g., single, dating, partnered, married) and relationship length have received less attention even though this information is more readily available in clinical settings (i.e., clinic intake forms include marital status but not assessments of satisfaction). In a sample of 475 men and women (76% heterosexual), exclusive dating and engaged participants had higher sexual satisfaction than friends with benefits, casual dating, or married (Birnie-Porter & Hunt, 2015). The authors point to variability in the roles of intimacy and attachment avoidance to explain differences in sexual satisfaction. This has yet to be studied in gay and bisexual populations, with mixed results among lesbians. In one study of lesbians, having a partner was associated with less desire for sex, less difficulty with lubrication, and greater sexual satisfaction compared with nonpartnered participants (Tracy & Junginger, 2007). Other studies of lesbians found no relationship between cohabitation status and sexual satisfaction (Scott et al., 2018) or between partner status and sexual function (Boehmer et al., 2014). In addition, a small number of studies have shown a relationship between higher internalized homophobia and lower sexual satisfaction (and relationship satisfaction) in LGB individuals (Calvillo et al., 2020; Grabski et al., 2019).
Regardless of gender or sexual orientation, many studies have found a negative correlation between length of relationship and sexual satisfaction (del Mar Sánchez-Fuentes et al., 2014; del Mar Sánchez-Fuentes & Sierra, 2015). Among lesbians, length of relationship has been associated with less desire for sexual activity, less arousal and greater difficulty with lubrication during sexual activity, and decreased sexual satisfaction (Scott et al., 2018; Tracy & Junginger, 2007). Extant literature examining the associations between relationship status or length and sexual function and satisfaction in gay men are limited by analyses that combine the gender and/or sexual orientation subgroups (del Mar Sánchez-Fuentes & Sierra, 2015; Fleishman et al., 2019). In previous work, we described partnered versus unpartnered sexual activity in an LGB sample but did not explore relationship status or length as predictors of sexual (Flynn et al., 2017).
Though psychological health is a primary target for counseling and cognitive behavioral therapy for sexual dysfunction, the literature suggests a complex relationship between anxiety and sexual function (Kane et al., 2019), further obfuscated by gender (McCabe et al., 2010), the degree of anxiety (Bradford & Meston, 2006), and how anxiety is conceptualized, such as state or trait anxiety, attachment anxiety, or sexual anxiety (e.g., fear of penetration; Brassard et al., 2015; Calvillo et al., 2020; Kane et al., 2019). In the general population, psychological health is positively associated with sexual satisfaction in men and women (del Mar Sánchez-Fuentes et al., 2014). In LGB people, higher levels of psychological wellbeing are associated with greater sexual satisfaction, whereas anxiety, depression, and other psychological disorders are associated with lower sexual satisfaction (Calvillo et al., 2020; De Ryck et al., 2012; del Mar Sánchez-Fuentes et al., 2014). Compared with heterosexual men, gay and bisexual men have higher risk for general anxiety (Gilman et al., 2001), and gay men report higher levels of relationship attachment anxiety than lesbian women (Calvillo et al., 2020).
The extent to which demographic factors, such as sexual orientation, relationship status, and length, contribute to orgasm occurrence and experiences is largely unknown. A probability sample of almost 4,000 U.S. adults showed more men (91.3%) than women (64.4%) reported orgasm during their most recent partnered sexual event (Herbenick et al., 2010). A study of partnered sexual activity in over 6,000 U.S. men and women found that orgasm occurrence did not vary by sexual orientation for men but did for women (Garcia et al., 2014). Lesbian women had a higher probability of orgasm (74.7%) than either heterosexual (61.6%) or bisexual (58.0%) women. In our previous analysis, we found interest in sexual activity highest in heterosexual men and lowest in lesbian women (Flynn et al., 2017).
Taken together, these findings suggest more research is warranted to understand how relationship and psychological factors influence sexual function and satisfaction LGB people. Results will contribute to the existing literature by studying a nationally representative sample, disaggregating sexual minority groups, and exploring specific aspects of sexual function (interest, satisfaction, and orgasm pleasure). This knowledge can inform comprehensive and culturally sensitive sexual healthcare. The purpose of this study was to explore whether relationship status, relationship length, and anxiety were associated with sexual interest, orgasm pleasure, and satisfaction with sex life in LGB people. We anticipated LGB people in stable partnerships would perceive more sexual satisfaction while those who were single, dating, or in more casual relationships may have more sexual interest and orgasm pleasure. We anticipated a negative effect of anxiety on all aspects of sexual function and satisfaction in LGB people.
Methods
We conducted a cross-sectional survey of adults age 18 and older, able to read English, and residing in the United States who identify as gay, lesbian, or bisexual (Flynn et al., 2016). The survey was administered in July 2014 by KnowledgePanel®, a probability-based web panel designed to be representative of the U.S. population. Data from the sample was weighted for inferences to the national population using geodemographic distributions (age, gender, race, ethnicity, education, census region, household income, home ownership status, metropolitan area, and internet access) obtained from the Current Population Survey, the American Community Survey, the National Health Interview Survey (NHIS), and the weighted KP profile data. Panel members who met eligibility criteria were invited to participate until 1000 had completed the survey about health, including sexual health and fertility. We invited 2,016 to complete the study screener, 1,114 completed it and 1,011 qualified for the main survey (50% response rate). The Medical College of Wisconsin institutional review board approved the study (PRO00022492), and participants provided consent online. This study is a secondary data analysis exploring associations between relationship status, anxiety, and sexual function and satisfaction in lesbian, gay and bisexual people (n = 979).
Measures
The self-administered online questionnaire included approximately 177 items. Skip patterns determined the particular set of items participants received depending on their sex and sexual activity status. For example, if a participant reports no sexual activity in the past 30 days they were asked questions about interest in sexual activity, but they were not asked about pain, orgasm, or genital dysfunction (i.e., problems with erections or lubrication) related to sexual activity.
General and demographic information
Respondents were asked about their overall health (“In general, would you say your health is…” ranging poor to excellent), race and ethnicity, education level, age, and employment.
Mental health
To measure current mental health symptoms, single items from Patient-Reported Outcomes Measurement Information System® (PROMIS) anxiety and depression item banks were used (“My worries overwhelmed me” and “I felt depressed” each with a recall period of 7 days and response options ranging from never to always; Pilkonis et al., 2011).
Relationship characteristics
Relationship characteristics include current relationship status (married, civil union, partnered living together, partnered not living together, single dating, and single not dating), relationship length, and gender of partner(s). Respondents who were dating or in a relationship were asked the gender of their current partner(s). Those reporting they were in a relationship (not single) were asked to report relationship length (months and/or years).
Sexual activity
Sexual activity was assessed with a two-step process: (1) “In the past 30 days, did you have any type of sexual activity? (Examples of sexual activity are masturbation, oral sex, and sexual intercourse.)” and (2) “In the past 30 days, did you have any sexual activity with a partner? (Examples of sexual activity with a partner are oral sex and sexual intercourse.)”
Sexual function and satisfaction
Sexual interest, sexual satisfaction, and orgasm pleasure were the primary outcome measures and were assessed using the PROMIS Sexual Function and Satisfaction measure version 2.0 (SexFS v2). The PROMIS SexFS v2 is a comprehensive and customizable measurement system with evidence for validity in diverse populations including sexual minorities (Cronbach’s alpha for three primary outcome domains range 0.93–0.094; Weinfurt et al., 2015). All participants were asked about sexual interest (2 items: how interested have you been in sexual activity and how often have you felt like you wanted to have sexual activity). Only participants who were sexually active in the past 30 days were asked satisfaction (5 items; e.g., how satisfied have you been with your sex life and how much pleasure has your sex life given you) and orgasm pleasure (3 items; e.g., how much pleasure have your orgasms or climaxes given you and how often have your orgasms or climaxes been satisfying). PROMIS SexFS v2 scales use the T-score (0–100) metric, where 50 (SD 10) corresponds to the average for sexually active U.S. adults. Results from Cronbach’s alphas of our three outcome variables in the present study confirm moderate to high internal reliability, with alphas between 0.88 and 0.95.
Analysis
All statistics were adjusted for the complex sample design. KnowledgePanel provides weights according to benchmarks from the Current Population Survey. Additional benchmarks from the National Health Interview Survey were used in an iterative proportional fitting procedure to produce final weights. Respondents were removed from analysis if they responded “other” for relationship status (n = 15), and because of item nonresponse for anxiety (n = 6) and sexual activity (n = 11), resulting in an analysis sample of 979 cases. We present descriptive statistics separately by gender and sexual orientation groups for health, relationship, and sociodemographic characteristics. Univariate statistics with 95% confidence intervals describing relationship characteristics are presented separately by relationship status.
The final multivariable model for linear regression was used to assess associations between relationship characteristics (relationship status and length of relationship), sexual activity, and anxiety on sexual function (interest and orgasm pleasure) and satisfaction, separately for gender and sexual orientation group. We ran a single model that included gender and sexual orientation as a four-category variable (gay men, bisexual men, lesbian women, bisexual women) to be able to understand how or if these groups demonstrated significantly different sexual interest, satisfaction, or orgasm pleasure from another group. This single model, adjusting for gender, sexual orientation, and relationship status simultaneously, found very similar significant associations compared with models run individually for each gender and sexual orientation group (Supplemental Table). Because of sample size, we were unable to run interaction terms, therefore we ran separate models by sexual and gender identity to model the unique relationship between relationship status and sexual interest, satisfaction, and orgasm pleasure for each sexual and gender identity.
Sexual activity in the last 30 days was operationalized as a three-category variable for sexual interest models (none, solo only, solo/partnered) and as a dichotomous variable (solo only, solo/partnered) for satisfaction and orgasm pleasure models. Graphical inspection of scatterplots and loess curves suggested a non-linear relationship between sexual function scores and relationship years, leading to the inclusion of a squared term to model the quadratic relationships and interpret directionality. The calculation for inflection points was -b/2a where b is the coefficient and a is the intercept. Because of a small sample size, we were unable to control for gender of partner for bisexual analysis.
We conducted sensitivity analyses to ensure parsimonious models. First, we examined correlations between potential explanatory variables to assess multicollinearity. Because anxiety and depression were highly correlated (r = 0.73), we prioritized anxiety, which plays a central role in sexual dysfunction (Kaplan, 1980). Likewise, age and relationship years were highly correlated (r = 0.66), and we prioritized relationship years due to our interest in the associations of relationship factors on sexual function and satisfaction. We compared the reported models with ones with age and depressive symptoms, and we found no substantive differences in results. Second, we examined models of sexual interest after removing participants who reported no sexual activity in the past 30 days and again found no substantive differences in results. To avoid type II error from interpretation of small sample sizes, we do not report coefficients where cell counts were fewer than 10 participants. We used Stata® version 14.2 and two-tailed significance level of α = 0.05 for direct comparisons.
Results
Sociodemographic characteristics of the sample are shown in Table 1. Participants (n = 979) were an average age of 41 years, mostly non-Hispanic White (69.2%), had at least some college or college degree (71.6%), and were employed (64.2%). Notably, 74% of bisexual men and 84% of bisexual women reported opposite sex partners.
Table 1.
Demographic Characteristics by Sexual Orientation and Gender Identity.
| Gay men (n = 382) | Bisexual men (n = 138) | Lesbian women (n = 200) | Bisexual women (n = 259) | |
|---|---|---|---|---|
| Mean (95% CI) |
Mean (95% CI) |
Mean (95% CI) |
Mean (95% CI) |
|
| Age | 43.1 (41.2, 45.0) |
41.6 (38.1, 45.0) |
44.9 (42.5, 47.3) |
35.3 (33.5, 37.2) |
| Relationship Years | 5.3 (4.4, 6.2) |
8.4 (6.2, 10.6) |
8.4 (6.9, 9.8) |
5.9 (4.8, 7.0) |
| % (95% CI) |
% (95% CI) |
% (95% CI) |
% (95% CI) |
|
| Relationship status | ||||
| Married | 8.5 (5.9, 11.9) |
35.2 (25.7, 46.0) |
22.1 (16.4, 29.1) |
32.1 (26.1, 38.7) |
| Civil union | 5.2 (3.2, 8.5) |
0.9 (0.2, 3.6) |
8.2 (4.8, 13.6) |
2.8 (1.0, 7.7) |
| Partnered, living together | 26.7 (20.9, 33.5) |
7.3 (3.5, 14.8) |
27.3 (20.3, 35.7) |
16.8 (12.2, 22.7) |
| Partnered, not living together | 12.2 (8.2, 17.9) |
11.7 (5.3, 23.6) |
14.2 (9.3, 21.2) |
15.8 (11.0, 22.2) |
| Single, dating | 5.3 (3.4, 8.3) |
2.2 (.8, 5.8) |
7.3 (3.9, 13.3) |
7.0 (4.1, 11.7) |
| Single, not dating | 42.1 (35.8, 48.6) |
42.8 (31.7, 54.7) |
20.9 (15.2, 27.9) |
25.5 (19.6, 32.5) |
| Sexual activity in the last 30 days | ||||
| None | 12.0 (8.1, 17.4) |
11.0 (5.3, 21.5) |
29.0 (22.3, 36.6) |
13.8 (9.9, 18.9) |
| Solo only | 31.1 (25.2, 37.7) |
40.5 (29.6, 52.4) |
23.6 (17.2, 31.6) |
20.6 (15.5, 56.9) |
| Partnered ± Solo | 56.9 (50.2, 63.4) |
48.6 (37.4, 59.9) |
47.5 (39.4, 55.7) |
65.6 (58.7, 71.9) |
| Dating partner(s) | ||||
| 1 or more men | 100 | 22.5 (1, 91.3) |
3.3 (0.3, 27.5) |
64.0 (33.9, 86.0) |
| 1 or more women | 48.4 (4.0, 95.4) |
96.8 (72.3, 99.7) |
4.9 (0.5, 33.8) |
|
| Both men and women | 29.1 (1.1, 93.7) |
31.1 (11.0, 62.2) |
||
| Relationship partner | ||||
| Male | 93.2 (83.5, 97.5) |
26.5 (15.1, 42.3) |
84.1 (76.3, 89.7) |
|
| Female | 6.7 (2.6, 16.5) |
73.5 (57.7, 84.9) |
100 | 15.9 (10.3, 23.7) |
| Anxiety (“In the past 7 days, my worries overwhelmed me”) | ||||
| Never | 38.6 (32.6, 45.0) |
30.4 (22.3, 40.1) |
40.9 (33.4, 50.0) |
21.0 (16.1, 27.1) |
| Rarely | 24.4 (19.5, 30.4) |
38.1 (27.5, 50.0) |
30.9 (23.7, 39.1) |
25.0 (19.5, 31.4) |
| Sometimes | 26.9 (21.0, 33.7) |
20.0 (11.9, 31.4) |
19.2 (13.3, 26.9) |
34.0 (27.5, 41.2) |
| Often/always | 10.1 (6.4, 15.7) |
11.5 (5.1, 24.1) |
9.0 (5.5, 14.4) |
20.0 (14.5, 57.0) |
| Overall health (“In general, would you say your health is …”) | ||||
| Excellent | 12.4 (8.5, 17.6) |
17.6 (10.3, 28.3) |
9.8 (5.6, 16.5) |
7.0 (4.0, 12.2) |
| Very good | 43.6 (37.2, 50.3) |
25.2 (17.7, 34.6) |
46.1 (38.2, 54.1) |
33.1 (26.9, 40.0) |
| Good | 29.5 (24.0, 35.7) |
37.3 (26.8, 49.1) |
31.7 (24.4, 40.0) |
38.5 (31.9, 45.6) |
| Fair | 12.5 (8.7, 17.6) |
18.4 (10.4, 30.3) |
11.5 (7.3, 17.9) |
18.7 (13.3, 25.5) |
| Poor | 2.1 (1.1, 3.9) |
1.6 (0.5, 4.6) |
1.0 (0.3, 3.2) |
2.7 (1.3, 5.6) |
| Race/ethnicity | ||||
| Non-Hispanic (NH) White | 66.0 (59.0, 72.3) |
75.1 (64.0, 83.6) |
70.3 (62.1, 77.4) |
67.7 (60.4, 74.3) |
| NH Black | 10.2 (6.3, 16.0) |
9.4 (4.3, 19.4) |
12.4 (7.3, 20.3) |
12.8 (8.0, 20.1) |
| NH Other | 4.5 (2.6, 7.6) |
3.0 (0.8, 9.7) |
0.6 (0.1, 2.6) |
1.1 (0.4, 3.1) |
| Hispanic | 15.0 (10.6, 20.8) |
7.1 (3.5, 13.7) |
13.6 (9.0, 19.9) |
14.0 (9.9, 19.5) |
| NH 2+ races | 4.4 (2.1, 9.3) |
5.5 (1.9, 14.6) |
3.2 (1.6, 6.3) |
4.3 (2.3, 7.8) |
| Education | ||||
| Less than High School | 9.2 (4.8, 16.2) |
8.6 (2.8, 23.6) |
5.1 (1.61, 15.2) |
8.6 (4.3, 16.3) |
| High school | 16.2 (11.3, 22.7) |
26.1 (16.4, 38.9) |
15.3 (9.5, 23.8) |
26.0 (19.5, 33.9) |
| Some college | 29.6 (24.2, 35.6) |
38.6 (28.5, 49.6) |
35.0 (27.8, 42.9) |
38.9 (32.5, 45.7) |
| College + | 45.0 (38.8, 51.4) |
26.7 (19.2, 35.9) |
44.5 (36.9, 52.4) |
26.5 (21.6, 32.1) |
| Employment | ||||
| Working | 65.8 (59.4, 71.7) |
58.2 (46.5, 69.0) |
69.4 (61.5, 76.3) |
61.0 (53.6, 68.0) |
| Disabled/retired | 19.6 (15.7, 24.0) |
23.2 (16.0, 32.5) |
20.9 (15.6, 27.4) |
12.9 (8.6, 19.0) |
| Not working | 14.7 (9.9, 21.1) |
18.6 (9.8, 32.3) |
9.7 (5.3, 17.4) |
26.1 (19.9, 33.3) |
Living with a partner and civil union were significantly associated with sexual satisfaction and orgasm pleasure in bivariable analyses but were no longer significant when entered into the multivariable model. This occurred among gay men, lesbian women, and bisexual women for satisfaction and among bisexual men and lesbian women for orgasm pleasure.
Table 2 presents multivariable models for sexual health outcome variables by gender and sexual orientation. Sexual activity results were consistent across group and sexual function outcome. Partnered/solo activity was associated with higher sexual function (interest, satisfaction, and orgasm) compared with either solo-only or no activity ranging from 5 to 15 points (p < 0.05 to p < 0.01).
Table 2.
Multivariable Models for PROMIS Sexual Interest, Satisfaction and Orgasm Pleasure Sores in Gay and Bisexual Men and Lesbian and Bisexual Women
| Interest |
Satisfaction |
Orgasm Pleasure |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Gay men | Bisexual men | Lesbian women | Bisexual women | Gay men | Bisexual men | Lesbian women | Bisexual women | Gay men | Bisexual men | Lesbian women | Bisexual women | |
| Regression coefficients (95% confidence intervals) | ||||||||||||
| Relationship status | ||||||||||||
| Single, not dating | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) |
| Married | –2.3 | 4.3 | 4.9* | 4.9* | –6.7* | |||||||
| (–9.1, 4.4) | (–1.3, 10.0) | (.31, 9.4) | (.04, 9.7) | (–12.7, −0.75) | ||||||||
| Civil union | –3.3 | 5.4 | –1.0 | 7.1 | 3.6 | 3.1 | 6.0* | –4.9 | 3.1 | 10.1** | ||
| (–8.9, 2.3) | (–7.9, 18.6) | (–6.4, 4.3) | (–.69, 14.8) | (–1.0, 8.2) | (–3.1, 9.3) | (.01, 12.1) | (–11.1, 1.3) | (–6.6, 12.7) | (4.5, 15.8) | |||
| Living w/ partner | –2.8 | 8.2 | 1.8 | 10.9** | 2.8 | –0.6 | 4.2 | 5.4 | –5.6* | 2.6 | 6.9 | 1.5 |
| (–7.2, 1.5) | (–2.1, 18.6) | (–3.3, 6.9) | (4.8, 16.9) | (–.6, 6.2) | (–10.0, 8.8) | (–.4, 8.8) | (–.2, 10.9) | (–10.0, −1.2) | (–7.1, 12.3) | (–.9, 14.7) | (–3.8, 6.7) | |
| Not living w/ partner | –2.6 | 6.3** | 11.0** | 6.0* | 7.8** | 5.1* | –2.8 | 7.4 | –1.8 | |||
| (–6.4, 1.2) | (1.6, 11.1) | (5.6, 16.3) | (1.2, 10.9) | (3.3, 12.3) | (.6, 9.6) | (–8.0, 2.3) | (–.4, 15.2) | (–7.4, 3.8) | ||||
| Single, dating | –1.2 | 13.2* | 5.9 | 12.6** | 3.5* | 1.4 | –0.5 | 4.1* | –1.1 | 9.1** | –0.7 | 0.01 |
| (–6.3, 4.0) | (1.2, 25.2) | (–.7, 12.5) | (7.7, 17.5) | (.2, 6.8) | (–10.9, 13.7) | (–5.6, 4.5) | (.02, 8.2) | (–5.1, 2.9) | (3.0, 15.1) | (–9.3, 7.9) | (–4.3, 4.3) | |
| Sexual activity | ||||||||||||
| None | (ref) | (ref) | (ref) | (ref) | ||||||||
| Solo only | 8.7** | 12.7** | 12.3** | 7.4* | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) |
| (3.3, 14.2) | (5.0, 20.4) | (8.6, 16.1) | (.7, 14.0) | |||||||||
| Partnered/solo | 14.1** | 12.6** | 14.8** | 11.8** | 5.9** | 7.3** | 9.4** | 7.9** | 5.1** | 7.4* | 1.5 | 5.7** |
| (9.1, 19.1) | (4.6, 20.7) | (11.7, 17.8) | (5.9, 17.8) | (3.7, 8.0) | (3.4, 11.2) | (6.2, 12.6) | (4.9, 10.9) | (2.2, 7.9) | (1.7, 13.2) | (–3.4, 6.4) | (2.8, 8.5) | |
| Relationship years | 0.2 | –0.5 | –0.04 | –0.8** | –0.1 | 0.4 | –0.4* | –0.5 | 0.6** | 0.3 | –0.3 | –0.5 |
| (–0.3, 0.7) | (–1.2, 0.2) | (–0.5, 0.4) | (–1.3, −0.3) | (–0.4, 0.3) | (–0.008, 0.8) | (–0.8, −0.02) | (–1.1, 0.1) | (0.2, 1.0) | (–0.4, 0.9) | (–0.9, 0.4) | (–1.2, 0.2) | |
| Relationship years2 | –0.01 | 0.01 | –0.001 | 0.02* | –0.0003 | –0.01* | 0.01* | 0.01 | –0.02** | –0.01 | 0.01 | 0.02 |
| (–0.02, 0.004) | (–0.003, 0.02) | (–0.01, 0.01) | (0.002, 0.03) | (–0.01, 0.01) | (–0.01, −0.001) | (0.002, 0.02) | (–0.007, 0.03) | (–0.02, −0.006) | (–0.02, 0.004) | (–0.01, 0.03) | (–0.005, 0.04) | |
| Anxiety | ||||||||||||
| Never | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) | (ref) |
| Rarely | –2.1 | –1.0 | –0.4 | 0.6 | –2.7* | –6.3** | –2.6 | –1.3 | –3.8** | –5.8** | –1.0 | 0.2 |
| (–5.1, 1.0) | (–7.6, 5.6) | (–3.4, 2.5) | (–3.3, 4.4) | (–4.8, −0.6) | (–9.1, −3.4) | (–5.3, 0.2) | (–4.3, 1.7) | (–6.5, −1.1) | (–10.1, −1.4) | (–4.8, 2.7) | (–2.9, 3.2) | |
| Sometimes | –3.2* | 0.03 | –0.1 | –3.1 | –3.8** | 1.9 | –1.9 | –3.3* | –4.0* | –4.4 | 1.3 | –2.1 |
| (–6.5,–.03) | (–6.7, 6.8) | (–3.5, 3.4) | (–6.8, 0.55) | (–6.3, −1.3) | (–6.4, 10.2) | (–5.1, 1.2) | (–6.5, −0.18) | (–7.0, −0.94) | (–11.0, 2.1) | (–3.4, 6.0) | (–5.8, 1.6) | |
| Often/always | –7.5* | –2.7 | 1.6 | 0.7 | –7.6** | –8.1** | –0.7 | –3.0 | –5.8* | –3.8 | –6.4 | –0.4 |
| (–14.7, −0.4) | (–17.8, 12.3) | (–2.7, 5.8) | (–4.2, 5.6) | (–11.6, −3.6) | (–12.9, −3.2) | (–4.7, 3.2) | (–6.9, 0.8) | (–10.2, −1.4) | (–9.2, 1.7) | (–14.7, 2.0) | (–4.4, 3.6) | |
| Constant | 40.3** | 32.6** | 29.8** | 33.5** | 43.4** | 44.5** | 40.3** | 42.7** | 49.1** | 43.8** | 44.6** | 45.5** |
| Observations | 382 | 137 | 200 | 259 | 344 | 123 | 134 | 215 | 335 | 119 | 129 | 205 |
| R 2 | 0.230 | 0.218 | 0.467 | 0.323 | 0.321 | 0.379 | 0.477 | 0.255 | 0.167 | 0.386 | 0.171 | 0.153 |
Note. Regression coefficients with 95% confidence intervals reported in parentheses. Unstandardized betas are used because PROMIS SexSF scores are already on a standardized scale.
*p < 0.05. **p < 0.01. Significant associations are bolded.
Among gay men, those married, cohabitating, and dating reported higher sexual satisfaction compared with those who were not dating (p < 0.05). Married and cohabitating gay men reported lower orgasm pleasure than those not dating (>5 points; p < 0.05). Longer relationships were associated with more orgasm pleasure up to 21 years (p < 0.01), after which longer time in the relationship was associated with less orgasm pleasure. Increased anxiety was associated with less orgasm pleasure (p < 0.05 to p < 0.01). Gay men with anxiety had lower sexual interest compared with those with no anxiety (p < 0.05). Anxiety symptoms were associated with less satisfaction (p < 0.05 to p < 0.01).
Bisexual men who were single and dating had much higher interest in sexual activity (13 points) compared with those not dating (p < 0.05). Dating was associated with more orgasm pleasure compared with not dating (9 points; p < 0.01). Anxiety symptoms were associated with less satisfaction compared with reporting no anxiety (p < 0.01).
Lesbian women who were partnered but not living together reported more interest in sexual activity than those who were single and not dating (6 points; p < 0.01). Relationship length and anxiety were not associated with interest in sexual activity. Married lesbian women (5 points; p < 0.05), as well as those partnered but not living together (8 points; p < 0.01), reported higher sexual satisfaction compared with those not dating. Longer relationships were associated with less sexual satisfaction up to 18.5 years (p < 0.05), after which longer relationships were associated with more sexual satisfaction. Anxiety was not associated with sexual satisfaction. Neither relationship status, relationship length, sexual activity, nor anxiety symptoms were associated with lesbian women’s orgasm pleasure.
Bisexual women in relationships or dating reported more sexual interest than those not dating (p < 0.01). Longer relationships were associated with less sexual interest up to 27 years (p < 0.05), after which longer relationships were associated with more sexual interest. Bisexual women in a civil union, partnered not living together, and dating reported more sexual satisfaction than those single, not dating (p < 0.05). Relationship length was not associated with satisfaction. Cohabitating was the only relationship category related to orgasm pleasure for bisexual women, with an average 10 points higher compared with those single, not dating (p < 0.01). Length of relationship and anxiety were not associated with orgasm pleasure. Anxiety was not associated with interest. Reporting anxiety “sometimes” was associated with lower satisfaction compared to never (p < 0.05).
Discussion
Using a large, nationally representative sample of LGB men and women, we found differences between groups in factors related to sexual function and satisfaction by gender and sexual orientation. Differences ranged in magnitude, but many were one half standard deviation to over 1 standard deviation, indicating large differences that are likely to be clinically relevant (Cohen, 1988).
Our results provide evidence for using relationship status, which is often known in clinical settings and recorded in the medical record, as a potential indicator of sexual satisfaction among LGB patients. Relationship status was associated with sexual satisfaction for gay men and lesbian and bisexual women after controlling for relationship length and type of sexual activity. The lack of significant correlation between sexual satisfaction and length of relationship among gay men may be due to shorter relationships and higher rate of unmarried status in the present sample compared to lesbian or bisexual individuals. Lesbians have reported the lowest levels of sexual satisfaction in the context of casual sex compared with gay men who reported the most sexual satisfaction within casual sex contexts (Mark et al., 2015). Gay men and lesbian women who were partnered but did not live with their partner had the highest levels of sexual satisfaction compared to other relationship statuses, potentially indicating that co-habitation affects the degree of sexual joy for those individuals.
Overall, length of relationship years was inconsistently related to sexual function and satisfaction across different LGB groups. The nonlinear relationship between years in a relationship and sexual satisfaction in lesbians aligns with previous findings of heterosexual women (Heiman et al., 2011). Relationship status was most associated with orgasm pleasure for gay men. Although it may appear somewhat contradictory that married gay men have less orgasm pleasure but more sexual satisfaction, this may be the result of satisfactory intimacy in the relationship despite age-related decline in sexual function. Gay men’s average relationship length in the current study was shorter than the other groups, and there was a curvilinear association between relationship length and orgasm pleasure, possibly related to declining health status or age-related sexual dysfunction (Lindau et al., 2007).
Similar to a study conducted in Sweden (Björkenstam et al., 2017), we found bisexual women to have more anxiety compared with other LGB groups. We did not find statistically higher rates of anxiety symptoms among gay men compared with lesbian women, as reported elsewhere (Calvillo et al., 2020). Unlike these comparative studies, we examined the association between anxiety symptoms and sexual function and satisfaction across LGB groups. For lesbian women in the present sample, anxiety symptoms were not associated with interest, satisfaction, or orgasm, whereas for gay men, anxiety symptoms were associated with all three sexual function outcomes. For both bisexual men and women, anxiety symptoms were associated with satisfaction but not interest or orgasm. The results for the relationship of anxiety with sexual function and satisfaction across groups was somewhat unexpected, particularly the lack of association in lesbian women, and more research is needed to parse out these differences and what it might mean for clinical interventions. These findings are unique, because contemporary studies describing associations of mood with sexual function either used composite measures of psychological symptoms or did not separate LGB groups for analysis (del Mar Sánchez-Fuentes & Sierra, 2015; Tracy & Junginger, 2007).
Strengths and limitations
Our study has several limitations. The results of this study are based on a cross-sectional survey, and therefore no causal conclusions can be drawn. The data was collected in 2014, 12 months before the U.S. Supreme Court’s Obergefell v. Hodges (2015) ruling. Social changes over the years with respect to the legalization of same sex marriage and limits on LGBTQ rights and protections have changed the experiences of LGB people. It will be important to repeat research on anxiety, relationship status, and sexual function and satisfaction in a more contemporary sample of LGB people to assess how legal and social changes have influenced these important outcomes over time.
Because of a high correlation with relationship length, our models did not include participant age. Age-related decline in sexual function, health limitations of the individual or their partner, or loss of a partner would affect measures of sexual function and satisfaction, and must be accounted for in results interpretation (Arthur et al., 2021). Prevalence of sexual activity declines with age, particularly for women, and nearly half of older men and women reported at least one bothersome sexual problem (Lindau et al., 2007). Age-related changes in sexual function and satisfaction have not been studied in LGB people.
Although our measures of anxiety and depression were drawn from the high-quality PROMIS item banks, use of single items limit the variability we could observe. Despite these limitations, the models explained 17–48% of the variance in the sexual function outcomes, is one of the few studies to use a national probability-based sample that included bisexual men and women in addition to gay men and lesbian women and use a measure that references sexual activity broadly instead of referring to heteronormative sexual activities.
Conclusion
Sexual function and satisfaction are multifaceted, encompassing physical, emotional, and social factors. Similarly, sexual orientation and gender are also complex attributes experienced differently by individuals. Sexual function and satisfaction are not the same for gender groups (e.g., lesbian and bisexual women) or sexual orientation groups (e.g., bisexual men and women), and neither are the factors most associated with sexual function and satisfaction. The findings highlight differences in sexual function among sexual minority groups that should be considered when researching sexual health, within the healthcare system, or designing interventions to address sexual problems. In gay men, anxiety was associated with low sexual interest, sexual satisfaction, and orgasm pleasure. Gay men married or living together had higher sexual satisfaction, despite lower orgasm pleasure. In bisexual men, anxiety was associated with less sexual satisfaction but not interest in sex or orgasm pleasure. In general, anxiety was not associated with sexual function or satisfaction in lesbian and bisexual women. For lesbian women, those married or partnered reported more interest in sex and higher sexual satisfaction. Relationship length was associated with less interest in sex in bisexual women, but it was not associated with interest in sexual activity in lesbian women. Clinicians should assess people’s sexual health and intimate relationships as part of routine care in a way that is inclusive of all partnership types and statuses (Kamen, 2018).
Supplementary Material
Funding Statement
The original study was supported by the Research and Education Program Fund, a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin.
Disclosure statement
The authors declare that they have no conflict of interest or competing interest.
Data availability statement
The data is not publicly available but may be provided upon reasonable request.
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Supplementary Materials
Data Availability Statement
The data is not publicly available but may be provided upon reasonable request.