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. Author manuscript; available in PMC: 2026 Jun 23.
Published in final edited form as: J Affect Disord. 2025 Oct 10;393(Pt B):120389. doi: 10.1016/j.jad.2025.120389

Change in Sexual Distress during Cognitive Processing Therapy: Characterization and Baseline Predictors

Laura A Meis 1,2,3, Elizabeth Alpert 1,4, Zoë D Peterson 5, Whitney S Livingston 1,4,6, Leah Blain 7, Tara E Galovski 1,4
PMCID: PMC13284763  NIHMSID: NIHMS2118378  PMID: 41076157

Abstract

Experiences of interpersonal trauma can negatively impact survivors’ sexual wellness, including leading to increased sexual distress. Cognitive processing therapy (CPT) has been shown to reduce symptoms of posttraumatic stress disorder (PTSD), but the extent to which treatment gains extend to sexual distress is less known. We examined change in sexual distress and baseline predictors of change in sexual distress in a sample of 161 adult survivors of score models showed sexual distress significantly decreased (d = −0.79 at posttreatment; d = −0.95 at 3-month follow-up). Change in sexual distress covaried significantly with change in PTSD from pretreatment to posttreatment. We examined several potential baseline predictors of change in sexual distress during treatment. Greater pretreatment dissociation predicted poorer improvement in sexual distress during treatment. None of the following uniquely predicted change in sexual distress over time: pretreatment PTSD severity, relationship impairment with the respondent’s significant other, gender, index trauma (childhood physical assault, childhood sexual assault, or adult sexual assault vs. adult physical assault), pretreatment depression, or pretreatment posttraumatic cognitions. Findings help characterize change in sexual functioning over the course of CPT and point to dissociation as a potential negative prognostic indicator of sexual distress change during CPT.

Keywords: posttraumatic stress disorder, sexual functioning, dissociation, Cognitive Processing Therapy

Introduction

Posttraumatic stress disorder (PTSD) is a destructive mental health condition associated with numerous problems in intimate relationships, including problems with sexual health and sexual distress (Birkley et al., 2016; Kotler et al., 2000; McCall-Hosenfeld et al., 2009; Monson et al., 2009; Schnurr et al., 2009; Suvak et al., 2012). A recent meta-analysis indicated that PTSD treatments, particularly trauma-focused psychotherapies, have a moderate effect on improving relationship functioning (Sijercic et al., 2022). However, less is known about the impact of PTSD treatment on sexual health. Sexual health is a multidimensional construct that encompasses sexual functioning, sexual satisfaction, and sexual distress. It is defined as “a state of physical, emotional, mental and social well-being in relationship to sexuality; it is not merely the absence of disease, dysfunction or infirmary” (World Health Organization, 2006, p. 3). Sexual distress, the focus of the present study, refers to negative emotions associated with sexual functioning and sexuality, such as anxiety, worry, frustration, and feelings of inadequacy (Pescatori et al., 2007; Stephenson & Meston, 2010). A focus on sexual distress emphasizes one’s subjective experience of sexual health versus focusing solely on physiological function (Santos-Iglesias et al., 2018). Sexual distress is uniquely important in that it largely influences quality of life (Wagner et al., 1996), drives treatment seeking for sexual functioning difficulties (Evangelia et al., 2010), and is critical to understanding sexual dysfunction severity (Hayes et al., 2008).

Relationship Between PTSD and Sexual Health

There are multiple pathways through which PTSD likely contributes to sexual distress. For individuals with PTSD who have experienced sexual trauma, experiences of physical closeness, intimacy, and/or sexual arousal may evoke intrusive memories of prior traumas (Foa & Kozak, 1986; Steil et al., 2024). Sexual trauma and subsequent distress can condition links between later sexual acts and negative emotions (Letourneau et al., 1996), which may be negatively reinforced through avoidance of sexual activity (Kelley & Gidycz, 2017). In the case of non-sexual traumas, physical closeness or touch to certain parts of the body can trigger memories from traumatic events involving physical violence or injury (Tran et al., 2015).

Cognitive processes can also contribute to the association between PTSD and reduced sexual health (Yehuda et al., 2015). According to Barlow’s (1986) theory of sexual dysfunction, interpretations of negative sexual experiences can drive the development of maladaptive sexual self-schemas; these problematic beliefs can, in turn, affect information processing of future sexual experiences, producing further negative emotions (Barlow, 1986; Wiegel et al., 2005). In the case of PTSD, maladaptive schemas (e.g., physical touch is dangerous; sexual arousal is shameful) may be activated in sexual situations, creating anxiety, hypervigilance to threat, decreased attention to sexual stimuli, and reduced sexual arousal and desire. Changes in sexual response (e.g., decreased arousal, lack of orgasm) driven by these maladaptive cognitions can then create a negative feedback loop (e.g., worry lack of arousal and orgasm in future sexual interactions; Barlow, 1986; Wiegel et al., 2005), fueling their continued association. Again, even in the case of non-sexual trauma, PTSD may prompt maladaptive interpersonal cognitions (e.g., people are dangerous and cannot be trusted) that could fuel this negative feedback loop.

Impact of Cognitive Processing Therapy on Sexual Health

Overall, the documented effects of PTSD treatment broadly on sexual functioning have yielded mixed findings. In a meta-analysis of four randomized trials of PTSD treatment, O’Driscoll and Flanagan (2016) found no effect of PTSD treatment on sexual health outcomes compared to control interventions and small-to-moderate pre-post treatment pooled effects of PTSD treatment on sexual health outcomes. Importantly, effects were largest for Cognitive Processing Therapy (CPT) and Prolonged Exposure, both evidence-based, trauma-focused treatments for PTSD.

CPT (Resick et al., 2017), the focus of the present study, is a gold-standard, cognitive-behavioral therapy for PTSD. Based on cognitive theory, CPT posits that individuals with PTSD develop inaccurate and maladaptive beliefs about the meaning of the trauma (e.g., why the trauma occurred: “I was raped because I wore a short skirt.”). These maladaptive beliefs impede natural psychological recovery from trauma, and trauma survivors get “stuck” in PTSD. CPT teaches patients to identify and challenge these beliefs, or “stuck points”, and to arrive at more accurate conclusions. Although CPT does not directly target sexual health, stuck points related to intimacy, vulnerability, and sexuality may all contribute to the maintenance of both PTSD and PTSD-related sexual distress and would be a natural focus of treatment.

To the best of our knowledge, there are only three studies that have specifically examined the effects of CPT on sexual health (i.e., O’Driscoll & Flanagan, 2016; Resick et al., 2012; Wells et al., 2019). Both Wells et al. (2019) and Resick et al. (2012) found moderate to large effects (standard mean differences) of CPT on pre-to-post treatment sexual health outcomes, including reductions in sexual concerns and dysfunctional sexual behaviors and increases in sexual satisfaction and sexual arousal. A third study (Steil et al., 2024) involved a randomized controlled trial comparing CPT to Dialectical Behavior Therapy for PTSD (DBT-PTSD) among women with PTSD following child abuse. As the authors found no significant differences in female sexual dysfunction symptoms (symptoms of female sexual interest/arousal disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder) between the two treatment conditions, effects were pooled across treatment conditions. This study reported that CPT and DBT-PTSD had small and moderate effect size changes in a variety of sexual dysfunction symptoms (Steil et al., 2024). Importantly, this study differs from Resick et al. (2002) and Wells et al. (2019) in that it only assessed sexual dysfunction disorders consistent with the DSM-5 (American Psychiatric Association, 2013), using an objective structured clinical interview rather than subjective self-report instruments. This may explain the smaller effects when compared to Wells et al. (2019) and Resick et al. (2002).

Predictors of Sexual Distress Change during PTSD Treatment

Research on predictors of sexual distress change during CPT is even more limited. Identifying predictors of change in sexual distress following CPT is important to tailoring treatments to individuals’ needs. In the present study, we examined several factors that may enhance or inhibit change in sexual distress during the context of CPT. These include characteristics of the person’s experience (e.g., sexual versus non-sexual trauma) and relevant baseline clinical characteristics (i.e., baseline symptoms of PTSD, depression, negative posttraumatic cognitions, dissociation, relationship functioning). The rationale for each of these candidate predictors is reviewed below.

First, the type of trauma addressed in CPT might influence the degree of change experienced in sexual distress. Individuals who are addressing a sexual trauma within CPT might have more opportunity to directly address a maladaptive sexual schema than those addressing a non-sexual trauma (see e.g., Meston et al., 2013), and thus might experience greater sexual distress improvements. However, one study (Wells et al., 2019) evaluated trauma type as a predictor of sexual health change during CPT (i.e., sexual satisfaction, desire, and arousal) and found no significant link. Relatedly, Resick and colleagues (2003) compared the effect sizes of CPT on sexual concerns and dysfunctional sexual behavior between those with and without a childhood sexual abuse history. They found no significant differences in the size of the effect of CPT on sexual health between these two groups. Given the limited work in this area, more research is needed.

Second, PTSD and depression severity are consistent predictors of improvement in PTSD following treatment (Dewar et al., 2019). Given robust associations between PTSD symptoms and sexual function, smaller changes in PTSD severity during treatment and/or more severe baseline PTSD symptoms may predict attenuated change in sexual distress during CPT. In two prior studies, improvement in PTSD symptoms predicted improvement in sexual functioning among those receiving CPT (Steil et al., 2024; Wells et al., 2019). Wells et al. (2019) also considered the role of baseline PTSD symptom severity, finding baseline PTSD severity did not predict sexual health change, controlling for PTSD changes during treatment. To the best of our knowledge, the role of depression severity in predicting change in sexual health during CPT has not been examined. However, baseline depression has been linked to poorer improvement in interest in sex following Prolonged Exposure (Badour et al., 2020).

Third, negative posttraumatic cognitions are likely a shared driver of both PTSD severity and sexual distress; therefore, the baseline severity of these negative cognitions may influence the effectiveness of CPT on improving sexual distress. To the best of our knowledge, this has yet to be tested in published research.

Fourth, baseline dissociative symptoms may impair improvements in sexual distress following PTSD treatment. Dissociation refers to a “disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (American Psychiatric Association, 2013). In treatment for PTSD, dissociative symptoms are theorized to inhibit recovery through preventing memory consolidation and impairing emotional information processing (Lanius et al., 2010). With sexual distress, severity of baseline dissociative symptoms may prevent an individual from being fully present during sexual activities, prevent one from feeling connected to one’s partner or oneself during sex, and/or promote numbness to physical touch (Gewirtz-Meydan & Godbout, 2023). This may interfere with the ability to apply learning from CPT to sexual encounters and experiences. To our knowledge, no prior published studies have examined baseline dissociation as a predictor of change in sexual distress during CPT.

Finally, relationship adjustment or quality at the time of treatment entry is a natural candidate for predicting improvements in sexual distress during treatment. Relationship adjustment predicts treatment response in psychotherapy for sexual difficulties, generally (Hummel et al., 2018; Stephenson et al., 2013). Sexual distress may be less responsive to change in a PTSD treatment in the context of a relationship that is less well-adjusted at baseline. To our knowledge, there is also no published work examining relationship quality as a predictor of sexual distress change during CPT.

The Current Study

The objectives of the present study were to examine sexual distress changes during CPT and to identify baseline predictors of change in sexual distress. We assessed sexual distress at pretreatment, posttreatment, and 3-month follow-up among individuals participating in a randomized controlled trial of CPT. We examined whether reductions in PTSD symptom severity were associated with improvements in sexual distress. We also examined several potential baseline predictors of change in sexual distress during CPT, including index trauma type and clinical characteristics (i.e., severity of baseline PTSD, depression, maladaptive posttraumatic cognitions, dissociation, and relationship adjustment).

Method

Data were extracted from two randomized controlled trials examining the efficacy of CPT among civilians with PTSD related to interpersonal violence (i.e., sexual or physical assault; Galovski et al., 2012; 2016) that were part of a repository of trials (Galovski et al., 2021). Participants were recruited from the St. Louis area with advertisements, word-of-mouth, and referrals. These studies were approved by the University of Missouri—St. Louis Institutional Review Board, with secondary data analysis approved by Boston VA’s Institutional Review Board. See Galovski et al. (2012) and Galovski et al. (2016) for more information.

Participants

Participants included 161 adults with PTSD randomized to either CPT or crossed over to CPT after being randomized to 10 weeks of symptom-monitoring (69 participants from Galovski et al., 2012; 92 participants from Galovski et al., 2016). Participants were included if they were at least 18 years old, stable for at least a month on psychotropic medications, and received a diagnosis of PTSD secondary to sexual or physical assault. Participants were excluded if their traumatic event(s) occurred less than 3 months prior to initial study assessment, they were currently being stalked or engaged in an abusive relationship, or they were currently experiencing psychosis, mania, active suicide risk, or drug or alcohol dependence. One study required participants to have a clinically significant sleep impairment (Galovski et al., 2016).

Demographic characteristics (age, sex, marital status, race, ethnicity, education, income, trauma type) are presented in Table 1. The sample was mostly female (85.7%) and relatively low-income (68.5% made <$20,000 per year). Half (49.7%) identified as White, and 46.6% identified as African American or Black. The most common index trauma (i.e., traumatic event that was the focus of therapy) was childhood sexual assault (N = 65, 40.4%), followed by adult sexual assault (N = 39, 24.2%), adult physical assault (N = 36, 22.4%). The least common was childhood physical assault (N = 18, 11.4%). The majority of patients identified lifetime experience with each of the categories (56.5% for both childhood physical assault and adult sexual assault, 65.5% for adult physical assault, and 67.7% for childhood sexual assault). On average, participants’ index event occurred 16.93 years prior (SD = 15.12); 101 participants (62.7%) completed treatment, 112 (69.6%) completed the posttreatment assessment, 121 (75.2%) completed the 3-month follow-up. Participants in Galovski et al. (2012) were considered to have completed treatment when they achieved good end state functioning (operationalized as loss of PTSD diagnosis, PDS scores < 20 and BDI-II < 18) or completion of maximum of 18 sessions. Participants in Galovski et al. (2016) were considered to have completed treatment when they completed the 12 sessions of CPT.

Table 1.

Demographic Characteristics for the Sample (N = 161).

Characteristic M (SD) or N (%)
Age 38.44 (11.73)
Sex
Female 138 (85.7%)
Male 22 (13.7%)
Marital status
Single 87 (54.0%)
Cohabitating 5 (3.1%)
Married 23 (14.3%)
Separated 15 (9.3%)
Divorced 26 (16.1%)
Widowed 4 (2.5%)
Race
African American or Black 75 (46.6%)
American Indian or Alaska Native 1 (0.6%)
Asian 1 (0.6%)
White 80 (49.7%)
Another Race 3 (1.9%)
Ethnicity
Hispanic or Latino 8 (5.0%)
Not Hispanic or Latino 143 (88.8%)
Years of education 13.76 (2.89)
Annual income
<$5000 49 (30.4%)
$5,001–10,000 27 (16.8%)
$10,001–20,000 34 (21.1%)
$20,001–30,000 11 (6.8%)
$30,001–50,000 21 (13.0%)
>$50,000 16 (9.9%)
Index      Lifetime
Childhood sexual assault 65 (40.4%)   109 (67.7%)
Childhood physical assault 18 (11.2%)   91 (56.5%)
Adult sexual assault 39 (24.2%)   91 (56.5%)
Adult physical assault 36 (22.4%)   106 (65.8%)
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Note. Percentages do not add up to 100 due to missing data or multiple lifetime traumas endorsed. Lifetime = endorsed any history of that type of trauma. Index = selected a trauma of that type to work on in therapy.

Procedure

Both RCTs were conducted in the same clinic and similar methodologically in recruitment, location, sample type, administration of CPT, therapist training, and outcome measures. Both trials included assessments at baseline, 2-week posttreatment, and 3-month follow-up. The first study (Galovski et al., 2012), randomized women and men to either a 1) modified cognitive processing therapy (MCPT) condition, designed to allow for more flexibility in session number by allowing anywhere from 4 to 18 possible sessions, or 2) symptom-monitoring delayed treatment (SMDT). Around half of the participants (n = 25) in the SMDT condition were crossed over to MCPT following symptom monitoring for 10 weeks. The second study (Galovski et al., 2016), randomized women with sleep impairment to either 1) sleep-directed hypnosis + CPT or 2) symptom monitoring + CPT. Between the two active treatment conditions there were no significant differences on any primary outcomes; thus, the current study combines participants from Galovski et al. (2016) in both CPT conditions. Across both studies, participants attended an average of 7.83 CPT sessions (SD = 5.47, range 0–18).

Measures

Sexual Distress.

The Sexual Distress Scale (SDS) is a 12-item, unidimensional scale assessing sexual distress in the past 30 days. Items assess how often the respondent has been bothered by feelings or problems related to sexual health (e.g., “distressed about your sex life,” “dissatisfied with your sex life”) on a 0 (never) to 4 (always) scale. Item responses are summed, and higher sores indicate greater sexual distress (range = 0 – 48). Scores discriminate between those with and without sexual dysfunction, using a cut-off of 18.5 or higher for men (Santos-Iglesias et al., 2018) and 15 or higher for women (DeRogatis et al., 2008; Derogatis et al., 2002). The scale demonstrates good criterion and content validity and test-retest reliability (Derogatis et al., 2002; Santos-Iglesias et al., 2018). It also is sensitive to change in treatment (DeRogatis et al., 2008). In the present sample, the SDS had good internal consistency at pretreatment (Cronbach’s α = .96), posttreatment (α = .97), and 3-month follow-up (α = .97).

Trauma Type.

Index trauma was assessed using the clinician-administered Trauma Interview adapted from Resick et al. (2008). Participants were asked about a number of prior potentially traumatic events and asked to identify which prior event is most related to their PTSD symptoms. Participants’ index events were categorized into childhood sexual assault, childhood physical assault, adult sexual assault, or adult physical assault.

PTSD Severity.

The Clinician-Administered PTSD Scale (CAPS, Blake et al., 1995) is a 22-item gold-standard, diagnostic structured clinical interview for PTSD, based on the DSM-IV criteria (American Psychiatric Association, 2000). Items evaluate each of the 17 DSM-IV symptoms of PTSD on a 5-point scale. Each symptom is evaluated separately for frequency ranging from 0 (never) to 4 (daily or almost daily) and intensity ranging from 0 (none) to 4 (extreme). PTSD severity can be scored through summing frequency and severity scores. The instrument demonstrates excellent validity and reliability (e.g., Weathers et al., 2001). In the present sample, Cronbach’s α = .83 at pretreatment and .88 at posttreatment.

All CAPS interviewers were trained by senior study staff with expertise in administering this instrument. Training consisted of rating CAPS using training tapes util interviewers reached diagnostic reliability with experts. Initial interviews were then supervised and rated, and all subsequent CAPS interviews were recorded. After reliability was established, audiotapes were continually reviewed by senior staff, and interviewers met weekly to maintain reliability, prevent drift, discuss diagnostic issues, and reconcile any diagnostic inconsistencies. Interrater reliability was excellent in both trials (CAPS kappa for current diagnosis was 1.00 in both studies).

Depression Symptom Severity.

The Beck Depression Inventory–II (BDI-II; Beck et al., 1996) assesses depression via 21 self-report items. Items are rated on a 4-point scale and summed. Higher total values indicate more severe symptoms of depression. The instrument has excellent validity and reliability (Beck et al., 1996; Dozois et al., 1998). In the present sample, Cronbach’s α = .89 (pretreatment).

Maladaptive PTSD-Related Cognitions.

The Posttraumatic Cognitions Inventory (PTCI, Foa et al., 1999) is a widely used 36-item self-report questionnaire designed to assess trauma-related beliefs about one’s self, about the world, and related to self-blame. Its psychometrics have been evaluated across numerous populations, including those with trauma histories both with and without PTSD (Foa et al., 1999; Lu et al., 2023). For the present study, we used the total score. Higher scores indicate greater agreement with maladaptive trauma-related cognitions. In the present sample, Cronbach’s α = .95 (pretreatment).

Relationship Adjustment.

The Significant Other subscale from the Social Adjustment Scale (SAS; Weissman, 1976) was used to measure relationship adjustment. The SAS is a self-report scale that evaluates expressive or instrumental role performance across multiple domains. Items are rated on a 5-point scale, with higher ratings meaning greater impairment. The scale has established reliability and validity, demonstrates good agreement with collateral and interview reports, and is sensitive to change in treatment (Edwards et al., 1978; Weissman, 1976). The Significant Other subscale assesses self-reported performance in one’s role as an intimate partner, with higher scores indicating greater role impairment. Items that are not relevant to the participant can be skipped, so participants who did not have a significant other would not have a score for this subscale. In the present sample, Cronbach’s α = .75 (pretreatment).

Severity of Dissociation.

The Dissociation Subscale from the Trauma Symptom Inventory (TSI) was used to measure the severity of dissociative symptoms. The TSI (Briere, 1995) is a 100-item self-report instrument that evaluates a range of trauma-related symptoms, such as dissociation (9 items). Items are assessed on a 3-point scale ranging from 0 (never) to 3 (often), with higher total scores indicating more severe dissociation. The TSI successfully differentiates between individuals with and without PTSD and demonstrates good reliability and validity (Briere et al., 1995; McDevitt-Murphy et al., 2005). The dissociation scale evaluates dissociative experiences including depersonalization, derealization, cognitive disengagement, and emotional numbing. In the present sample, Cronbach’s α = .83 (pretreatment).

Data Analytic Plan

Descriptive statistics were conducted in SPSS version 29. Structural equation modeling was conducted in R version 4.3.1 using the lavaan package. Missing data were handled using maximum likelihood estimation to produce unbiased estimates using all available data, in order to account for missing data due to therapy attrition and assessment attrition. We identified correlates of therapy and posttreatment assessment noncompletion. However, the size of the subsample of who did not complete therapy was insufficient to support separate analyses for this group.

A paired sample t-test was conducted to examine change in sexual distress from pretreatment to posttreatment and Cohen’s d was calculated to examine the effect size of change. These analyses were repeated to examine change in sexual distress from pretreatment to 3-month follow-up. Sexual distress levels at posttreatment and follow-up were also examined to see what percentage of the sample had scores above the cutoff for dysfunction.

Structural equation modeling was used to model whether latent change in sexual distress from pretreatment to posttreatment significantly covaried with latent change in PTSD symptoms across the same time period. Latent change scores were used to model error-free change across the two time points using all available data (Castro-Schilo & Grimm, 2018). All latent change scores included the regression path in which the pretreatment score predicted (rather than correlated with) the latent change score, as including this regression path improved model fit.

For the main analysis, structural equation modeling was used to estimate a regression in which the dependent variable was latent change in sexual distress from pretreatment to posttreatment. The latent change score in sexual distress was regressed on baseline predictors, including self-reported gender as a covariate (coded 0 = male, 1 = female) and three dummy-coded variables reflecting the participant’s index trauma type (childhood sexual assault, childhood physical assault, and adult sexual assault, coded 0 = no, 1 = yes; the reference category was adult physical assault). Baseline predictors also included pretreatment dissociation, relationship functioning with one’s significant other, depression symptoms, PTSD symptoms, and maladaptive posttraumatic cognitions.

Results

Descriptive Analyses and Treatment Effect Sizes

Means, standard deviations, ranges, and correlations among study variables are provided in Table 2. Of note, three baseline variables were associated with lower likelihood of completing both therapy and the posttreatment assessment: higher dissociation (r = −.29, p < .01 treatment completion, r = −.28, p < .01 assessment completion), higher relationship functioning impairment (r = −.28, p < .05 treatment completion, r = −.29, p < .05 assessment completion), and higher PTSD severity (r = −.27, p < .01 treatment completion, r = −.27, p < .01 assessment completion).

Table 2.

Descriptive Statistics and Correlations among Variables of Interest

Female TSI-DS SAS-SO BDI-II PTCI CAPS pre CAPS post SDS pre SDS post SDS f/u
Female -
TSI-DS −.25** -
SAS-SO .07 .26 -
BDI-II .02 .32*** .41*** -
PTCI .05 .31** .18 .38*** -
CAPS pre .00 .30** .25* .42*** .25** -
CAPS post −.14 .45*** .34* .26** .30** .29* -
SDS pre .09 .18 .43*** .29*** .42*** .14 .19 -
SDS post −.01 .34*** .44** .18 .40*** .15 .49*** .62*** -
SDS f/u −.09 .34*** .23 .07 .31** .14 .35*** .63*** .83*** -
Mean or N 138 9.13 2.73 31.92 150.00 75.45 26.60 34.93 20.34 18.37
SD or % 85.7% 5.67 0.79 10.63 40.28 216.84 22.92 22.43 21.47 20.60
Range 0–1 0–23 1.44–5.11 0–58 43–252 29–119 0–108 0–80 0–80 0–77
N with data 160 113 64 153 148 158 112 146 106 119
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Note.

*

p < .05

**

p < .01

***

p < .001.

TSI-DS = pretreatment Trauma Symptom Inventory Dissociation Subscale; SAS-SO = pretreatment Social Adjustment Scale Significant Other Subscale; BDI-II = pretreatment Beck Depression Inventory–II; CAPS = pretreatment Clinician-Administered PTSD Scale Severity score; PTCI = pretreatment Posttraumatic Cognitions Inventory; SDS pre = pretreatment Sexual Distress Scale; SDS post = posttreatment Sexual Distress Scale; f/u = follow-up, SD = standard deviation.

A paired-sample t-test showed that sexual distress decreased significantly from pretreatment to posttreatment (t(96) = −7.80, SE = 1.88, p < .001, 95% CI [−18.35, −10.91]), with a medium effect size (Cohen’s d = −0.79; 95% CI [−1.02, −0.56]) and from pretreatment to 3-month follow-up (t(108) = −9.88, SE = 1.77, p < .001, 95% CI [−20.98, −13.97]), with a large effect size (Cohen’s d = −0.95; 95% CI [−1.17, −0.72]). At pretreatment, 75.2% of women and 62.5% of men had SDS scores above the cutoff for dysfunction. At posttreatment, this had decreased to 48.3% of women and 37.5% of men, and at follow-up, the same was true for 43.7% of women and 46.7% of men.

A descriptive structural equation model was estimated to examine whether latent change in sexual distress from pretreatment to posttreatment covaried with latent change in PTSD severity, using the CAPS, from pretreatment to posttreatment. The model had good fit to the data, χ2(2) = 2.34, p > .05; comparative fit index = 1.00, Tucker-Lewis Index = 1.00, root mean square error of approximation = .04, standardized root mean square residual = .05. The covariance between the two latent change scores was significant (covariance = 161.10, SE = 38.85, z = 4.15, p < .001, 95% CI [84.96, 237.24]), suggesting that participants who experienced a greater decrease in PTSD severity also tended to experience a greater decrease in sexual distress over the course of CPT.

Predictors of Change in Sexual Distress

The model including baseline predictors of latent change in sexual distress was saturated (df = 0), so fit indices were not available. When estimating a latent change score from pretreatment to posttreatment, a negative change score reflects a greater decrease in sexual distress from pretreatment to posttreatment. Thus, greater improvement in sexual distress is reflected by a more negative change score. One variable emerged as a significant predictor of latent change in sexual distress from pretreatment to posttreatment: higher pretreatment dissociation. This association was positive, reflecting that greater baseline dissociation predicted less of a decrease in sexual distress over time. Trauma type and baseline PTSD severity, depression severity, maladaptive posttraumatic cognitions, and relationship adjustment did not uniquely predict change in sexual distress. See Table 3 for detailed model results.

Table 3.

Results of Model Estimating Baseline Predictors of Latent Change in Sexual Distress from Pretreatment to Posttreatment

Predictor Estimate SE z p 95% CI Lower 95% CI Upper
Pretreatment SDS −0.29 0.17 −1.73 .084 −0.63 0.04
Female gender 4.17 8.58 0.49 .627 −12.65 20.98
CSA vs. APA −10.49 7.76 −1.35 .177 −25.70 4.73
CPA vs. APA −7.31 10.05 −0.73 .467 −27.00 12.39
ASA vs. APA −2.44 7.89 −0.31 .757 −17.90 13.02
CAPS −0.29 0.16 −1.77 .076 −0.61 0.03
BDI-II −0.02 0.23 −0.10 .923 −0.48 0.43
PTCI 0.07 0.08 0.90 .366 −0.08 0.22
SAS-SO −1.71 4.97 −0.34 .731 −11.45 8.03
TSI-DS 1.63** 0.55 2.98 .003 0.56 2.69
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Note.

**

p < .01

SE = standard error, CI = confidence interval, SDS = sexual distress scale, CSA = index trauma childhood sexual assault, APA = index trauma adult physical assault, CPA = index trauma childhood physical assault, ASA = index trauma adult sexual assault, CAPS = pretreatment Clinician-Administered PTSD Scale Severity score, BDI-II = pretreatment Beck Depression Inventory–II, PTCI = pretreatment Posttraumatic Cognitions Inventory, SAS-SO = pretreatment Social Adjustment Scale Significant Other Subscale, TSI-DS = pretreatment Trauma Symptom Inventory Dissociation Subscale. Gender was coded 0 = female, 1 = male. Trauma types were coded 0 = no, 1 = yes, and the reference category was adult physical assault.

Discussion

The current study examined changes in sexual distress among civilians with PTSD who received CPT in one of two randomized controlled trials (Galovski et al., 2021). We found that sexual distress decreased significantly across CPT, with moderate effects at posttreatment and large effects 3-months later. Reductions in PTSD were associated with improvements in sexual distress. Given CPT intervenes on PTSD by restructuring trauma-related cognitions (Resick et al., 2017), CPT may alter pathways between PTSD and sexual health by correcting maladaptive sexual schemas that lead to negative emotion when faced with sexual stimuli (Barlow, 1986). In this way, CPT may influence sexual health even though the intervention does not involve components of traditional sex therapy (e.g., sex education, behavioral homework assignments to improve sexual health). Our findings parallel the results of past CPT studies linking reductions in PTSD to improvements in sexual health (Steil et al., 2024; Wells et al., 2019). Together, these findings support the conclusion that addressing PTSD through CPT is an effective way to improve co-occurring sexual distress.

In the current study, worse dissociation at baseline was associated with less improvement in sexual distress during CPT, even when accounting for gender, trauma type, relationship functioning, depression, PTSD, and posttraumatic cognitions. Dissociation functions as a non-voluntary process for regulating emotions through avoidance and disengagement (Cavicchioli et al., 2021). Among those receiving CPT and experiencing sexual distress, dissociation can be detrimental for two reasons. First, dissociation may create a negative feedback loop when it is used during sexual activity. Those who dissociate during sexual activity may experience more shame and have more negative experiences during sex. This is supported by research linking dissociation during sex to sex-related shame, difficulty relaxing and enjoying intimacy (Chen et al., 2024), and physical reactions to trauma reminders (Kratzer et al., 2022). Negative sexual experiences may maintain dissociation in the future when these individuals engage in sexual intimacy as a way to escape negative emotions.

Second, dissociation may interfere with the effectiveness of CPT more generally. For instance, although dissociation can be protective during traumatic experiences (Chen et al., 2024), dissociation during CPT sessions or home practice exercises may impair learning and adoption of more balanced beliefs related to sexual intimacy through preventing full engagement in the therapy. Although the literature is mixed on whether dissociation affects trauma-focused treatment outcomes more generally (Haagen et al., 2018; Halvorsen et al., 2014; Resick et al., 2012; Zoet et al., 2018), past research had not examined sexual health as an outcome and, thus, may not capture the extent to which dissociation interferes with improvements in specific types of functioning.

Clinical Implications

Sexual health is an important aspect of human functioning (Bird et al., 2021; Schnurr et al., 2009; WHO, 2025), yet rarely assessed among individuals seeking therapy for mental health concerns. Trauma therapists should consider a sexual health assessment as part of their regular pre-treatment battery to invite individuals to consider how their PTSD and trauma histories have affected their sexual health. Given trauma type was not a unique predictor of sexual distress changes, these types of conversations are likely valuable for all patients, regardless of whether their trauma was sexual in nature.

As findings suggest that dissociation may be a barrier to improving sexual distress through CPT, greater clinical attention to dissociation may also be warranted. Clinicians often lack the skillset for detecting and intervening on dissociation (Boyer et al., 2022). Additional training among clinicians for recognizing, assessing, and addressing dissociation is warranted to bolster the effectiveness of CPT in improving important functional outcomes, such as sexual health (Boyer et al., 2022). Future research should examine whether change in dissociation during treatment is related to change in sexual distress, as well as how therapists might facilitate improvement in sexual distress among patients with high baseline levels of dissociation.

Additionally, couple therapists treating couples with sexual distress should consider assessing for PTSD. Even couple therapies that explicitly target sexual health do not consistently account for trauma and may attempt to target symptoms misaligned with the mechanism driving sexual health challenges for those with PTSD (Yehuda et al., 2015). For example, some sexual therapy behavioral exercises are designed to increase sexual arousal (Weiner, 2022). Such exercises are unlikely to be effective (or completed) if the client is avoidant of sensations of physiological arousal because they simulate trauma-related thoughts and feelings (Foa & Kozak, 1986; Yehuda et al., 2015). Couple therapists should consider directly treating patients with co-occurring sexual distress and PTSD with CPT to address problems in both domains. Future research should evaluate newer couple therapies that align with the cognitive-behavioral approach of CPT, such as Cognitive Behavioral Therapy for Sexual Dysfunction (Metz et al., 2017), to determine if they can effectively address co-occurring sexual distress and PTSD.

Limitations

There are several limitations of note. First, for this set of analyses, there was no comparison group. Such a design cannot confirm that CPT caused reductions in sexual distress, nor speak to how changes during CPT compare to changes with no intervention or alternative treatments. Second, sexual distress was not measured between the pretreatment and posttreatment assessments, limiting our ability to directly test if changes in PTSD preceded and predicted changes in sexual distress during treatment and/or vice versa. Future research should include multiple assessment points during treatment to understand the temporal sequence of change in sexual distress and PTSD symptoms and potential predictors of these relationships. Additionally, as all participants had experienced interpersonal violence, we cannot know to what extent these findings generalize to other trauma populations.

We identified pretreatment differences in participants who completed versus did not complete treatment and/or the posttreatment assessment. These variables were accounted for in the regression models due to their inclusion as predictors. However, due to sample size limitations, we were unable to perform sensitivity analyses to identify whether our findings held in the subsample of therapy non-completers. Because we were unable to identify whether these differences introduced bias into our results, generalization of our findings to therapy non-completers may be limited, in that the positive effects of therapy may be different among therapy non-completers.

Conclusions

The benefits of CPT extend beyond PTSD symptom reduction to other types of functional outcomes, such as reduction in sexual distress. Given the detrimental impact of PTSD symptoms and sexual distress on individuals’ lives, improvements in both of these factors can lead to meaningful changes for those with trauma histories. However, dissociation may impede improvements in sexual distress during CPT and should be assessed and accounted for by clinicians early in treatment.

Highlights:

  • CPT participants achieved moderate to large improvements in sexual distress

  • These improvements continued to grow from posttreatment to 3 months after treatment

  • Improvements in PTSD symptoms were associated with reductions in sexual distress

  • Greater baseline dissociation predicted less improvement in sexual distress

  • Dissociation may be a useful prognostic indicator for sexual distress change in CPT

Acknowledgements

This material is the result of work supported with resources and the use of facilities at the Minneapolis and Boston VA Healthcare Systems. The authors are grateful to study participants for their support and help with our research.

Footnotes

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