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The Impact of Sleep on Female Sexual Response and Behavior: A Pilot Study: Sex and Sleep

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Introduction. The etiological role of sleep disturbance in sexual difficulties has been largely overlooked. Research suggests that short sleep duration and poor sleep quality lead to poor female sexual response. However, prior research consists of cross-sectional studies, and the influence of sleep on sexual functioning and behavior has not been prospectively examined. Aims. We sought to examine the influence of nightly sleep duration, sleep quality, and sleep onset latency on daily female sexual response and activity. Methods. This study used a longitudinal design to study 171 women free of antidepressants and with reliable internet access who were recruited from a university setting in the US. Participants first completed baseline measures in a laboratory, and then completed web-delivered surveys at their habitual wake time for 14 consecutive days. Main outcome measures. All outcome measures were modified for daily recall. Participants completed the Profile of Female Sexual Function’s desire, subjective arousal, and orgasmic functioning scales, the Female Sexual Function Index’s genital arousal scale, and indicated whether they engaged in partnered sexual activity or self-stimulation in response to dichotomous items. Results. Analyses revealed that longer sleep duration was related to greater next-day sexual desire (b=.32, p=.02), and that a 1-hour increase in sleep length corresponded to a 14% increase in odds of engaging in partnered sexual activity (OR=1.14, p<.05). In contrast, sleeping longer predicted poorer next-day genital arousal (b=-.19, p<.01). However, results showed that women with longer average sleep duration reported better genital arousal than women with shorter average sleep length (b=.54, p=.03). Conclusions. Obtaining sufficient sleep is important to the promotion of healthy sexual desire and genital response, as well as the likelihood of engaging in partnered sexual activity. These relationships were independent of daytime affect and fatigue. Future directions may investigate sleep disorders as risk factors for sexual dysfunction.
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The Impact of Sleep on Female Sexual Response and Behavior:
A Pilot Study
David A. Kalmbach, PhD,* J. Todd Arnedt, PhD,* Vivek Pillai, PhD,and Jeffrey A. Ciesla, PhD
*Sleep and Circadian Research Laboratory, Department of Psychiatry, University of Michigan Medical School, Ann
Arbor, MI, USA; Sleep Disorders & Research Center, Henry Ford Health System, Detroit, MI, USA; Department of
Psychological Sciences, Kent State University, Kent, OH, USA
DOI: 10.1111/jsm.12858
ABSTRACT
Introduction. The etiological role of sleep disturbance in sexual difficulties has been largely overlooked. Research
suggests that short sleep duration and poor sleep quality lead to poor female sexual response. However, prior research
consists of cross-sectional studies, and the influence of sleep on sexual functioning and behavior has not been
prospectively examined.
Aim. We sought to examine the influence of nightly sleep duration, sleep quality, and sleep onset latency on daily
female sexual response and activity.
Methods. This study used a longitudinal design to study 171 women free of antidepressants and with reliable
Internet access who were recruited from a university setting in the United States. Participants first completed
baseline measures in a laboratory, and then completed web-delivered surveys at their habitual wake time for 14
consecutive days.
Main Outcome Measures. All outcome measures were modified for daily recall. Participants completed the Profile
of Female Sexual Function’s desire, subjective arousal, and orgasmic functioning scales and the Female Sexual
Function Index’s genital arousal scale, and indicated whether they engaged in partnered sexual activity or self-
stimulation in response to dichotomous items.
Results. Analyses revealed that longer sleep duration was related to greater next-day sexual desire (b =0.32,
P=0.02), and that a 1-hour increase in sleep length corresponded to a 14% increase in odds of engaging in partnered
sexual activity (odds ratio =1.14, P<0.05). In contrast, sleeping longer predicted poorer next-day genital arousal
(b =−0.19, P<0.01). However, results showed that women with longer average sleep duration reported better genital
arousal than women with shorter average sleep length (b =0.54, P=0.03).
Conclusions. Obtaining sufficient sleep is important to the promotion of healthy sexual desire and genital response,
as well as the likelihood of engaging in partnered sexual activity. These relationships were independent of daytime
affect and fatigue. Future directions may investigate sleep disorders as risk factors for sexual dysfunction. Kalmbach
DA, Arnedt JT, Pillai V, and Ciesla JA. The impact of sleep on female sexual response and behavior: A pilot
study. J Sex Med 2015;12:1221–1232.
Key Words. Sleep Duration; Sleep Quality; Female Sexual Response; Sexual Dysfunction; Insomnia; Sleep
Disturbance
Introduction
The biopsychosocial model of female sexual
response highlights the complexity of
the factors underlying sexual dysfunction. Prior
research has identified medical illness [1], psycho-
logical disorder [1–3], and relationship dissatisfac-
tion [4] as risk factors for sexual dysfunctions, such
as hypoactive desire or diminished sexual arousal.
Though initially studied as early as the 1960s, the
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© 2015 International Society for Sexual Medicine J Sex Med 2015;12:1221–1232
intersection of sleep and sexual functioning has
since been largely overlooked. The literature on
sleep and female sexuality is limited to a modest
number of studies on rapid eye movement (REM)
sleep and nocturnal vaginal vasocongestion from
the 1960s through mid-1980s [5–7], then more
recently on the roles of hormones in sexual function
and sleep, and sleep-disordered breathing (e.g.,
obstructive sleep apnea) as a risk factor for sexual
problems [8–10]. With growing recognition of the
morbidity associated with disordered or insufficient
sleep [11], it is surprising that the fields of sexology
and sleep medicine have paid little attention to this
area. As a step toward addressing this gap, we
examined the influence of nightly sleep on sexual
response and activity in young women.
In the 1960s, the occurrence of penile tumes-
cence during REM sleep periods became the focus
of much research, eventually aiding differential
diagnosis between psychogenic and organic causes
of erectile dysfunction [12]. These findings natu-
rally led to an interest in sleep stage-related genital
arousal changes in women. Researchers identified
sleep-related changes in nocturnal vaginal
vasocongestion such that, similar to nocturnal
penile tumescence in men, increases in vaginal
blood flow occurred during 95% of REM periods
[6,12]. However, unlike men, women experienced a
moderately high frequency of vaginal blood flow
increases during non-REM periods (66% [6]). To
this day, it remains unclear what function REM
sleep plays, if any, in human sexual response. One
theory from the 1970s, based on findings that
chronic REM sleep deprivation in laboratory
animals led to hypersexuality, proposed that REM
sleep decreases waking drive-motivated behavior,
such as appetitive sexual behavior [7,13]. This
theory, however, has not been borne out in the
literature.
More recently, Andersen and colleagues’ quali-
tative review [12] offered that neuroendocrine
reproductive control activity may mediate the
influence of sleep on human sexual response. To
support their theory, the authors attempted to
marry two literatures: (i) sex hormones (namely
androgens) and sexual behavior; and (ii) sex hor-
mones and sleep. They noted that sufficient levels
of testosterone, progesterone, and estrogen have all
been identified as important to healthy sexual func-
tion (indicated by greater desire and arousability)
and increased sexual behavior in women. Addition-
ally, the authors highlighted that sleeping increases
androgen levels, whereas waking is related to their
reduction. Therefore, they hypothesized that one
pathway from sleep loss or deprivation to impaired
sexual function may be mediated by deficient
androgen levels. They concluded their review by
emphasizing the importance of sufficient sleep
duration and sleep quality (SQ) as crucial to the
maintenance of healthy sexual functioning in men
and women.
Despite this growing body of research, a
number of gaps exist in our understanding of the
impact of sleep on female sexual response and
behavior. Though it has been hypothesized that
poor sleep duration and quality lead to greater
difficulties with sexual function [12], no studies to
date have prospectively examined this hypothesis.
Experience sampling techniques would capture
the manner in which nightly sleep experience is
related to next-day sexual functioning and behav-
ior. Additionally, though studies have demon-
strated poorer sexual response in patients with
untreated sleep-related breathing disorders (e.g.,
Köseog˘lu et al. and other authors [8–10]), it is
presently unclear if this association is directly
sleep-related or due to confounding comorbid
conditions. As such, it is important to investigate
sleep and sexual function and behavior in a rela-
tively healthy sample that is less likely to be con-
founded by medical, psychiatric, or sleep-related
illnesses or disorders.
Aims
Using a 2-week daily diary approach, we character-
ized the manner in which nightly sleep predicted
next-day sexual functioning and behavior in a
sample of young adult women. To reduce potential
confounds, we accounted for the influence of age,
oral contraceptive use, baseline severity of sexual
distress, anxiety, and depression. Additionally, as
changes in sexual activity [14] and desire [15] have
been associated with the menstrual cycle, the pres-
ence of menstruation was also examined as a pos-
sible confound. We also accounted for daily affect
and fatigue to minimize the potential confounding
influences of affect and fatigue on sleep and sexual
response. Regarding affect, we specifically focused
on affect balance, which is conceptualized as the
ratio of positive to negative affect an individual
experiences. That is, more important than how
happy or sad someone may be is how much happier
than they were sad within a certain time period.
Affect balance has been viewed as an overall
measure of psychological well-being that has
shown to be related to sexual functioning [16]. By
using repeated assessments, we aimed to capture
nightly variations in total sleep time (TST), SQ,
1222 Kalmbach et al.
J Sex Med 2015;12:1221–1232
and sleep onset latency (SOL) and their correspon-
dence to day-to-day fluctuations in desire, arousal,
genital response, and orgasmic function. We
hypothesized that nights characterized by sleep loss
(i.e., shorter TST), poorer SQ, and greater diffi-
culty initiating sleep (i.e., longer SOL) would lead
to poorer next-day sexual functioning.
Methods
Participants
Participants were recruited for a parent study
investigating the relationship between female
sexual response and mood. One hundred and
seventy-one healthy female college students were
assessed for a period of 14 days (see Table 1 for
sample characteristics). Approximately half of the
sample reported having a significant other; the
average length of the relationship was over two and
a half years, though substantial variability was
observed. Further, more than half of the sample
reported having at least one sexual partner at base-
line. A little more than half of the women in this
study reported taking some form of oral contracep-
tive. Participants were recruited from psychology
courses at a Midwestern university and received
course credit for their participation. Inclusion cri-
teria were reliable Internet access and being free of
antidepressants (to reduce medication-related iat-
rogenic effects) for at least 4 weeks prior to partici-
pation. The local institutional review board
approved this study. All women provided written
informed consent prior to participation.
Procedure
The study protocol involved a baseline assessment
and 14 daily follow-up assessments. At baseline,
participants reported demographic information
and completed questionnaires about sexual distress,
depression, and anxiety, and then received instruc-
tions on how to complete the daily, web-delivered
questionnaires. Participants were instructed to
complete all daily assessments on their home com-
puter, in private, upon waking each morning at
their habitual wake time. Questionnaires assessed
affect and sexual function over the previous 24
hours, whereas sleep questions asked about partici-
pants’ sleep experiences “last night.”
Baseline Measures
Demographic information, relationship history,
and oral contraceptive use were reported at base-
line (see Table 1 for sample characteristics).
The Female Sexual Distress Scale-Revised
(FSDS-R) [17] is a 13-item self-report question-
naire used to assess sex-related personal distress in
women. In the present study, respondents indi-
cated the extent to which they experienced sexual
distress over the past month with higher scores
indicating higher levels of sexual distress. Internal
consistency in our sample was adequate (α=0.74).
The Center for Epidemiologic Studies Depres-
sion Scale (CESD) [18] is a 20-item self-report
Table 1 Sample descriptive characteristics (N =171)
Age M ±SD: 20.07 ±3.32
Race
White n =139; 81.29%
Black n =23; 13.45%
Eastern Asian or Pacific Islander n =4; 2.34%
Hispanic or Latino n =2; 1.17%
Western Asian or Middle Eastern n =1; 0.58%
“Other” n =2; 1.17%
Significant other status
Do you currently have a significant other? “Yes” n =86; 50.59% of 170 responders
Length of relationship M ±SD: 20.71 months ±18.57
Sexual partner status
0 partner n =76; 44.44%
1 partner n =92; 53.80%
2 partners n =2; 1.17%
3 partners n =1; 0.58%
Sexual orientation
Mostly or completely heterosexual n =160; 93.57%
Bisexual, equally attracted to men and women n =3; 1.75%
Mostly or completely homosexual n =8; 4.68%
Number of lifetime sexual partners M ±SD, range: 4.29 ±4.74, 0–24
Using oral contraceptives n =97; 56.73%
M=mean; SD =standard deviation
Sex and Sleep 1223
J Sex Med 2015;12:1221–1232
inventory used to measure symptoms of depres-
sion. It was modified to assess these symptoms
over the past month. Scores on the CESD range
from 0 to 60 with higher scores indicating greater
depression severity. In the present sample,
the CESD achieved high internal consistency
(α=0.90).
State-Trait Anxiety Inventory Form X-State
(STAIXS) [19] is a 20-item self-report inventory
intended to assess levels of anxiety. It was modified
to assess these symptoms over the past month.
Possible scores on the STAIXS range from 20 to
80 with higher scores indicating greater anxiety
severity. Internal consistency of the STAIXS was
high (α=0.94) in the present sample.
Main Outcome Measures
Daily Measures
The Profile of Female Sexual Function (PFSF)
[20,21] is a self-report tool assessing sexual
response. It was modified for daily use in the
present study and has been validated for use in
nonclinical samples [22]. For the present study,
women reported on their experiences of sexual
desire (α=0.94), subjective sexual arousal
(α=0.99), and orgasmic function (α=0.97) over
the previous 24 hours. These high internal consis-
tency values indicated that the structural integrity
of the scales was not compromised by altering the
recall period. Furthermore, construct validity
remained uncompromised as indicated by similar
correlation values found between these subscales
when using daily recall (see presented correlations
found in this same sample reported in Kalmbach
et al. [23]) and 4-week recall (see similarly aged
women’s correlations in Kalmbach et al. [24]).
Each scale in the present study was scored using raw
scores with higher scores indicating better sexual
function. Items specific to sexual activity were
provided with the response choice of “No sexual
activity,”1which was based on Meyer-Bahlburg and
Dolezal’s critique of Female Sexual Function Index
(FSFI) scoring procedures [25].
The FSFI [26] is a 19-item self-report measure
of female sexual response that was modified for
daily use and has been validated for use in norma-
tive samples [22,27,28]. For the present report, we
examined daily experiences of female genital
response using the lubrication scale (α=0.96).
The high internal consistency value indicated
that the structural integrity of the scale was not
compromised by altering the recall period. Fur-
thermore, construct validity remained uncom-
promised as indicated by similar correlation values
found between this subscale and those of the PFSF
when using daily recall (see presented correlations
found in this same sample reported in Kalmbach
et al. [23]) and 4-week recall (see similarly aged
women’s correlations in Kalmbach et al. [24]). This
scale was scored using raw scores with higher scores
indicating better genital response. Based on the
recommendations of Meyer-Bahlburg and Dolezal
[25], FSFI items were presented with a “No sexual
activity” response option.1
Three dichotomous items were used for partici-
pants to indicate presence of menstruation and
occurrence of partnered sexual activity and self-
stimulation. Specifically, participants were asked
each day “Have you menstruated over the past 24
hours?” and responded either “Yes” (coded as 1) or
“No” (coded as 2). Regarding sexual activity, par-
ticipants were asked “Did you have sex (oral, anal,
hand, vaginal, etc.) with another person within the
past 24 hours?” and “Did you masturbate within
the past 24 hours?” and responded either “Yes”
(coded as 1) or “No” (coded as 0).
The present study used three items from the
Pittsburgh Sleep Quality Index [29] to assess
nightly levels of TST, SOL, and subjective SQ.
After waking each morning, participants rated the
“quality of sleep last night” and responded to items
asking “How many hours of sleep did you get last
night?” and “How long did it take you to fall asleep
last night?” Participants reported SOL in minutes,
TST in hours (to the tenths place), and SQ was
measured on a 1–4 Likert-type scale with higher
scores indicating better SQ.
The Positive and Negative Affect Schedule-
Expanded Form (PANAS-X) [30] was used to
measure fatigue and affect balance. To minimize
the time demand of the daily assessments, admin-
istration of the PANAS-X was limited to seven
subscales assessing daily levels of fatigue, positive
affect (PA) (joviality [e.g., happy], self-assurance
[e.g., proud], and serenity [e.g., calm]), and
1These responses were treated as missing data. For indi-
viduals who had less than 25% missing data in a given scale,
proration using participants’ mean scores (within that same
scale) was used to estimate total factor scores. However,
individuals’ scale scores were treated as missing if more
than 25% of data in a factor were missing. The rationale
was that treating a response of “No sexual activity” as zero
would artificially bias scores into indicating higher dys-
function, whereas proration allows us to estimate the total
scale score based on their other responses in the same scale.
However, we decided to only prorate when the response
rate was 75% and above as to minimize the impact of our
estimation on the data.
1224 Kalmbach et al.
J Sex Med 2015;12:1221–1232
negative affect (NA) (fear [e.g., afraid], sadness
[e.g., sad], and hostility [e.g., angry]). To create the
affect balance variable, we first computed both (i)
the mean item rating among PA items; and (ii) the
mean item rating among NA items. Then, a ratio
was created to serve as the affect balance variable
PA:x¯NA. Of note, item means were used rather
than total PA and NA scores as the ranges of PA
and NA were not equal. Affect balance scores
greater than 1.00 indicate a greater ratio of posi-
tive to negative affect, whereas scores less than
1.00 indicate a greater ratio of negative to positive
affect. Scores close to 1.00 would indicate experi-
encing relatively equal amount of PA and NA.
Data Analysis
The data collected involved repeated assessments.
To account for the time-nested structure of the
data, analyses were conducted using hierarchical
linear modeling (HLM; also known as multilevel
modeling). HLM allows for the simultaneous
examination of inter-individual differences and
intra-individual change. As such, this analytic
approach can test the predictive qualities of base-
line sexual distress and age (Level 2 predictors, i.e.,
inter-individual differences) as well as nightly sleep
parameters and daily affect balance and presence
of menstruation (Level 1 predictors, i.e., intra-
individual changes). In order to evaluate the tem-
poral precedence of sleep on next-day sexual
functioning, sleep predictors were lagged in the
HLM models (i.e., Sleep at time t-1 predicting
Sexual Response at time t).
Preliminary Analyses
To determine relevant covariates in predicting
female sexual function (for individual iat time t),
each outcome variable was predicted by baseline
sexual distress, depression, anxiety, oral contracep-
tive use, and age (for individual i), and daily affect
balance and presence of menstruation (for indi-
vidual iat time t). These analyses were conducted
to determine which variables to use as covariates in
the models testing our substantive hypotheses.
Example 12:
Desire Sexual distress Age
Affect balance
it i i i
it
=+ +
++
ββ β
ββ
01 2
34
MMenstruation
Fatigue Depression
Anxiety
Ora
it
it i
i
++
+
+
ββ
β
β
56
5
5ll contraceptive useiiit
++ζε
0
Example 1 examined differences in sexual func-
tion outcomes for women with varying degrees of
baseline sexual distress, depression, and anxiety.
Additionally, this model evaluated any daily influ-
ence of menstruation, affect balance, and fatigue
on sexual response, as well as effects of age and oral
contraceptives. Subsequent analyses included sig-
nificant predictors as covariates to allow for the
testing of relationships between sleep and sexual
function independent of fatigue, affect balance,
age effects, and impact of daily menstruation.
Substantive Hypotheses
To examine the influence of sleep on sexual
response and behavior, sexual response indices
were regressed on the previous night’s sleep (i.e.,
lagged predictors) while controlling for relevant
covariates.
Example 2:
Desire TST SOL SQ
Covariates
it i it it it
it
=+ + +
+
−−
(
ββ β β
β
01 12 13 1
4
))
++ζε
0i it
Finally, to examine sleep’s influence on sexual
behavior, sexual activity and self-stimulation
(dichotomous variables) were regressed on the
previous night’s sleep parameters and relevant
covariates using multilevel mixed-effects logistic
regression.
Example 3:
Sexual Activity TST SOL
SQ Covar
it i it it
it
=+ +
++
−−
ββ β
ββ
01 12 1
314
iiatesit
iit
()
++ζε
0
Results
Preliminary Analyses
According to the FSDS-R3, 19.30% of women in
the present study indicated clinically significant
levels of sexual distress (19.81 ±11.24). Regarding
sexual activity, women reported self-stimulation
on 8.90% of days and sexual activity with a partner
on 24.53% of days (the latter was calculated only
among women who reported having a significant
other at baseline). Healthy sexual functioning
was indicated for subjective sexual arousal (17.19 ±
2.15, range: 3–18), genital response (18.57 ±2.55,
2β=Predictor coefficients; ζ=Level 2 stochastic part;
ε=Level 1 stochastic part; i=individual; t=time.
3Unlike the original 0–4 scale, the present study adminis-
tered the FSDS-R using a 1–6 scale. As such, a clinical
cutoff of 27 (calculated to be most parallel to the 11-point
cutoff) was used to adjust for the scaling difference.
Sex and Sleep 1225
J Sex Med 2015;12:1221–1232
range: 4–20), and orgasmic function (20.46 ±3.93,
range: 4–24) as evidenced by each scale’s mean
being within 1 standard deviation (SD) of the
maximum scale value. Average daily sexual desire
was reported as within normal limits (24.71 ±
10.45, range: 9–54) as indicated by the mean being
approximately in the middle of range of values.
Regarding sleep parameters, participants reported
good SQ (3.09 ±0.38, 1–4) with an average SOL
of 21 minutes (±13.88 minutes) and an average
TST of 7 hours and 22 minutes (±52 minutes). In
examining prevalence of clinical levels of depres-
sion and anxiety, 3% of participants reported clini-
cally significant levels of baseline depression
(CESD: 13.37 ±9.78) [31], whereas 9% of partici-
pants indicated clinical levels of anxiety (STAIXS:
41.92 ±10.98) [32]. As an initial step in examining
the data, we ran zero-order correlations between
sexual response indices and predictor variables for
descriptive purposes (see Table 2).
Prior to conducting analyses for the substan-
tive hypotheses, we examined whether observed
intra-individual variance in our outcome variables
supported our use of HLM analyses. We first
ran a null model with sexual desire regressed on
an intercept, a Level 1 (intra-individual) residual,
and a Level 2 (inter-individual) residual (see
Singer and Willett [33]). Results indicated that
approximately 54% of the total variance in sexual
desire was due to day-to-day fluctuations
(i.e., intra-individual variations), whereas the
remaining 46% was due to between-subjects
factors (i.e., inter-individual differences). Thus,
the data revealed marked variations in daily levels
of desire to justify the examination of time-
varying outcomes. Similarly, null models for sub-
jective arousal (44%), genital response (48%),
and orgasmic function (43%) revealed marked
day-to-day changes, thus supporting our statisti-
cal approach.
Sleep Predicting Sexual Response
To test our substantive hypotheses, we first esti-
mated sexual desire as predicted by age, sexual
distress, oral contraceptive use, baseline depres-
sion and anxiety, and daily affect balance, fatigue,
and menstruation (see Table 3). Analyses revealed
affect balance (P<0.001), menstruation (P<0.01),
and oral contraceptive use (P=0.03) to be signifi-
cant predictors. Specifically, greater PA balance
and oral contraceptive use were associated with
higher levels of desire, whereas women desired less
sex when menstruating. We then estimated desire
as predicted by TST, SOL, and SQ, controlling
for affect balance, menstruation, and oral contra-
ceptive use (see Table 3). Analyses revealed that
longer sleep duration predicted greater next-day
sexual desire (P=0.02). This effect was indepen-
dent of the influence of both affect balance
(P<0.001), menstruation (P=0.01), and contra-
ceptive use (P=0.04).
Next, we examined subjective arousal and iden-
tified baseline sexual distress (b =−0.05, z =−2.74,
P<0.01) and age (b =−11, z =−2.23, P=0.03) as
relevant covariates such that greater sexual distress
and older age were related to poorer subjective
arousal. However, estimation of subjective arousal
as predicted by sleep parameters revealed no sig-
nificant findings (all Pvalues >0.05).
We then estimated daily genital response, which
showed older age was associated with greater dif-
ficulty with vaginal lubrication (P<0.01), but that
a more PA balance was associated with better
genital arousal during sexual activity (P=0.01; see
Table 4). Analyses then revealed that longer TST
the prior night was associated with poorer vaginal
Table 2 Zero-order correlations between female sexual response indices and predictors
Desire
Subjective
arousal
Vaginal
lubrication
Orgasmic
function
TST 0.06 0.13 0.14 0.13
SOL 0.04 0.13 0.01 0.05
SQ 0.09 0.10 0.13 0.25
Affect balance 0.18 0.14 0.13 0.19
Fatigue 0.05 0.08 0.02 0.11
Depression 0.04 0.14 0.06 0.21
Anxiety 0.04 0.13 0.08 0.17
Age 0.05 0.17 0.19 0.13
Sexual distress 0.05 0.23 0.15 0.22
Correlations are presented for descriptive purposes only; thus, no significant values are shown
Affect balance and fatigue were measured using the Positive and Negative Affect Schedule-Revised. Depression was measured using the Center for Epidemio-
logical Studies Depression Scale. Anxiety was measured using the State-Trait Anxiety Inventory-Revised. Sexual distressed was measured using the Female
Sexual Distress Scale-Revised
SOL =sleep onset latency; SQ =sleep quality; TST =total sleep time
1226 Kalmbach et al.
J Sex Med 2015;12:1221–1232
lubrication (b =−0.15, z =−2.22, P=0.03). As this
result was unexpected and contrary to prior
research [12] as well as to our bivariate descriptive
correlation between TST and vaginal lubrication
(see Table 2), we followed up this analysis by
regressing genital response on only TST to rule
out multicollinearity artifact. Longer sleep dura-
tion once again predicted poorer genital response
(P=0.02) in the single-predictor model. Again,
given the descriptive correlation showing a posi-
tive relationship, this finding was unexpected. We
then examined if the relationship between TST
and vaginal lubrication was different for within-
person changes (i.e., intra-individual change,
Level 1 analysis) than between-person differences
(inter-individual differences, Level 2 analysis). To
test this possibility, mean TST was calculated for
each participant, thus creating a Level 2 predictor.
Descriptive analyses revealed that participants’
average sleep duration over the 2-week protocol
was 7 hours and 22 minutes (±50 minutes). We
re-ran the model examining both the previous
night’s sleep duration (Level 1 predictor) and
average TST for that person (Level 2 predictor),
along with all relevant covariates, to estimate
vaginal lubrication. Interestingly, both TST pre-
dictors were significant (see Table 4). Irrespective
of average sleep duration, women reported better
genital response on days following a night of
shorter duration of sleep (Level 1 analysis;
P<0.01). In contrast, women who slept longer on
average reported better genital response than
women who averaged shorter durations of sleep
(Level 2 analysis; P=0.03).
We then found age (b =−0.19, z =−2.27, P=
0.02), baseline sexual distress (b =−0.19, z =−2.61,
P<0.05), and daily affect balance (b =2.33,
z=2.80, P<0.01) to be relevant covariates when
predicting ability to reach orgasm. Follow-up
analysis, however, did not reveal an influence
of sleep on next-day orgasmic function (all
Pvalues >0.05).
Sleep Predicting Next-Day Sexual Behavior
Multilevel logistic regression was used to examine
whether sleep parameters were associated with
next-day self-stimulation and partnered sexual
activity. In predicting next-day self-stimulation,
women with greater baseline sexual distress were
more likely to masturbate (odds ratio =1.06,
Table 3 The influence of sleep on next-day sexual desire
Outcome Predictor b z Pvalue χ2(Pvalue)
Determining covariates
(N =171, Obs =2,156)
Desireit Level 1 108.75 (<0.001)
Intercept 16.40 3.69 <0.001
Menstruationit 1.48 2.79 <0.01
Affect balanceit 13.01 8.96 <0.001
Fatigueit 0.18 1.68 0.09
Level 2
Sexual Distressi0.08 1.49 0.14
Agei0.23 1.41 0.16
Depressioni0.04 0.49 0.63
Anxietyi0.01 0.08 0.93
Oral contraceptivesi2.46 2.23 0.03
Testing hypotheses
(N =171, Obs =1,859)
Desireit Level 1 89.98 (<0.001)
Intercept 11.82 6.13 <0.001
Total sleep timeit-1 0.32 2.31 0.02
Sleep onset latencyit-1 0.01 1.26 0.21
Sleep qualityit-1 0.19 0.58 0.56
Menstruationit 1.42 2.47 0.01
Affect balanceit 12.80 8.58 <0.001
Level 2
Oral contraceptivesi2.23 2.03 0.04
In multilevel modeling, the chi-square (χ2) statistic reflects the difference between the tested model and a null model with no predictors. Thus, a significant
chi-square is desirable, as it is indicative of a model that accounts for significant variance in the outcome. This is in contrast to the use of chi-square in structural
equation modeling, in which significant chi-square statistics are undesirable and reflect a lack of model fit. b =unstandardized beta coefficient. z-scores represent
testing the predictor’s significance. Desire was measured by the Profile of Female Sexual Function. Affect balance and fatigue were measured by the Positive and
Negative Affect Schedule-Expanded Form. Sexual distress was measured by the Female Sexual Distress Scale-Revised. Depression was measured using the
Center for Epidemiological Studies Depression Scale. Anxiety was measured using the State-Trait Anxiety Inventory-State scale. Total sleep time, sleep onset
latency, and sleep quality were measured using modified items from the Pittsburgh Sleep Quality Index
Sex and Sleep 1227
J Sex Med 2015;12:1221–1232
z=3.64, P<0.001). No other covariates or sleep
parameters were significant (all Pvalues >0.05).
Lastly, we predicted the occurrence of
partnered sexual activity among women who indi-
cated having a significant other at baseline (see
Table 5). Menstruation (P<0.01) and affect
balance (P<0.01) were identified as relevant
covariates such that women were more than twice
as likely to engage in partnered sexual activity
when they were not menstruating and that they
were nearly eight times more likely to engage in
sexual activity with a partner when their affect
balance ratio score increased by one point. We
then examined sleep’s influence on sexual activity
and found that sleep duration predicted a greater
likelihood of engaging in sexual activity with a
partner such that a 1 hour increase in TST corre-
sponded to a 14% greater likelihood of engaging
in partnered sexual activity (P<0.05).
Discussion
The present study used a daily diary approach over
a 2-week period to examine prospectively how
changes in nightly sleep duration, SQ, and SOL
correspond to variations in female sexual response
and sexual activity. Analyses revealed the impor-
tance of sleep duration in healthy sexual desire and
genital response, as well as partnered sexual activ-
ity. Observing that sleep duration played an impor-
tant role in the regulation of sexual desire and
genital arousal in a sample of young, healthy
women highlights the influence of sleep on sexual
functioning and behavior.
The impact of sleep duration on female sexual
response was both consistent and robust to other
daytime factors. In support of Andersen and col-
leagues’ hypothesis [12], sleep duration was critical
to next-day sexual desire. This relationship was
independent of affect balance and fatigue, indicat-
ing a direct influence of sleep on sexual response
that is not better accounted by other sleep-related
daytime sequelae.
Sleep duration was also an important determi-
nant of genital response. However, this relation
was more complex than TST’s influence on desire.
The relationship between sleep duration and
vaginal lubrication differed when examining how
sleep duration predicted next-day genital arousal
within women (Level 1 analysis) as compared with
testing differences in genital arousal between
women with varying levels of average sleep dura-
tion (Level 2 analysis). Specifically, we found
that women with greater average sleep duration
Table 4 Sleep predicting next-day genital response
Outcome Predictor b z Pvalue
χ2
(Pvalue)
Determining covariates
(n =137, Obs =473)
Lubricationit Level 1 22.79 (<0.01)
Intercept 20.79 11.71 <0.001
Menstruationit 0.31 0.86 0.39
Affect balanceit 1.96 2.59 0.01
Fatigueit 0.07 1.23 0.22
Level 2
Sexual distressi0.03 1.63 0.10
Agei0.15 2.84 <0.01
Depressioni0.02 0.71 0.48
Anxietyi0.01 0.38 0.71
Oral contraceptivesi0.30 0.73 0.47
Testing hypotheses
(n =122, Obs =407)
Lubricationit Level 1 28.61 (<0.001)
Intercept 18.37 8.11 <0.001
Total sleep timeit-1 0.19 2.63 <0.01
Sleep onset latencyit-1 0.00 0.22 0.83
Sleep qualityit-1 0.06 0.39 0.70
Affect balanceit 1.37 2.46 0.01
Level 2
Total sleep time averagei0.54 2.18 0.03
Agei0.17 2.98 <0.01
Lubrication was measured by the Female Sexual Function Index. Affect balance and fatigue were measured by the Positive and Negative Affect Schedule-
Expanded Form. Sexual distress was measured by the Female Sexual Distress Scale-Revised. Depression was measured using the Center for Epidemiological
Studies Depression Scale. Anxiety was measured using the State-Trait Anxiety Inventory-State scale. Total sleep time, sleep onset latency, and sleep quality were
measured using modified items from the Pittsburgh Sleep Quality Inventory
1228 Kalmbach et al.
J Sex Med 2015;12:1221–1232
reported better genital arousal compared with
women with lower average sleep duration. This
finding is consistent with prior research [12] sup-
porting sufficient sleep duration for the promotion
of healthy sexual functioning. In contrast, when
women had short duration of sleep, they experi-
enced better genital arousal the following day.
Though these relationships are in opposing direc-
tions, they are not mutually exclusive. Rather,
these relations may reflect the differential effects
on daytime functioning of a single night vs.
chronic nights of sleep deprivation.
Regarding sexual behavior, sleep duration pre-
dicted greater likelihood of next-day partnered
sexual activity among our participants in roman-
tic relationships such that an additional hour of
TST corresponded to a 14% increased chance of
sexual activity among our subsample of partnered
individuals.
The present study demonstrated sleep dura-
tion to be important to sexual response and
behavior. However, future research is necessary
to identify mechanisms facilitating this associa-
tion. Andersen et al. [12] posited that sleep loss
led to hormonal changes, which then manifested
as poorer sexual functioning. This theory sug-
gests that deficient androgen levels mediate the
impact of insufficient core sleep on sexual
response. However, future research is necessary
to directly test this hypothesis.
Though TST fails to capture aspects of sleep
beyond duration, it may serve as a rough proxy
for sleep architectural changes. For instance,
shorter sleep duration is associated with markedly
decreased time in REM sleep, as greater amounts
of REM sleep are obtained in the latter portion
of the sleep period [34]. Given that vaginal
vasocongestion increases during REM sleep [6], it
is possible that specific changes (within individuals)
or differences (between individuals) in REM sleep
may underlie the two different relationships
between genital arousal and nightly and habitual
sleep duration. However, as it is presently unclear
whether REM sleep serves a function for female
genital arousal or if REM-related vaginal vaso-
congestion is simply a marker of healthy genital
response, the role of REM sleep in human sexual
response is presently unclear. Comparing polysom-
nogram (PSG) profiles between women with clini-
cal sexual dysfunction and healthy controls may
provide insight into potential sleep architectural
differences between these two groups. Further-
more, PSG comparison allows for testing any
group differences in objectively measured sleep dis-
orders, such as sleep-related breathing disorders.
Importantly, sleep duration may also serve as a
proxy for sleep maintenance. Difficulty maintain-
ing sleep is characterized by frequent nighttime
awakenings, significant amount of time awake
following initial sleep onset, and early morning
Table 5 The influence of sleep on next-day partnered sexual activity among women with significant others at baseline
Outcome Predictor OR z Pvalue
χ2
(Pvalue)
Determining covariates
(n =86, Obs =1,092)
Sexual Activityit Level 1 13.27
Menstruationit 2.67 3.42 <0.01
Affect balanceit 7.90 3.26 <0.01
Fatigueit 0.93 1.47 0.14
Level 2
Sexual distressi0.98 0.80 0.43
Agei0.99 0.38 0.71
Depressioni1.02 0.60 0.55
Anxietyi1.01 0.52 0.60
Oral contraceptivesi1.59 1.40 0.16
Testing hypotheses
(n =86, Obs =953)
Sexual Activityit Level 1 22.01
Total sleep timeit-1 1.14 1.98 <0.05
Sleep onset latencyit-1 0.99 1.08 0.28
Sleep qualityit-1 0.87 0.99 0.32
Menstruationit 2.37 2.72 0.01
Affect balanceit 5.59 3.13 <0.01
Affect balance and fatigue were measured by the Positive and Negative Affect Schedule-Expanded Form. Sexual distress was measured by the Female Sexual
Distress Scale-Revised. Depression was measured using the Center for Epidemiological Studies Depression Scale. Anxiety was measured using the State-Trait
Anxiety Inventory-State scale. Total sleep time, sleep onset latency, and sleep quality were measured using modified items from the Pittsburgh Sleep Quality
Inventory
OR =odds ratio
Sex and Sleep 1229
J Sex Med 2015;12:1221–1232
awakenings (i.e., unintentionally waking before
the desired wake time followed by an inability to
re-initiate sleep). As such, it may be that frag-
mented, difficult-to-maintain sleep is a driving
force behind sleep duration and sexual difficulties.
Notably, fragmented sleep is a hallmark feature of
obstructive sleep apnea [35]. Thus, the inability to
maintain sleep may be an important driving force
behind both the relationships between obstructive
sleep apnea and sexual dysfunction, as well as sleep
duration and sexual function. It may behoove
researchers to explore these possibilities in future
investigations.
Though the specific underlying mechanisms are
presently unknown, it appears that sleep loss
begets poorer sexual desire and reduced sexual
activity. Further, women with chronically insuffi-
cient sleep may be at greater risk for genital
arousal difficulties, though one night of sleep loss
appears to lead to short-term improvement in
genital arousal the following day. Given that
insomnia is the most prevalent clinical sleep disor-
der with rates of 10% in the adult U.S. population
[36,37] and is characterized by persistent noctur-
nal symptoms of difficulty initiating and maintain-
ing sleep [38], insomnia may pose an important
risk factor for sexual dysfunction. Notably, insom-
nia disorder also consists of daytime impairment
(e.g., fatigue, irritability, concentration difficulties)
because of nocturnal symptoms. If the inability to
maintain sleep contributed to sleep duration
reports in the present study, then impaired sexual
response following sleep loss may constitute a
daytime sequela of insomnia. To our knowledge,
the comorbidity between insomnia and female
sexual dysfunction has not been studied. Based on
our findings, the potential etiological role of
insomnia in female sexual dysfunction may present
a largely untapped and potentially rich area for
future investigation.
Findings of the present study must be inter-
preted in light of some methodological limitations.
A notable consideration regards the nature of our
sample and that individuals were not screened for
sleep disorders or use of sleep aids. College stu-
dents are known for having irregular sleep sched-
ules and greater prevalence of delayed sleep/wake
patterns [39]. Further, participants were not
screened for psychiatric conditions other than
depression and anxiety, chronic medical condi-
tions, medication use (other than antidepressants
and oral contraceptives), or sleeping environmen-
tal factors, thus we cannot account for their poten-
tial influences. Additionally, our sample reported
healthy sexual functioning over the 2-week period
(all sexual response scale means were within 1 SD
of the maximum value of the scale, except desire).
As such, range restriction may have impeded our
ability to detect statistically significant relations
between sleep parameters and sexual functioning
and limits generalizability to individuals with
sexual dysfunction. Moreover, though participants
reported healthy sexual response over the 2-week
study, it is difficult to compare their sexual health
with samples in other studies, as it is unclear
whether aggregated daily sexual response ratings
can be compared validly with ratings of longer
recall periods such as month-long recall. Thus,
though the ratings appeared to reflect healthy
sexual response in this sample, we caution against
drawing decisive clinical impressions based on
daily sexual functioning ratings. Further, regard-
ing measurement of study variables, though self-
report is an important and useful method for
collecting sleep data, the gold standard of assessing
sleep parameters involves the use of both subjec-
tive and objective (i.e., PSG, actigraphy) measures.
In addition to our findings regarding sleep and
sexual response, we found a number of relation-
ships between daily affect balance and same-day
sexual functioning. PA balance (i.e., greater ratio
of PA to NA) was a robust predictor of sexual
desire and ability to achieve orgasm, as well as
self-stimulation and partnered sexual activity. In
comparison, NA balance (i.e., greater ratio of NA
to PA) was related to poorer genital response.
Affect balance was not associated with subjective
arousal. Though prior studies have shown that
specific affect states are important to daily sexual
response [40], this investigation suggests that the
balance of these affect states is meaningfully
related to daily desire, genital response, orgasmic
function, and sexual behavior.
Conclusions
Good sleep is important for maintaining healthy
sexual functioning. Decreases in desire and genital
response, as well as reduced likelihood of
partnered sexual activity, are predicted by both
nightly and habitual sleep duration. Notably, these
effects were independent of age, sexual distress,
daytime affect and fatigue, or presence of men-
struation. These findings suggest that acute sleep
disturbance may contribute to sexual complaints
and reduced sexual activity. Future research may
benefit from taking a more comprehensive
approach to examining sleep parameters by
using both subjective and objective measures.
1230 Kalmbach et al.
J Sex Med 2015;12:1221–1232
Additionally, the relationship between insomnia
and sexual dysfunction may prove to be an over-
looked and important area of interest for clinical
research. Clinicians may consider assessing
patients’ sleep habits and insomnia symptoms as
potential factors influencing sexual difficulties.
Corresponding Author: David A. Kalmbach, PhD,
Sleep and Circadian Research Laboratory, Department
of Psychiatry, University of Michigan Medical School,
Rachel Upjohn Building, 4250 Plymouth Rd, Ann
Arbor, MI 48105, USA. Tel: 330-204-6942; Fax: 734-
936-7868; E-mail: dkalmbac@gmail.com
Conflict of Interest: The authors report no conflicts of
interest.
Statement of Authorship
Category 1
(a) Conception and Design
David A. Kalmbach; Jeffrey A. Ciesla
(b) Acquisition of Data
David A. Kalmbach
(c) Analysis and Interpretation of Data
David A. Kalmbach
Category 2
(a) Drafting the Manuscript
David A. Kalmbach
(b) Revising It for Intellectual Content
David A. Kalmbach; Vivek Pillai; J. Todd Arnedt;
Jeffrey A. Ciesla
Category 3
(a) Final Approval of the Completed Manuscript
David A. Kalmbach; J. Todd Arnedt; Vivek Pillai;
Jeffrey A. Ciesla
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... As such, it perhaps makes sense that the chronic stress of women's heteronormative roles could be responsible for low desire-for example, because this chronic stress could blunt the acute cortisol responses that would more typically accompany sexual stimuli in ways that contribute to low desire. Supporting this notion more broadly, issues with sleep, physical health and well-being, and mental health, are highly correlated with sexual difficulties (Basson et al., 2005;Kalmbach et al., 2015), and indeed many women report they are simply too fatigued to experience desire (Sims & Meana, 2010). ...
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This authoritative guide to sleep medicine is also available as an e-dition, book (ISBN: 1416003207) plus updated online reference! The new edition of this definitive resource has been completely revised and updated to provide all of the latest scientific and clinical advances. Drs. Kryger, Roth, and Dementand over 170 international expertsdiscuss the most recent data, management guidelines, and treatments for a full range of sleep problems. Representing a wide variety of specialties, including pulmonary, neurology, psychiatry, cardiology, internal medicine, otolaryngology, and primary care, this whos who of experts delivers the most compelling, readable, and scientifically accurate source of sleep medicine available today. Includes user-friendly synopses of important background information before all basic science chapters. Provides expert coverage of narcolepsy * movement disorders * breathing disorders * gastrointestinal problems * neurological conditions * psychiatric disturbances * substance abuse * and more. Discusses hot topics such as the genetic mechanisms of circadian rhythms * the relationship between obesity, hormones, and sleep apnea * sleep apnea and arterial hypertension * and more. Includes a new section on Cardiovascular Disorders that examines the links between sleep breathing disorders and cardiovascular abnormalities, as well as the use of sleep related therapies for congestive heart failure. Provides a new section on Womens Health and Sleep Disorders that includes information on the effects of hormonal changes during pregnancy and menopause on sleep. Features the fresh perspectives of 4 new section editors. Employs a more consistent chapter organization for better readability and easier navigation.