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J Sex Med 2006;3:838–852 © 2006 International Society for Sexual Medicine
838
Blackwell Publishing IncMalden, USAJSMJournal of Sexual Medicine1743-6095© 2006 International Society for Sexual Medicine200635838852Original ArticleCues Resulting in Desire for Sexual ActivityMcCall and Meston
ORIGINAL RESEARCH—PSYCHOLOGY
Cues Resulting in Desire for Sexual Activity in Women
Katie McCall, MA, and Cindy Meston, PhD
University of Texas at Austin, Department of Psychology, Austin, TX, USA
DOI: 10.1111/j.1743-6109.2006.00301.x
ABSTRACT
Introduction. A number of questionnaires have been created to assess levels of sexual desire in women, but to our
knowledge, there are currently no validated measures for assessing cues that result in sexual desire. A questionnaire
of this nature could be useful for both clinicians and researchers, because it considers the contextual nature of sexual
desire and it draws attention to individual differences in factors that can contribute to sexual desire.
Aim. The aim of the present study was to create a multidimensional assessment tool of cues for sexual desire in
women that is validated in women with and without hypoactive sexual desire disorder (HSDD).
Methods. Factor analyses conducted on both an initial sample (N = 874) and a community sample (N = 138) resulted
in the Cues for Sexual Desire Scale (CSDS) which included four factors: (i) Emotional Bonding Cues; (ii) Erotic/
Explicit Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/Romantic Cues.
Main Outcome Measures. Scale construction of cues associated with sexual desire and differences between women
with and without sexual dysfunction.
Results. The CSDS demonstrated good reliability and validity and was able to detect significant differences between
women with and without HSDD. Results from regression analyses indicated that both marital status and level of
sexual functioning predicted scores on the CSDS. The CSDS provided predictive validity for the Female Sexual
Function Index desire and arousal domain scores, and increased cues were related to a higher reported frequency
of sexual activity in women.
Conclusions. The findings from the present study provide valuable information regarding both internal and external
triggers that can result in sexual desire for women. We believe that the CSDS could be beneficial in therapeutic
settings to help identify cues that do and do not facilitate sexual desire in women with clinically diagnosed desire
difficulties. McCall K, and Meston C. Cues resulting in desire for sexual activity in women. J Sex Med
2006;3:838–852.
Key Words. Sexual Desire; Female Sexual Dysfunction
Introduction
sing a random probability sample, Laumann,
Paik, and Rosen [1] reported that concerns
regarding sexual desire are the largest sexual prob-
lem among women in the United States. In this
sample of 1,486 women, approximately 32% of the
women reported a lack of sexual interest. Although
the statistics based on clinical samples of women
reporting to sexual health clinics and/or gyneco-
logic offices generally report somewhat lower esti-
mates of sexual desire problems; the incidence of
these concerns is still high [2–5]. Despite the high
U
prevalence of sexual desire concerns, there are
currently no empirically validated treatments for
hypoactive sexual desire disorder (HSDD) [6]. To
date, evidence from clinical and research reports
suggests that sexual desire problems are relatively
difficult to treat and efforts to treat HSDD have
often provided inconsistent results [7–9]. It is fea-
sible that these inconsistencies could, in part, be
accounted for by the highly complex and individ-
ualized nature of factors that facilitate and result
in desire for sexual activity in women.
Reports from clinicians involved in the treat-
ment of sexual desire concerns often include dis-
Cues Resulting in Desire for Sexual Activity 839
J Sex Med 2006;3:838–852
cussions of both internal and external triggers or
cues that result in sexual desire. Based on his
20 years of psychiatry experience, Levine [10] pro-
posed a list of 11 stimuli that result in sexual
desire, including: (i) psychological intimacy; (ii)
falling in love; (iii) viewing, reading about, or lis-
tening to people having explicitly described enjoy-
able sex; (iv) viewing, reading about, or listening
to a romantic sequence between two personally
appealing people; (v) invoking a fantasy that has
been reliably erotic in the past; (vi) wanting to be
pregnant; (vii) low doses of street drugs; (viii)
enlightenment; (ix) repairing a recently troubled
relationship; (x) reclaiming an errant lover; and
(xi) alleviation from a previous form of sexual dys-
function. Consistent with Levine’s perspectives,
in their book, “Reclaiming Desire,” Goldstein
and Brandon [11] discuss the importance of one’s
receptivity to sexual cues in order to ignite feelings
of sexual desire. Throughout the book, Goldstein
and Brandon discuss various clinical vignettes in
which external cues (e.g., romantic or erotic sexual
escapades, provocative clothing, sexy music, swim-
ming naked) were crucial in eliciting feelings of
sexual desire. In Leiblum and Sachs’s book, Getting
the Sex you Want [12], the authors suggest many
external solutions for women with low sexual
desire, such as using sex toys or pornography, and
engaging in masturbation or sexual visualization.
They also discuss how certain music, tastes, and
scents can create feelings of sexual desire for some
women. Leiblum and Sachs acknowledge the indi-
vidualized nature of sexual desire by encouraging
women to experiment with many of these external
resources to determine “what works for them.” In
Pridal and LoPiccolo’s [13] multielement treat-
ment of sexual desire disorders, they propose a
behavioral intervention stage labeled as “drive
induction” which involves assigning couples to
attend to and record sexual cues in a “desire diary.”
The aim of this phase of treatment is to raise
awareness of sexual cues and to implement behav-
ioral interventions in which individuals attempt to
increase exposure to these cues or stimuli.
Little empirical research has focused specifically
on sexual desire cues. Exceptions include studies
examining the relation between misjudgment of
sexual cues and sexually aggressive behavior [14–
16] and a study by Regan and Berscheid [17] that
investigated potential gender differences in the
beliefs about the causes of sexual desire. In this
study, participants were given a broad definition of
sexual desire and asked to answer a series of open-
ended questions regarding their beliefs about the
causal antecedents of sexual desire. Results indi-
cated that women more than men viewed sexual
desire as caused by external factors (e.g., social or
physical environment, relationship factors). Inter-
estingly, both men and women believed that female
sexual desire was caused by interpersonal factors
(e.g., feeling of love) and physical environmental
factors (e.g., romantic setting), whereas male sexual
desire was caused by intraindividual factors (e.g.,
“maleness”) and erotic factors (e.g., porn media).
A number of validated questionnaires have been
created to assess levels of sexual desire in women
(e.g., [18,19]), but to our knowledge, there are no
validated measures intended for the assessment of
cues that result in sexual desire. A questionnaire
of this nature could be useful for both clinicians
and researchers, because it considers the contex-
tual nature of sexual desire and it draws attention
to potential individual differences in the various
factors that can contribute to sexual desire.
The overall aim of the present study was to
create a multidimensional assessment tool of cues
associated with sexual desire in women. Specifi-
cally, we hoped to empirically categorize stimuli
associated with sexual desire and to validate this
assessment tool in a clinical population of women
with female sexual dysfunction (FSD), in particu-
lar, women with HSDD.
Initial Methods
Phase I: Initial Item Generation and Factor Analyses
Fifty women (age range 18–67 years) were in-
volved in the item generation stage. Participants
were recruited from community volunteers and
students enrolled in a human sexuality course at
the University of Texas. Participants were asked
the following open-ended prompt, “What makes
you desire sexual activity?” Sexual activity was
defined as “kissing, petting, oral sex, intercourse,
and/or masturbation.” Participants were encour-
aged to list as many responses as possible. Over-
lapping responses were combined and yielded a
total of 125 items.
The 125 generated items (see Appendix 1) were
listed using a conventional questionnaire format
with each item presented as a brief descriptive
statement to which respondents rated the likeli-
hood that a given item would make them desire
sexual activity. The response choices were listed
on a 5-point Likert scale, with scale interval
anchors being: Not at all likely (1), Somewhat likely
(2), Moderately likely (3), Ve ry likely (4), and
Extremely likely (5). This 125-item questionnaire,
840 McCall and Meston
J Sex Med 2006;3:838–852
a demographics questionnaire, and several other
measures not relevant to the current study were
administered to 874 females. Participants included
students at the University of Texas and community
volunteers. Sixty-four percent of the subjects iden-
tified themselves as Caucasian, 6% as African
American, 16% as Hispanic, 13% as Asian, and
1% as other. Subjects ranged in age from 17 to
72 years (mean = 21 years, SD = 7 years). The
questionnaires were administered to small groups
of women, and a female research assistant was
available to answer any potential questions. To
help ensure confidentiality and anonymity, female
respondents were asked to seal their completed
questionnaires in a blank envelope and then
deposit it into a large “drop box” containing
numerous other identical envelopes.
We completed a factor analysis based on prin-
cipal components extraction followed by oblique
rotation to simple structure via the Direct
Oblimin method. Upon inspection of the corre-
sponding screen plot, we extracted four factors
with eight values exceeding a value of one. All
factor loadings were to be limited to values >0.40.
Factor 1 initially included 31 items that loaded
greater than 0.40. Fifteen items were eliminated
because of high inter-item correlations (>0.60),
three items were eliminated for theoretical rea-
sons, and three items were eliminated because they
cross-loaded on two or more factors. Factor 2 ini-
tially included 34 items that loaded greater than
0.40. Seventeen items were eliminated because of
high inter-item correlations (>0.60), six items were
eliminated for theoretical reasons, and one item
was eliminated because it cross-loaded on two or
more factors. Factor 3 initially included 24 items
that loaded greater than 0.40. Nine items were
eliminated because of high inter-item correlations
(>0.60), four items were eliminated for theoretical
reasons, and one item was eliminated because it
cross-loaded on two or more factors. Factor 4 ini-
tially included 19 items that loaded greater than
0.40. Six items were eliminated because of high
inter-item correlations (>0.60), two items were
eliminated for theoretical reasons, and one item
was eliminated because it cross-loaded on two or
more factors. In an effort to derive a more concise
measure, several items that had high inter-item
correlations and similar meaning/wording were
collapsed into single items. The resulting 40-item
scale included four factors (10 items within each)
and was labeled the Cues for Sexual Desire Scale
(CSDS). The factors of the CSDS were described
as: Emotional Bonding Cues, Erotic/Explicit
Cues, Visual/Proximity Cues, and Romantic/
Implicit Cues. See Table 1 for a list of final scale
items and factor loadings; see Appendix 2 for the
final version of the CSDS.
Phase II: Validation on a Community Sample of
Women with FSD and Age-Matched Controls
Procedure
Participants were recruited through local radio
and newspapers advertisements and were paid
$50.00 for participation in the study. Inclusion
criteria included: age between 18 and 70 years, and
current involvement in a stable, sexually active
relationship. Participants who met these criteria
completed interviews with a trained female clini-
cian to determine whether or not they met Diag-
nostic and Statistical Manual (DSM-IV-TR) [20]
criteria for any of the following sexual dysfunc-
tions: HSDD, female sexual arousal disorder
(FSAD), female orgasmic disorder (FOD), dys-
pareunia, vaginismus, or sexual aversion disorder.
Measures
Participants completed a basic participant infor-
mation questionnaire, the Female Sexual Function
Index (FSFI) [18], the Beck Depression Inventory
(BDI) [21], and additional measures not relevant
to the present study (for details, see Meston [22]).
In addition to asking about basic demographic
information (e.g., age, education, ethnicity, and
income), our participant information question-
naire also included questions regarding marital
status (single vs. married vs. divorced), whether
women had children (Yes or No), whether women
were taking antidepressants or contraceptives
(Yes or No), and frequency of sexual activity. Fre-
quency of sexual activity was assessed through the
following question “How often do you engage in
sexual activity?” Answer choices included: “less
than once per month,” “1–2 times per month,”
“1–2 times per week,” “3–4 times per week,” and
“more than 4 times per week.”
The FSFI was used to assess current levels of
sexual function. The FSFI is composed of 19 items
divided into factor-analytic derived subscales:
desire (two items), arousal (four items), lubrication
(four items), orgasm (three items), satisfaction
(three items), and pain (three items). In a recent
article, Wiegel, Meston, and Rosen [23] reported
internal consistency within each subscale to reflect
values in an acceptable range (Cronbach’s alpha =
0.82–0.98). Rosen et al. [18] reported inter-item
reliability values within the acceptable range for
sexually healthy women (Cronbach’s alpha = 0.82–
Cues Resulting in Desire for Sexual Activity 841
J Sex Med 2006;3:838–852
0.92), as well as for women with diagnosed FSAD
(Cronbach’s alpha = 0.89–0.95). Test–retest reli-
abilities assessed using a 4-week interval ranged
between Pearson’s r = 0.79–0.86 [18]. Addition-
ally, Weigel, Meston, and Rosen [23] provided
strong evidence of discriminant validity between
women with and without sexual dysfunction for
FSFI total score and each subscale score, although
a high degree of overlap was present across various
diagnostic groups.
The BDI is the most widely used instrument to
assess severity of depressive symptoms. The BDI
is a 21-item questionnaire with well-published
reliability and validity [21]. Past studies using the
BDI have reported that scores above 16 are spe-
cific to major depression [24].
Participants
Data from 138 women were included in the
present analysis. Sixty-three women did not meet
DSM-IV-TR [20] criteria for HSDD, FSAD,
FOD, dyspareunia, vaginismus, or sexual aversion
disorder. These women were considered sexually
healthy controls and had a mean age of 26.1 years
Table 1 Phase I factor analysis of the 40-item CSDS in initial sample
Item
Factors
1234
Emotional Bonding Cues
1. Feeling a sense of love with a partner 0.81
2. Feeling a sense of security in your relationship 0.77
3. Your partner is supportive of you 0.86
4. Your partner does “special” or “loving” things for you 0.73
5. Feeling a sense of commitment from a partner 0.77
6. Your partner expresses interest in hearing about you 0.68
7. Talking about the future with your partner 0.62
8. Feeling protected by a partner 0.40
9. Experiencing emotional closeness with a partner 0.45
10. Feeling protective of a partner 0.54
Explicit/Erotic Cues
1. Watching an erotic movie 0.82
2. Reading about sexual activity (e.g., pornographic magazine) 0.73
3. Watching or listening to other people engage in sexual behavior/activity 0.73
4. Talking about sexual activity or “talking dirty” 0.71
5. Watching a strip tease 0.66
6. Sensing your own or your partner’s wetness, lubrication, or erection 0.69
7. Asking for or anticipating sexual activity 0.64
8. Hearing your partner tell you that he or she fantasized about you 0.61
9. Having a sexual fantasy (e.g., having a sexual dream, daydreaming) 0.61
10. You experience genital sensations (e.g., increased blood flow to genitals) 0.57
Visual/Proximity Cues
1. Seeing someone who is well-dressed or “has class” 0.58
2. Seeing/talking with someone powerful 0.66
3. Being in close proximity with attractive people 0.57
4. Seeing/talking with someone famous 0.63
5. Seeing a well-toned body 0.52
6. Seeing/talking with someone wealthy 0.64
7. Watching someone engage in physical activities (e.g., sports) 0.52
8. Seeing someone act confidently 0.44
9. Seeing/talking with someone intelligent 0.50
10. Flirting with someone or having someone flirt with you 0.50
Romantic/Implicit Cues
1. Whispering into your partner’s ear/having your par tner whisper into your ear 0.61
2. Dancing closely 0.59
3. Watching a sunset 0.47
4. Having a romantic dinner with a partner 0.48
5. Watching a romantic movie 0.46
6. Being in a hot tub 0.50
7. Touching your partner’s hair or face 0.54
8. Giving or receiving a massage 0.52
9. Laughing with a romantic partner 0.45
10. Smelling pleasant scents (e.g., perfume/cologne, shampoo, aftershave) 0.40
Factor loadings <0.40 have been suppressed. All factor loadings are absolute values.
CSDS = Cues for Sexual Desire Scale.
842 McCall and Meston
J Sex Med 2006;3:838–852
(SD = 7.6 years, range = 18–53 years). Seventy-
five women met criteria for some form of FSD and
had a mean age of 28.6 years (SD = 8.7 years,
range = 18–51 years). Thirty-two (23.1%) of these
women met criteria for FSAD, 30 (21.7%) met
criteria for HSDD, 48 (34.7%) met criteria for
FOD, and seven (5%) met criteria for a sexual pain
disorder. Thirty-two (23.2%) of the women with
FSD met criteria for more than one sexual dys-
function (FSAD and HSDD, N = 3; FSAD and
FOD, N = 8; FSAD and pain, N = 1; HSDD and
FOD, N = 10; FSAD, HSDD, and FOD, N = 8;
FSAD, FOD, and pain, N = 2).
Participant characteristics are reported in
Table 2. These participants represent a subset of
the women who participated in a FSFI validation
study by Meston [22]. An independent samples t-
test revealed that there were no significant age
differences between sexually healthy women and
women with FSD, t (2, 136) = −1.74, P = 0.09.
Women with FSD had significantly higher scores
on the BDI as compared with sexually healthy
women, t (2, 136) = −2.83, P = 0.006. Consistent
with this finding, likelihood ratios indicated that
women with FSD were more likely to be currently
taking antidepressant medication as compared
with sexually healthy controls, LR (1) = 5.53,
P = 0.02. Results from likelihood ratios also indi-
cated that women with FSD were more likely to
have reported having children as compared with
Table 2 Phase II participant characteristics
FSD
N = 75
Controls
N = 63 P value
Age 0.09
Mean (±SEM) 28.56 (8.7) 26.13 (7.6)
Range 18–51 18–53
BDI 0.006
Mean (±SEM) 10.39 (6.9) 7.17 (5.4)
Range 0–30 0–22
Ethnicity N (%) 0.77
Caucasian 55 (73.3) 44 (69.8)
African American 3 (4.0) 2 (3.2)
Hispanic 12 (16.0) 9 (14.3)
Asian 3 (4.0) 6 (9.5)
Other 2 (2.7) 2 (3.2)
Education N (%) 0.58
High school/GED 13 (17.3) 6 (9.5)
2 years of college 28 (37.3) 25 (39.7)
4 years of college 27 (36.0) 24 (38.1)
Graduate school 7 (9.3) 8 (12.7)
Annual income N (%) 0.99
<50,000 47 (62.7) 40 (63.5)
50,000–100,000 16 (21.3) 13 (20.6)
>100,000 12 (16.0) 10 (15.9)
Marital status N (%) 0.15
Married 15 (20.0) 7 (11.1)
Divorced or single 60 (80.0) 56 (88.9)
Have children (% Yes) 18 (25.4) 5 (9.3) 0.02
Birth control use (% Yes) 54 (72.0) 48 (76.2) 0.58
Antidepressant use (% Yes) 8 (11.0) 1 (1.6) 0.02
Frequency of sexual activity 0.09
<once per month 0 (0.0) 1 (1.6) 0.10
1–2 per month 11 (14.7) 7 (11.1)
1–2 per week 43 (57.3) 27 (42.9)
3–4 per week 17 (22.7) 17 (27.0)
>4 per week 4 (5.3) 11 (17.5)
FSFI domain scores* (mean ± SEM)
Desire 3.9 (0.99) 4.4 (0.88) 0.002
Arousal 4.3 (1.1) 5.2 (0.75) <0.001
Lubrication 4.6 (1.5) 5.4 (0.75) <0.001
Orgasm 3.8 (1.6) 5.2 (1.0) <0.001
Pain 5.1 (1.3) 5.8 (0.58) <0.001
Satisfaction 4.3 (1.3) 4.9 (1.1) 0.01
Total 26.2 (4.6) 30.9 (3.3) <0.001
The FSFI scores reported here were included in the calculation of the FSFI scores reported in Meston [22].
*Higher scores represent higher levels of function for all domains except pain.
FSD = female sexual dysfunction; BDI = Beck Depression Inventory; GED = general educational development; FSFI = Female Sexual Function Index.
Cues Resulting in Desire for Sexual Activity 843
J Sex Med 2006;3:838–852
sexually healthy controls, LR (1) = 5.64, P = 0.02.
Likelihood ratios indicated that the two groups
did not significantly differ on race/ethnicity, LR
(4) = 1.83, P = 0.77; contraceptive use, LR (1) =
0.31, P = 0.58; or marital status, LR (1) = 2.07,
P = 0.15. Results from chi-squared analyses indi-
cated the groups did not differ significantly on
annual income, χ (2) = 0.01, P = 0.99; reported
frequency of sexual activity, χ (4) = 7.83, P = 0.10;
and educational background, χ (3) = 1.96, P =
0.58. Univariate ANOVAs revealed significant
differences in FSFI domain and total scores
between women with FSD and sexually healthy
women. That is, women with FSD reported lower
levels of desire, F (1, 137) = 10.15, P = 0.002;
arousal, F (1, 137) = 29.36, P < 0.001; lubrication,
F (1, 137) = 16.06, P < 0.001; orgasm, F (1, 137)
= 37.05, P < 0.001; satisfaction, F (1, 137) = 6.81,
P = 0.01; higher levels of sexual pain, F (1, 137)
= 12.83, P < 0.001; and overall FSFI total scores,
F (1, 137) = 44.26, P < 0.001 (see Table 2).
Phase II: Confirmatory Factor Analyses
Based on our Phase I factor analysis results, we
expected that a confirmatory factor analysis would
demonstrate a clear, four-factor structure. To eval-
uate this, using the data from the 138 women
included in our community sample, we conducted
a principal components analysis on the 40 items,
extracting four factors, and rotating the factors to
oblique simple structure via the Direct Oblimin
method. Item loadings of the resulting four factors
are presented in Table 3. All four factors closely
replicated those obtained in Phase I with the
exception of one item from Factor 3 (i.e., “Seeing
someone act confidently”) which cross-loaded
onto Factor 1 (i.e., 0.51 on Factor 3 vs. 0.47 on
Factor 1). See Table 3.
Intercorrelations
Separate values to represent the four factors of
Emotional Bonding Cues, Erotic/Explicit Cues,
Visual/Proximity Cues, and Romantic/Implicit
Cues were scored by taking an average of the
responses to the 10 constituent items assigned to
each factor. Intercorrelations among the resulting
four factor values are presented in Table 4 sepa-
rately for Phase I initial sample (N = 874); and
Phase II full community sample (N = 138), sexu-
ally healthy controls from the community sample
(N = 63), the combined group of women with
FSD from the community sample (N = 75), and
women with HSDD from the community sample
(N = 30). Most notably, correlations between Emo-
tional Bonding Cues and Romantic/Implicit Cues
were high in magnitude for all subsamples of
FSD and sexually healthy women (all rs > 0.64).
Also noteworthy, correlations between Emotional
Bonding Cues and Visual/Proximity Cues and
correlations between Erotic/Explicit Cues and
Visual/Proximity Cues indicated moderate rela-
tionships (range of 0.37–0.59) in all groups, except
for women with HSDD. In this group of women,
correlations between these factors were lower,
r = 0.16 and r = 0.13, respectively (see Table 4).
Reliability
Cronbach’s coefficient alphas for the four factors
of the CSDS are presented in Table 5 for the
Phase I initial sample (N = 874) and the Phase II
full community sample (N = 138). All alphas were
>0.78 for both samples.
Discriminant Validity
The ability of the CSDS to differentiate between
sexually healthy women and women with FSD,
and between sexually healthy women and a subset
of FSD women with a specific diagnosis of HSDD
was assessed by comparing the mean responses of
these women on each of the four factors and the
total scale of the CSDS. Results from between-
group (HSDD vs. Controls) ANOVAs revealed
significant differences between sexually healthy
women and women with HSDD on all four factors
and total score of the CSDS. Between-group
ANOVAs that compared sexually healthy women
and women with FSD revealed significant differ-
ences between groups on the CSDS total score,
but there were no significant differences between
groups for each factor of the CSDS. It is important
to note that for all four factors and total score of
the CSDS, women in the HSDD group had the
lowest scores, sexually healthy controls had the
highest scores, and women in the FSD combined
group score values were between these two groups
(See Table 6 for means (±SD) for each individual
item, factor, and total scores of CSDS by partici-
pant group).
Concurrent/Divergent Validity
Concurrent validity was assessed by calculating
relations between the four factor scores and the
total score of the CSDS with the FSFI desire
domain scores for women with HSDD (N = 30).
Correlational results indicated that, although the
two scales are related, they clearly do not measure
the same construct (range in Pearson’s correlation
coefficients = 0.10–0.24, with none reaching sta-
tistical significance).
844 McCall and Meston
J Sex Med 2006;3:838–852
Predictors of Sexual Desire Cues
Predictors of how women scored on the different
factors of the CSDS were examined using simple
linear regression analyses. The examined predic-
tor variables included: age, level of sexual dysfunc-
tion (FSFI total scores), marital status (single/
divorced vs. married), having children (Yes/No),
and depressive symptomology (BDI scores).
Age, depressive symptomology, and whether a
woman had children were not significant predic-
tors of the CSDS total score or any of the indi-
vidual factor scores. Level of sexual functioning
significantly predicted Factor 1 (i.e., Emotional
Bonding Cues), Factor 2 (Erotic/Explicit Cues),
Factor 4 (Romantic/Implicit Cues), and total
scores of the CSDS. That is, women with higher
sexual function scores had higher scores for Fac-
tors 1, 2, and 4 and total score of the CSDS (all
ts ≥ 2.28, all Ps ≤ 0.03). Additionally, marital status
significantly predicted Factor 1 and total scores of
the CSDS. Specifically, unmarried women indi-
cated higher scores for Emotional/Bonding Cues
and total score values for the CSDS. For further
details, see Table 7.
Table 3 Phase II confirmatory factor analysis of the 40-item CSDS in a community sample
Item
Factors
1234
Emotional Bonding Cues
1. Feeling a sense of love with a partner 0.75
2. Feeling a sense of security in your relationship 0.76
3. Your partner is supportive of you 0.79
4. Your partner does “special” or “loving” things for you 0.70
5. Feeling a sense of commitment from a partner 0.89
6. Your partner expresses interest in hearing about you 0.66
7. Talking about the future with your partner 0.66
8. Feeling protected by a partner 0.56
9. Experiencing emotional closeness with a partner 0.49
10. Feeling protective of a partner 0.62
Explicit/Erotic Cues
1. Watching an erotic movie 0.76
2. Reading about sexual activity (e.g., pornographic magazine) 0.75
3. Watching or listening to other people engage in sexual behavior/activity 0.83
4. Talking about sexual activity or “talking dirty” 0.65
5. Watching a strip tease 0.57
6. Sensing your own or your partner’s wetness, lubrication, or erection 0.59
7. Asking for or anticipating sexual activity 0.55
8. Hearing your partner tell you that he or she fantasized about you 0.68
9. Having a sexual fantasy (e.g., having a sexual dream, daydreaming) 0.66
10. You experience genital sensations (e.g., increased blood flow to genitals) 0.43
Visual/Proximity Cues
1. Seeing someone who is well-dressed or “has class” 0.65
2. Seeing/talking with someone powerful 0.76
3. Being in close proximity with attractive people 0.71
4. Seeing/talking with someone famous 0.69
5. Seeing a well-toned body 0.59
6. Seeing/talking with someone wealthy 0.78
7. Watching someone engage in physical activities (e.g., sports) 0.51
8. Seeing someone act confidently 0.47 0.51
9. Seeing/talking with someone intelligent 0.61
10. Flirting with someone or having someone flirt with you 0.62
Romantic/Implicit Cues
1. Whispering into your partner’s ear/having your partner whisper into your ear 0.62
2. Dancing closely 0.73
3. Watching a sunset 0.60
4. Having a romantic dinner with a partner 0.68
5. Watching a romantic movie 0.63
6. Being in a hot tub 0.61
7. Touching your partner’s hair or face 0.52
8. Giving or receiving a massage 0.71
9. Laughing with a romantic partner 0.57
10. Smelling pleasant scents (e.g., perfume/cologne, shampoo, aftershave) 0.51
Factor loadings which are inconsistent with those from Phase I have been placed in italics.
CSDS = Cues for Sexual Desire Scale.
Cues Resulting in Desire for Sexual Activity 845
J Sex Med 2006;3:838–852
Predictive Validity of CSDS
To begin examining the predictive validity of the
CSDS, we conducted simple linear regression
analyses using all four factor scores of the CSDS
as predictor variables and FSFI desire and arousal
domain scores as outcome variables. Additionally,
separate univariate ANOVAs were conducted using
each CSDS factor score as the dependent variable
and frequency of sexual activity as the independent
variable. In particular, we were interested in
whether these cues for sexual desire predicted the
frequency of sexual activity, frequency and degree
of sexual interest or desire, and frequency and
degree feelings of being sexually aroused.
Factor 2 (i.e., Erotic/Explicit Cues) and Factor
4 (i.e., Implicit/Romantic Cues) both significantly
predicted FSFI desire domain scores and FSFI
arousal domain scores, whereas Factors 1 (i.e.,
Emotional Bonding Cues) and Factor 3 (i.e.,
Visual/Proximity Cues) did not significantly pre-
dict either FSFI desire or arousal domain scores
(see Table 8). Univariate ANOVAs revealed that
the four factors and total score of the CSDS also
predicted frequency of sexual activity, F (4,
134) = 2.67, P = 0.04, F (4, 134) = 3.28, P = 0.01,
F (4, 134) = 1.37, P = 0.07, F (4, 134) = 3.18,
P = 0.01, F (1, 134) = 3.46, P = 0.01, respectively,
for Factors 1, 2, 3, 4, and total score of the
CSDS. Examination of the means showed that as
cues for sexual desire increased, reported fre-
quency of sexual activity generally increased as
well.
Table 4 CSDS factor intercorrelations
Emotional
Bonding Cues
Erotic
Explicit Cues
Visual/
Proximity Cues
Romantic/
Implicit Cues
Initial sample (N = 874)
Emotional Bonding Cues 1.00 0.37 0.57 0.66
Erotic Explicit Cues — 1.00 0.41 0.51
Visual/Proximity Cues — — 1.00 0.57
Romantic/Implicit Cues — — — 1.00
Full community sample (N = 138)
Emotional Bonding Cues 1.00 0.31** 0.44** 0.67**
Erotic Explicit Cues — 1.00 0.37** 0.41**
Visual/Proximity Cues — — 1.00 0.44**
Romantic/Implicit Cues — — — 1.00
Community sample, controls only (N = 63)
Emotional Bonding Cues 1.00 0.17** 0.48** 0.64**
Erotic Explicit Cues — 1.00 0.35** 0.28**
Visual/Proximity Cues — — 1.00 0.38**
Romantic/Implicit Cues — — — 1.00
Community sample, all FSD women (N = 75)
Emotional Bonding Cues 1.00 0.40** 0.39** 0.68**
Erotic Explicit Cues — 1.00 0.38** 0.51**
Visual/Proximity Cues — — 1.00 0.48**
Romantic/Implicit Cues — — — 1.00
Community sample, HSDD women only (N = 30)
Emotional Bonding Cues 1.00 0.35** 0.16** 0.71**
Erotic Explicit Cues — 1.00 0.13** 0.33**
Visual/Proximity Cues — — 1.00 0.27**
Romantic/Implicit Cues — — — 1.00
**Correlation is significant at the 0.01 level (two-tailed).
CSDS = Cues for Sexual Desire Scale; FSD = female sexual dysfunction; HSDD = hypoactive sexual desire disorder.
Table 5 CSDS factor reliability
Factor
Initial
sample
N = 874
Full community
sample
N = 139
Community sample,
HSDD women only
N = 30
Community sample,
all FSD women
N = 75
Community sample,
control women only
N = 63
Emotional Bonding Cues 0.91 0.92 0.92 0.93 0.90
Erotic Explicit Cues 0.90 0.87 0.78 0.86 0.87
Visual/Proximity Cues 0.87 0.87 0.87 0.88 0.87
Romantic/Implicit Cues 0.86 0.88 0.88 0.88 0.89
Cronbach’s alpha (range = −1.00 to +1.00).
CSDS = Cues for Sexual Desire Scale.
846 McCall and Meston
J Sex Med 2006;3:838–852
Discussion
The purpose of the present study was to create a
multidimensional assessment of cues associated
with sexual desire in women. The resulting 40-
item CSDS provided four distinct factors that
highlight different clusters of cues associated with
female sexual desire. These factors were labeled as:
(i) Emotional Bonding Cues; (ii) Erotic/Explicit
Cues; (iii) Visual/Proximity Cues; and (iv) Implicit/
Romantic Cues. The CSDS reflected validity by
successfully demonstrating predictable differences
between women with and without HSDD.
A secondary analysis was conducted to examine
whether specific individual characteristics of the
women in our sample predicted their CSDS total
score and/or individual factor scores. Variables
which were examined included: age, level of sexual
Table 6 CSDS discriminant validity
Item
HSDD
(N = 30)
mean
(±SD)
Controls
(N = 62)
mean
(±SD)
FSD combined
(N = 72)
mean
(±SD)
Emotional Bonding Cues 2.65 (0.88)* 3.10 (0.84)†2.86 (0.95)
1. Feeling a sense of love with a partner 2.80 (1.22) 3.50 (1.18) 3.17 (1.26)
2. Feeling a sense of security in your relationship 2.40 (1.30) 3.05 (1.27) 2.67 (1.33)
3. Your partner is supportive of you 3.00 (1.19) 3.37 (1.32) 3.16 (1.25)
4. Your partner does “special” or “loving” things for you 2.73 (1.08) 3.27 (1.01) 2.99 (1.13)
5. Feeling a sense of commitment from a partner 2.46 (1.32) 2.89 (1.18) 2.67 (1.36)
6. Your partner expresses interest in hearing about you 2.30 (1.12) 2.94 (1.10) 2.63 (1.26)
7. Talking about the future with your partner 1.93 (0.86) 2.54 (1.20) 2.27 (1.11)
8. Feeling protected by a partner 2.63 (1.25) 2.81 (1.09) 2.65 (1.25)
9. Experiencing emotional closeness with a partner 3.60 (1.19) 4.27 (0.85) 3.92 (1.09)
10. Feeling protective of a partner 2.03 (1.10) 2.18 (1.27) 2.11 (1.21)
Explicit/Erotic Cues 3.31 (0.65)* 3.78 (0.80)†3.63 (0.77)
1. Watching an erotic movie 3.20 (1.16) 3.32 (1.46) 3.35 (1.27)
2. Reading about sexual activity (e.g., pornographic magazine) 3.32 (1.06) 3.43 (1.42) 3.27 (1.26)
3. Watching or listening to other people engage in sexual behavior/activity 2.86 (1.30) 3.21 (1.39) 3.19 (1.35)
4. Talking about sexual activity or “talking dirty” 3.07 (1.14) 3.76 (1.14) 3.56 (1.18)
5. Watching a strip tease 2.79 (1.37) 2.67 (1.23) 3.04 (1.32)
6. Sensing your own or your partner’s wetness, lubrication, or erection 3.48 (0.87) 4.41 (0.87) 3.97 (0.94)
7. Asking for or anticipating sexual activity 3.57 (0.94) 4.49 (0.78) 4.00 (0.97)
8. Hearing your partner tell you that he or she fantasized about you 3.11 (1.20) 4.06 (1.13) 3.53 (1.23)
9. Having a sexual fantasy (e.g., having a sexual dream, daydreaming) 3.57 (1.00) 3.87 (1.04) 3.78 (1.06)
10. You experience genital sensations (e.g., increased blood flow to genitals) 3.93 (1.02) 4.60 (0.75) 4.37 (0.84)
Visual/Proximity Cues 1.94 (0.75)* 2.27 (0.80)†2.09 (0.79)
1. Seeing someone who is well-dressed or “has class” 1.67 (1.09) 1.94 (1.05) 1.80 (1.16)
2. Seeing/talking with someone powerful 1.60 (0.89) 2.02 (1.25) 1.85 (1.21)
3. Being in close proximity with attractive people 2.33 (1.32) 2.63 (1.30) 2.59 (1.29)
4. Seeing/talking with someone famous 1.50 (0.92) 1.65 (0.92) 1.58 (1.03)
5. Seeing a well-toned body 2.23 (1.22) 2.68 (1.06) 2.44 (1.14)
6. Seeing/talking with someone wealthy 1.21 (0.63) 1.44 (0.78) 1.30 (0.76)
7. Watching someone engage in physical activities (e.g., sports) 1.96 (1.23) 2.22 (1.30) 2.03 (1.17)
8. Seeing someone act confidently 1.77 (1.07) 2.50 (1.29) 2.12 (1.21)
9. Seeing/talking with someone intelligent 2.39 (1.47) 2.79 (1.49) 2.60 (1.42)
10. Flirting with someone or having someone flirt with you 3.00 (1.09) 2.78 (1.29) 2.95 (1.08)
Romantic/Implicit Cues 2.59 (0.78)*‡3.11 (0.86)†2.84 (0.80)
1. Whispering into your partner’s ear or having your partner whisper into your ear 2.40 (1.16) 3.35 (1.25) 2.72 (1.23)
2. Dancing closely 3.20 (1.10) 3.59 (1.09) 3.33 (1.08)
3. Watching a sunset 1.93 (1.02) 2.17 (1.17) 2.00 (0.96)
4. Having a romantic dinner with a partner 2.67 (1.06) 3.41 (1.15) 3.03 (1.13)
5. Watching a romantic movie 2.40 (1.10) 3.03 (1.20) 2.83 (1.23)
6. Being in a hot tub 2.77 (1.22) 3.37 (1.32) 3.25 (1.22)
7. Touching your partner’s hair or face 2.23 (1.28) 2.59 (1.20) 2.39 (1.16)
8. Giving or receiving a massage 3.21 (1.13) 3.67 (1.22) 3.40 (1.18)
9. Laughing with a romantic partner 2.30 (1.40) 2.56 (1.25) 2.40 (1.22)
10. Smelling pleasant scents (e.g., perfume, cologne, shampoo, aftershave) 2.67 (0.96) 3.37 (1.26) 3.00 (1.19)
CSDS total score 10.45 (2.16)*‡12.31 (2.45)†11.45 (2.58)*
*Significant difference from controls.
†Significant difference from HSDD.
‡Significant difference from FSD combined.
CSDS = Cues for Sexual Desire Scale; FSD = female sexual dysfunction; HSDD = hypoactive sexual desire disorder.
Cues Resulting in Desire for Sexual Activity 847
J Sex Med 2006;3:838–852
dysfunction, marital status, having children, and
depressive symptomology. When all variables
were entered into one regression equation, a
woman’s age, having children, and depressive
symptomology did not predict scores on the
CSDS. This finding is particularly interesting
given that past research has often indicated that
age, having children, and depression are strongly
linked to sexual desire. For example, in Laumann,
Paik, and Rosen’s report [1], the prevalence of
sexual dysfunction decreased with increased age
for women (with the exception of vaginal lubrica-
tion concerns) and Cyranowski, Frank, Cherry,
Houck, and Kupfer [25] found a strong link
between depressive symptoms and sexual desire.
One possible explanation for these discrepant
findings could be related to a restricted range in
our sample. However, given that ages ranged from
18 to 53 years, BDI scores ranged from 0 to 30
and 23 of the 138 women in our sample had chil-
dren, it is unlikely that these differences could be
solely accounted for by a restricted range in our
data. It is possible, that although desire itself may
“wax and wane” throughout life and across situa-
tions, that cues that result in sexual desire may
reflect a more stable pattern.
Factors which did predict CSDS scores in-
cluded marital status and level of sexual function-
ing. Specifically, women with higher levels of
sexual dysfunction had lower scores on Factors 1,
2, and 4 and total score of the CSDS. The fact that
a woman’s level of sexual functioning was related
to cues for sexual desire seems intuitive as the
relative lack of cues for sexual desire could be
partly responsible and/or related to present sexual
concerns or problems. Additionally, married
women had lower scores for Emotional/Bonding
Cues and total score values for the CSDS as com-
pared with women who were unmarried. The
finding that married women endorsed fewer cues
for sexual desire is inconsistent with Laumann,
Paik, and Rosen’s [1] findings that unmarried
women had elevated rates of sexual problems as
compared with married women. It is possible that
as length of relationship increases, although sexual
desire increases, habituation to specific sexual cues
also occurs.
Also interesting to note, examination of domain
intercorrelations indicated that correlations
between Emotional Bonding Cues and Visual/
Proximity Cues and correlations between Erotic/
Explicit Cues and Visual/Proximity Cues were
lower for women with HSDD as compared with
all groups of women examined in this study. This
finding is theoretically interesting, as it suggests
that these constructs may be related to a lesser
degree in women with sexual desire problems.
Table 7 Simple linear regression for the prediction of the
CSDS
CSDS
Statistical Test
R2FB t P
Factor 1 0.06 2.56 0.03*
Age −0.02 −0.19 0.85
Children −0.06 −0.55 0.58
Marital status 0.23 2.36 0.02*
BDI total 0.17 1.68 0.10
FSFI total 0.23 2.28 0.03*
Factor 2 0.17 5.63 <0.001*
Age −0.18 −1.85 0.07
Children 0.07 0.79 0.43
Marital status 0.03 0.33 0.75
BDI total 0.12 1.29 0.20
FSFI total 0.40 4.22 <0.001*
Factor 3 0.03 1.07 0.38
Age −0.08 −0.77 0.44
Children 0.03 0.29 0.77
Marital status 0.09 0.94 0.35
BDI total 0.16 1.54 0.13
FSFI total 0.12 1.14 0.26
Factor 4 0.07 2.84 0.01*
Age 0.03 0.32 0.75
Children −0.01 −0.12 0.91
Marital status 0.15 1.60 0.11
BDI total 0.02 0.21 0.84
FSFI total 0.30 3.00 0.003*
Factor total 0.11 3.93 0.003*
Age 0.08 0.84 0.40
Children 0.01 0.06 0.95
Marital status 0.17 1.86 0.05*
BDI total 0.16 1.58 0.19
FSFI total 0.34 3.48 0.001*
*Significant at the 0.05 level.
Factor 1 = Emotional Bonding Cues, Factor 2 = Erotic/Explicit Cues, Factor
3 = Visual/Proximity Cues, and Factor 4 = Romantic/Implicit Cues.
FSD = female sexual dysfunction; BDI = Beck Depression Inventory;
FSFI = Female Sexual Function Index.
Table 8 Linear regression results of predictive validity of
CSDS
Statistical Test
CSDS R2FBt P
FSFI desire domain 0.07 10.63 0.001*
CSDS Factor 1 0.05 0.49 0.624
CSDS Factor 2 0.31 3.42 0.001*
CSDS Factor 3 −0.04 −0.39 0.700
CSDS Factor 4 0.22 1.94 0.05*
FSFI arousal domain 0.04 6.80 0.01*
CSDS Factor 1 0.05 0.43 0.67
CSDS Factor 2 0.34 3.69 <0.001*
CSDS Factor 3 −0.16 −1.74 0.08
CSDS Factor 4 0.22 1.93 0.05*
*Significant at the 0.05 level.
Factor 1 = Emotional Bonding Cues, Factor 2 = Erotic/Explicit Cues, Factor
3 = Visual/Proximity Cues, and Factor 4 = Romantic/Implicit Cues.
CSDS = Cues for Sexual Desire Scale; FSFI = Female Sexual Function Index.
848 McCall and Meston
J Sex Med 2006;3:838–852
An investigation of the predictive validity of the
CSDS indicated that although CSDS total scores
did predict FSFI desire and domain scores, inspec-
tion of each factor showed that only Factors 2 (i.e.,
Erotic/Explicit Cues) and 4 (i.e., Romantic/
Implicit Cues) significantly predicted FSFI desire
and arousal domain scores. Additionally, CSDS
total score and each factor score was related to
reported frequency of sexual activity, such that
women who indicated having more cues for sexual
desire were more likely to engage in more fre-
quent sexual activity.
In summary, findings from the present study
provide valuable information regarding both
internal and external triggers that can result in
sexual desire for women. In 1998, the Sexual
Function Health Council of the American Foun-
dation of Urologic Disease invited experts in the
field of sexual health to a consensus conference to
consider and discuss the diagnostic criteria being
used for FSDs [26]. Many researchers and clini-
cians felt that the DSM-IV [20] diagnostic catego-
ries being used for FSD were limited, and the
publications that have resulted from this meeting
and subsequent discussions (e.g., [26–29]) have
been an attempt to review and update the classi-
fication of female sexual problems. One of the
major modifications was in the conceptualization
of female sexual desire and the diagnostic criteria
for HSDD in women. The new conceptualization
of sexual desire emphasizes the importance of con-
sidering a woman’s receptivity to sexual stimuli, in
addition to her intrinsic or innate feelings of sexual
desire. This change was based on the observation
that the majority of women report infrequent
“spontaneous desire” [30–33] and because sexual
desire is frequently experienced only after expo-
sure to sexual stimuli [28]. Subsequently, sexual
interest/desire disorder was redefined as: “Absent
or diminished feelings of sexual interest or desire,
absent sexual thoughts or fantasies and a lack of
responsive desire,” whereas the “additional lack
of responsive desire is essential to the diagnosis of
dysfunction” [28]. Thus, concerns with low sexual
desire in women are currently being viewed more
as an inability to “trigger” or access desire when
sexual stimuli are present, as opposed to a lack of
spontaneous feelings of sexual desire. The present
article provides a comprehensive empiric catego-
rization of such triggers for sexual desire in
women.
The ongoing discussion regarding the concep-
tualization of female sexual desire dysfunction, as
well as the findings from the present study, draws
attention to the limitations of using the DSM-IV-
TR criteria for HSDD as entry criteria when
recruiting for clinical trials evaluating treatments
for low sexual desire in women. (For a review and
recommendations regarding outcome measure-
ments in clinical trials of FSD, see [34].)
Limitations of the present study worth noting
include the young age of women in the community
sample (mean age = 27.5 years, SD = 8.3 years)
and the relatively small sample size of women
with HSDD (N = 30). Given the prevalence of
reported changes in sexual desire for women
undergoing menopausal transition [35,36], we are
currently investigating the reliability and validity
of the CSDS in pre- and postmenopausal women
with and without diagnosed HSDD. If the find-
ings reported here are replicated, then we believe
the CSDS can be used to inform both researchers
and clinicians regarding how a particular woman
is attending and responding to sexual cues. In par-
ticular, we believe that the CSDS could be bene-
ficial in therapeutic settings to help identify cues
that do and do not facilitate sexual desire in
women with clinically diagnosed desire difficul-
ties. This knowledge would inform both the
patient and the clinician of specific areas to target
in attempting to enhance sexual desire.
Acknowledgments
This publication was made possible by Grant Number
5 RO1 AT00224-02 from the National Center for
Complementary and Alternative Medicine to the sec-
ond author. Its contents are solely the responsibility of
the authors and do not necessarily represent the views
of the National Center for Complementary and Alter-
native Medicine.
The authors wish to thank Greg Hixon for his assis-
tance with data analysis.
Corresponding Author: Katie McCall, MA, Univer-
sity of Texas at Austin—Clinical Psychology, 1 Univer-
sity Station Campus Mail Code: A8000 Austin TX
78712, USA. Tel: (512) 232-4805; Fax: (512) 471-5935;
E-mail: kmccall@mail.utexas.edu
Conflict of Interest: None declared.
References
1 Laumann EO, Paik A, Rosen RC. Sexual dysfunc-
tion in the United States: Prevalence and predictors.
J Am Med Assoc 1999;10:537–45.
2 Chandraiah S, Levenson JL, Collins JB. Sexual
dysfunction, social maladjustment, and psychiatric
disorders in women seeking treatment in a premen-
Cues Resulting in Desire for Sexual Activity 849
J Sex Med 2006;3:838–852
strual syndrome clinic. Int J Psychiatry Med 1991;
21:189–204.
3 Bhui K, Herriot P, Dein S, Watson JP. Asians pre-
senting to a sex and marital therapy clinic. Int J Soc
Psychiatry 1994;40:194–204.
4 Fass R, Fullerton S, Naliboff B, Hirsh T, Mayer EA.
Sexual dysfunction in patients with irritable bowel
syndrome and non-ulcer dyspepsia. Digestion 1998;
59:78–85.
5 Jamieson D, Steege J. The prevalence of dysmenor-
rhea, dyspareunia, pelvic pain, and irritable bowel
syndrome in primary care practices. Obstet Gynecol
1996;1:55–8.
6 Heiman JR, Meston CM. Empirically validated
treatments for sexual dysfunction. In: Dobson KS,
Craig KD, eds. Empirically supported therapies:
Best practice in professional psychology. New York:
Sage Publications; 1998:259–303.
7 DeAmicis L, Goldberg DC, LoPiccolo J, Friedman
J, Davies L. Clinical follow-up of couples treated for
sexual dysfunction. Arch Sex Behav 1985;14:467–89.
8 LoPiccolo J, Heiman JR, Hogan DR, Roberts CW.
Effectiveness of single therapists versus cotherapy
teams in sex therapy. J Consult Clin Psychol 1985;
53:287–94.
9 Kilmann PR, Boland JP, Norton SP, Davidson E,
Caid C. Perspectives of sex therapy outcome: A sur-
vey of AASECT providers. J Sex Marital Ther
1986;12:116–38.
10 Levine SB. What patients mean by love, intimacy,
and sexual desire. In: Levine SB, Risen CB, eds.
Handbook of clinical sexuality for mental health
professionals. New York: Brunner-Routledge; 2003:
21–36.
11 Goldstein A, Brandon M. Reclaiming desire: Four
keys to finding your lost libido. New York: St.
Martin’s Press; 2004.
12 Leiblum S, Sachs J. Getting the sex you want: A
woman’s guide to becoming proud, passionate, and
pleased in bed. New York: Crown Publishers; 2002.
13 Pridal CG, LoPiccolo J. Multielement treatment of
desire disorders: Integration of cognitive, behav-
ioral, and systemic therapy. In: Leiblum SR, Rosen
RC, eds. Principles and practice of sex therapy. New
York: Guilford Press; 2000:57–81.
14 Abbey A, Zawacki T, Buck PO. The effects of past
sexual assault perpetration and alcohol consumption
on men’s reactions to women’s mixed signals. J Soc
Clin Psychol 2005;24:129–55.
15 McDonel EC, McFall RM. Construct validity
of two heterosocial perception skill measures for
assessing rape proclivity. Violence Vict 1991;6:17–
30.
16 Kenyon-Jump R. Detection of sexual cues: An
assessment of nonaggressive and sexually coercive
college males. Dissert Abstr Int 1993;53B:6557.
17 Regan PC, Berscheid E. Gender differences in
beliefs about the causes of male and female sexual
desire. Pers Relat 1995;2:345–58.
18 Rosen R, Brown C, Heiman J, Leiblum S, Meston
C, Shabsigh R. The female sexual function index
(FSFI): A multi-dimensional self-report instrument
for the assessment of female sexual function. J Sex
Marital Ther 2000;26:191–208.
19 Sills T, Wunderlich G, Pyke R, Segraves RT. The
sexual interest and desire inventory—Female (SIDI-
F): Item response analyses of data from women
diagnosed with hypoactive sexual desire disorder. J
Sex Med 2005;2:801–18.
20 American Psychiatric Association. Diagnostic and
statistical manual of mental disorders, 4th edn.
Washington, DC: Author; 2000:493–522.
21 Beck AT, Steer RA, Garbin MG. Psychometric
properties of the Beck Depression Inventory:
Twenty-five years of evaluation. Clin Psychol Rev
1988;8:77–100.
22 Meston CM. Validation of the Female Sexual
Function Index (FSFI) in women with Female
Orgasmic Disorder and in women with Hypoactive
Sexual Desire Disorder. J Sex Marital Ther 2003;29:
39–46.
23 Wiegel M, Meston C, Rosen RC. The female sexual
function index (FSFI): Cross-validation and devel-
opment of clinical cutoff scores. J Sex Marital Ther
2005;31:1–20.
24 Canals J, Blade J, Carbajo G, Domenech-Llaberia
E. The beck depression inventory: Psychometric
characteristics and usefulness in nonclinical adoles-
cents. Eur J Psychol Assess 2001;17:63–8.
25 Cyranowski JM, Frank E, Cherry C, Houck P,
Kupfer DJ. Prospective assessment of sexual func-
tion in women treated for recurrent major depres-
sion. J Psychiatr Res 2004;38:267–73.
26 Leiblum S. Critical overview of the new consensus-
based definitions and classification of female sexual
dysfunction. J Sex Marital Ther 2001;27:159–68.
27 Basson R, Berman J, Burnett A, Derogatis L. Report
of the international consensus development confer-
ence on female sexual dysfunction: Definitions and
classifications. J Sex Marital Ther 2001;27:83–94.
28 Basson R, Leiblum S, Brotto L, Derogatis L. Defi-
nitions of women’s sexual dysfunction reconsidered:
Advocating expansion and revision. J Psychosom
Obstet Gynaecol 2003;24:221–9.
29 Basson R, Leiblum S, Brotto L, Derogatis L.
Revised definitions of women’s sexual dysfunction.
J Sex Med 2004;1:40–8.
30 Lunde L, Larson GK, Fog E, Garde K. Sexual
desire, orgasm, and sexual fantasies: A study of 625
Danish women born in 1910, 1936 and 1958. J Sex
Educ Ther 1991;17:111–5.
31 Hill CA, Preston LK. Individual differences in the
experience of sexual motivation: Theory and mea-
surement of dispositional sexual motives. J Sex Res
1996;33:27–45.
32 Galyer KT, Conaglen HM, Hare A, Conaglen JV.
The effect of gynecological surgery on sexual desire.
J Sex Marital Ther 1999;25:81–8.
850 McCall and Meston
J Sex Med 2006;3:838–852
33 Regan P, Berscheid E. Belief about the states, goals
and objects of sexual desire. J Sex Marital Ther
1996;22:110–20.
34 Althof SE, Rosen RC, Derogatis L, Cory E. Out-
come measurement in female sexual dysfunction
clinical trials: Review and recommendations. J Sex
Marital Ther 2005;31:153–66.
35 Dennerstein L, Goldstein I. Postmenopausal female
sexual dysfunction: At a crossroads. J Sex Med
2005;2:116–7.
36 Dennerstein L, Hayes RD. Confronting the chal-
lenges: Epidemiological study of female sexual dys-
function and the menopause. J Sex Med 2005;2:
118–32.
Appendix 1
Instructions:
Different factors cause different people to desire sexual activity (e.g., intercourse, kissing, oral sex,
petting, masturbation). Use the scale below to indicate what the likelihood is that each of the following
factors or cues would lead you to desire sexual activity.
12 3 45
Not at
all likely
Somewhat
likely
Moderately
likely
Very
likely
Extremely
likely
1Touching your par tner’s hair 1 2 3 4 5
2 Laughing with a romantic par tner 1 2 3 4 5
3 Dancing closely 1 2 3 4 5
4 Whispering into your partner’s ear 1 2 3 4 5
5 Nibbling on your partner’s neck 1 2 3 4 5
6 Seeing/talking with someone powerful 1 2 3 4 5
7 Engaging in competitive physical activity with a partner (i.e., tennis) 1 2 3 4 5
8 Engaging in competitive nonphysical activity with a partner
(i.e., Scrabble)
12 3 45
9Feeling protected by a partner 1 2 3 4 5
10 Achieving a success (e.g., promotion, good grade) 1 2 3 4 5
11 Experiencing emotional closeness with a partner 1 2 3 4 5
12 You experience genital sensations 1 2 3 4 5
13 Being in close proximity with attractive people 1 2 3 4 5
14 Talking about sexual activity 1 2 3 4 5
15 Having a romantic dinner with a partner 1 2 3 4 5
16 Being in a hot tub 1 2 3 4 5
17 Watching movies 1 2 3 4 5
18 Engaging in intercourse 1 2 3 4 5
19 Giving a massage 1 2 3 4 5
20 Being naked with someone of the opposite sex 1 2 3 4 5
21 Smelling pleasant scents (e.g., perfume/cologne, shampoo,
aftershave)
12 3 45
22 Receiving direct physical genital stimulation 1 2 3 4 5
23 Having a sexual dream 1 2 3 4 5
24 Seeing someone dressed provocatively 1 2 3 4 5
25 Touching your partner’s hair 1 2 3 4 5
26 Watching a sunset 1 2 3 4 5
27 Sharing a private smirk/grin 1 2 3 4 5
28 Seeing someone who is well-dressed or “has class” 1 2 3 4 5
29 Seeing a well-toned body 1 2 3 4 5
30 Talking about past shared experiences with a partner 1 2 3 4 5
31 Feeling like you look good 1 2 3 4 5
32 Anticipating sexual activity 1 2 3 4 5
33 Wearing sexy underwear 1 2 3 4 5
34 Holding hands 1 2 3 4 5
35 Reading a pornographic magazine 1 2 3 4 5
36 “Talking dirty” 1 2 3 4 5
37 Sensing your own/your partner’s erection 1 2 3 4 5
38 Seeing your par tner dressed up 1 2 3 4 5
39 Resolving a “heated” fight 1 2 3 4 5
40 Flirting with someone 1 2 3 4 5
41 Having someone flir t with you 1 2 3 4 5
42 Talking about the future with your partner 1 2 3 4 5
43 Watching a strip tease 1 2 3 4 5
44 Seeing/talking with someone famous 1 2 3 4 5
45 Soft kissing 1 2 3 4 5
46 Seeing/talking with someone wealthy 1 2 3 4 5
47 You experience increased blood flow to the genitals 1 2 3 4 5
48 Feeling a sense of connectedness 1 2 3 4 5
49 Being dressed up 1 2 3 4 5
Cues Resulting in Desire for Sexual Activity 851
J Sex Med 2006;3:838–852
50 Alcohol consumption 1 2 3 4 5
51 Having a sexual fantasy (daydreaming) 1 2 3 4 5
52 Feeling lonely 1 2 3 4 5
53 Reading about sexual activity 1 2 3 4 5
54 Engaging in eye contact 1 2 3 4 5
55 Asking for sex or sexual activity 1 2 3 4 5
56 Listening to other people engage in sexual behavior/activity 1 2 3 4 5
57 Feeling a desire to have children 1 2 3 4 5
58 Getting high on drugs 1 2 3 4 5
59 Having your partner whisper into your ear 1 2 3 4 5
60 Dressing provocatively (you) 1 2 3 4 5
61 Feeling a sense of commitment from a par tner 1 2 3 4 5
62 Talking “baby talk” 1 2 3 4 5
63 Hearing your partner talking “baby talk” 1 2 3 4 5
64 Receiving gifts from your partner 1 2 3 4 5
65 Hearing a sexy voice 1 2 3 4 5
66 Engaging in oral sex 1 2 3 4 5
67 Engaging in risky sexual behavior (i.e., having sex in public) 1 2 3 4 5
68 Engaging in intimate conversation 1 2 3 4 5
69 Watching a romantic movie 1 2 3 4 5
70 Tickling each other 1 2 3 4 5
71 Play wrestling with your partner 1 2 3 4 5
72 Taking a walk with your partner 1 2 3 4 5
73 Having a picnic in the park with your partner 1 2 3 4 5
74 You experience an increased heart rate 1 2 3 4 5
75 Watching someone engage in physical activities (e.g., sports) 1 2 3 4 5
76 Watching your partner or helping your partner get dressed for
a “formal”
12 3 45
77 Watching other people engage in sexual behavior/activity 1 2 3 4 5
78 Hearing your partner tell you that he or she fantasized about you 1 2 3 4 5
79 Your partner does “special” things for you 1 2 3 4 5
80 Your partner is supportive of you 1 2 3 4 5
81 Reading a romance novel 1 2 3 4 5
82 Feeling strong emotions for your partner 1 2 3 4 5
83 Feeling anger 1 2 3 4 5
84 Receiving a massage 1 2 3 4 5
85 Engaging in masturbation 1 2 3 4 5
86 Lying against someone’s body 1 2 3 4 5
87 Being told you are loved 1 2 3 4 5
88 Engaging in playful behavior 1 2 3 4 5
89 Seeing/talking with someone intelligent 1 2 3 4 5
90 You have the “itch” 1 2 3 4 5
91 Saying “I love you” 1 2 3 4 5
92 Engaging in physical activity with your partner (i.e., running) 1 2 3 4 5
93 Having someone flatter you 1 2 3 4 5
94 You experience heavy breathing 1 2 3 4 5
95 When your par tner does “loving” things for you 1 2 3 4 5
96 Engaging in more “kinky” or creative sexual behavior than usual 1 2 3 4 5
97 Wearing no underwear (you) 1 2 3 4 5
98 Listening to poetry 1 2 3 4 5
99 Watching an erotic movie 1 2 3 4 5
100 Being in a fearful situation 1 2 3 4 5
101 Seeing your par tner after absence 1 2 3 4 5
102 Feeling calm and relaxed 1 2 3 4 5
103 Touching your partner’s genitals 1 2 3 4 5
104 Acting out fantasies 1 2 3 4 5
105 Feeling a sense of security in your relationship 1 2 3 4 5
106 Trying new sexual positions 1 2 3 4 5
107 Snuggling with your partner 1 2 3 4 5
108 Engaging in petting 1 2 3 4 5
109 Experiencing grief/trauma together 1 2 3 4 5
110 Deep kissing 1 2 3 4 5
111 Laying together 1 2 3 4 5
112 Seeing/talking with someone successful 1 2 3 4 5
113 Sharing a sense of humor 1 2 3 4 5
114 Engaging in heavy petting 1 2 3 4 5
115 Listening to someone talk intelligently 1 2 3 4 5
116 Feeling a sense of love with a partner 1 2 3 4 5
117 Receiving a love letter/card 1 2 3 4 5
118 Sending a love letter/card 1 2 3 4 5
12 3 45
Not at
all likely
Somewhat
likely
Moderately
likely
Very
likely
Extremely
likely
Appendix 1 Continued
852 McCall and Meston
J Sex Med 2006;3:838–852
Appendix 2
Final Version of the Cues for Sexual Desire Scale (CSDS)
Instructions:
Different factors cause different people to desire sexual activity (e.g., intercourse, kissing, oral sex,
petting, masturbation). Use the scale below to indicate what the likelihood is that each of the following
factors or cues would lead you to desire sexual activity.
119 Seeing someone act confidently 1 2 3 4 5
120 Feeling jealous 1 2 3 4 5
121 Your partner expresses interest in hearing about you 1 2 3 4 5
122 Your partner takes charge of a problem situation 1 2 3 4 5
123 Winning a sports game 1 2 3 4 5
124 Feeling protective of a partner 1 2 3 4 5
125 Sensing your own/your partner’s wetness or lubrication 1 2 3 4 5
12 3 45
Not at
all likely
Somewhat
likely
Moderately
likely
Very
likely
Extremely
likely
1Feeling a sense of love with a partner 1 2 3 4 5
2 Seeing/talking with someone intelligent 1 2 3 4 5
3Watching an erotic movie 1 2 3 4 5
4 Smelling pleasant scents (e.g., perfume, cologne, shampoo, aftershave) 1 2 3 4 5
5Watching or listening to other people engage in sexual behavior/activity 1 2 3 4 5
6Your partner expresses interest in hearing about you 1 2 3 4 5
7 Seeing/talking with someone famous 1 2 3 4 5
8 Being in a hot tub 1 2 3 4 5
9 Experiencing emotional closeness with a partner 1 2 3 4 5
10 Asking for or anticipating sexual activity 1 2 3 4 5
11 Talking about the future with your par tner 1 2 3 4 5
12 Seeing/talking with someone powerful 1 2 3 4 5
13 Having a romantic dinner with a partner 1 2 3 4 5
14 Watching someone engage in physical activities (e.g., sports) 1 2 3 4 5
15 Talking about sexual activity or “talking dirty” 1 2 3 4 5
16 Laughing with a romantic partner 1 2 3 4 5
17 Sensing your own or your partner’s wetness, lubrication, or erection 1 2 3 4 5
18 Feeling protective of a partner 1 2 3 4 5
19 Hearing your partner tell you that he or she fantasized about you 1 2 3 4 5
20 Giving or receiving a massage 1 2 3 4 5
21 Your partner is supportive of you 1 2 3 4 5
22 Dancing closely 1 2 3 4 5
23 Seeing someone who is well-dressed or “has class” 1 2 3 4 5
24 Feeling a sense of commitment from a partner 1 2 3 4 5
25 Being in close proximity with attractive people 1 2 3 4 5
26 Touching your partner’s hair or face 1 2 3 4 5
27 You experience genital sensations (e.g., increased blood flow to genitals) 1 2 3 4 5
28 Seeing/talking with someone wealthy 1 2 3 4 5
29 Your partner does “special” or “loving” things for you 1 2 3 4 5
30 Seeing someone act confidently 1 2 3 4 5
31 Having a sexual fantasy (e.g., having a sexual dream, daydreaming) 1 2 3 4 5
32 Flirting with someone or having someone flirt with you 1 2 3 4 5
33 Watching a romantic movie 1 2 3 4 5
34 Seeing a well-toned body 1 2 3 4 5
35 Feeling a sense of security in your relationship 1 2 3 4 5
36 Watching a sunset 1 2 3 4 5
37 Reading about sexual activity (e.g., pornographic magazine) 1 2 3 4 5
38 Whispering into your partner’s ear/having your partner whisper into
your ear
12 3 45
39 Watching a strip tease 1 2 3 4 5
40 Feeling protected by a partner 1 2 3 4 5
12 3 45
Not at
all likely
Somewhat
likely
Moderately
likely
Very
likely
Extremely
likely
Appendix 1 Continued
