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Asexuality : investigations into a lack of sexual attraction Yule, Morag Allison 2016

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  ASEXUALITY: INVESTIGATIONS INTO A LACK OF SEXUAL ATTRACTION  by  Morag Allison Yule  M.A., The University of British Columbia, 2011 B.A., The University of British Columbia, 2007 B.Sc., Honours, The University of Victoria, 2003   A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY   in   The Faculty of Graduate and Postdoctoral Studies  (Psychology)    THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)       July 2016   © Morag Allison Yule, 2016  ii Abstract Human asexuality is generally defined as a lack of sexual attraction. Various theories have been proposed to explain how asexuality should best be conceptualized, including that asexuality should be classified as a sexual orientation, that it is due to a mental health difficulty, that it is an extreme variant of hypoactive sexual desire disorder (HSDD), or that some asexual individuals actually experience a paraphilia of some kind. This dissertation employed a series of Internet-based research studies to investigate these three topics: an examination into mental health correlates of asexuality, a comparison of asexual individuals with individuals who meet diagnostic criteria for HSDD, and an investigation into patterns of sexual fantasy among asexual individuals. By investigating these topics, I sought to test whether asexuality might be a psychopathology, sexual dysfunction, or a paraphilia, with the ultimate goal of testing my hypothesis that asexuality is, in fact, a unique sexual orientation.  My findings suggested that asexuality may be associated with higher prevalence of mental health and interpersonal problems, including anxiety, hostility, phobic anxiety, psychoticism, and suicidality, but that it is not, itself, a mental disorder. I concluded that this may be in response to perceived stigma against their sexual orientation, which might lead to psychological symptoms, or that lack of sexual attraction may arise from an underlying difficulty such as Autism Spectrum Disorder. Next, I found that asexuality is unique from the well-known sexual dysfunction HSDD. In my test of whether asexuality was a paraphilia, I found that asexual individuals were less likely to masturbate than sexual individuals, and that they were more likely to report never having had a sexual fantasy. Further, there was a large amount of  iii unexpected overlap in the content of sexual fantasies between asexual and sexual participants. Together, these findings suggest that at least some asexual individuals may have a paraphilic characterization. Overall, this dissertation highlights that no single theory can explain asexuality, and underscores the diversity among the asexual population. This dissertation leads to a number of new hypotheses about the nature of asexuality that will be the focus of future research.    iv Preface Ethics approval for the studies included in this dissertation was obtained from the University of British Columbia’s Behavioural Research Ethics Board (Certificate Numbers: H09-00671, H10-03130 & H14-01469).  The research in this dissertation has led to several peer-reviewed publications in well-known academic journals. These publications are included in the appropriate chapters. Modifications of some of the published material have been made to reduce redundancies throughout this dissertation and to improve continuity between chapters. However, there may continue to be some overlap in content between sections and chapters. I carried out all research under the supervision of Drs. Lori Brotto and Boris Gorzalka, was responsible for the majority of writing, data analysis, and manuscript preparation of all first-author publications, and played a significant role in manuscript preparation, data analysis, and writing of the co-authored publication. All reprints used with permission.  Relevant publications are as follows, by chapter:  Chapter 2: Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2013). Mental health and interpersonal functioning among asexual individuals. Psychology & Sexuality, 4(2), 136-151.  DOI:10.1080/19419899.2013.774162. Chapter 3: Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). 646-660. DOI: 10.1111/jsm.12806  v Chapter 4: Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409 Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (Provisionally Accepted). An in-depth exploration of sexual fantasy among asexual individuals. Archives of Sexual Behaviour.     vi Table of Contents Abstract ........................................................................................................................................ ii Preface ......................................................................................................................................... iv Table of Contents ..................................................................................................................... vi List of Tables ........................................................................................................................... vii List of Figures ............................................................................................................................ ix List of Abbreviations ............................................................................................................... x Acknowledgements ............................................................................................................... xii Dedication ............................................................................................................................... xiii Chapter 1: Introduction .......................................................................................................... 1 Chapter 2: Mental health and interpersonal functioning in self-identified asexual men and women ..................................................................................................... 12 2.1 Introduction ........................................................................................................................ 12 2.2 Method .................................................................................................................................. 15 2.3 Results ................................................................................................................................... 21 2.4 Discussion ............................................................................................................................ 28 2.5 Conclusion ............................................................................................................................ 36 Chapter 3: Asexuality: An extreme variant of sexual desire disorder? .............. 37 3.1 Introduction ........................................................................................................................ 37 3.2 Methods ................................................................................................................................ 39 3.3 Results ................................................................................................................................... 46 3.4 Discussion ............................................................................................................................ 60 3.5 Conclusion ............................................................................................................................ 71 Chapter 4: Sexual fantasy and masturbation among asexual individuals ......... 73 4.1 Preliminary study on sexual fantasy and masturbation ..................................... 73 4.1.1 Introduction ................................................................................................................................... 73 4.1.2 Method ............................................................................................................................................. 75 4.1.3 Results .............................................................................................................................................. 80 4.1.4 Discussion ....................................................................................................................................... 87 4.2 Sexual fantasy and masturbation among asexual individuals: An in-depth exploration ......................................................................................................................................... 92 4.2.1 Introduction ................................................................................................................................... 92 4.2.2 Method ............................................................................................................................................. 95 4.2.3 Results ........................................................................................................................................... 101 4.2.4 Discussion .................................................................................................................................... 128 4.2.5 Conclusion ................................................................................................................................... 137 Chapter 5: Conclusion ........................................................................................................ 140 References .............................................................................................................................. 151 Appendix A – Items on the Asexuality Identification Scale (AIS) ........................ 170   vii List of Tables Table 2.1 Mean scores on the Brief Symptom Inventory (BSI) by sexual orientation for men and women .................................................................................................................. 23 Table 2.2  Suicidal ideation among sexual orientation groups .......................................... 25 Table 2.3  Mean scores on the Inventory of Interpersonal Problems (IIP) by sexual orientation for men and women ........................................................................................... 27 Table 3.1  Demographic characteristics of participants in the AIS > 40 (n = 193), control (n = 122), Hypoactive Sexual Desire Disorder (HSDD; n = 50), and subclinical HSDD (n = 50) groups ........................................................................................ 48 Table 3.2  Sexual activity frequency by group. Data represent means and standard deviations ...................................................................................................................................... 50 Table 3.3  Reported sexual difficulties and distress across groups.................................. 53 Table 3.4  Alexithymia (TAS), depressive symptoms (BDI-II), self-deceptive enhancement (BIDR-SDE), and impression management (BIDR-IM) across groups. Data represent means and standard deviations. ........................................... 56 Table 3.5  Logistic regression predicting to HSDD group over AIS > 40 group ........... 58 Table 3.6  Comparison of those in the AIS > 40 group and those with Lifelong HSDD. Data represent means and standard deviations ............................................................ 60 Table 4.1  Ethnicity of participants ............................................................................................... 77 Table 4.2  Patterns of masturbation and sexual fantasy ....................................................... 86 Table 4.3  Ethnicity of participants ............................................................................................... 98 Table 4.4  Motives for masturbation among asexual individuals who engage in masturbation .............................................................................................................................. 103  viii Table 4.5  Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual women ......................................................................................................................................................... 108 Table 4.6  Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual men ......................................................................................................................................................... 112 Table 4.7  Patterns of masturbation and sexual fantasy ..................................................... 117 Table 4.8  Sexual fantasy comparisons between asexual women and sexual women ......................................................................................................................................................... 120 Table 4.9  Sexual fantasy comparisons between asexual men and sexual men ........ 123    ix List of Figures Figure 4.1  Percentage of participants who masturbate at least monthly ..................... 81 Figure 4.2  Percentage of participants who have had a sexual fantasy .......................... 83 Figure 4.3  Percentage of participants whose fantasies do not involve other people ........................................................................................................................................................... 85 Figure 4.4  Percentage of participants who masturbate at least monthly ................... 102 Figure 4.5  Percentage of participants who have never had a sexual fantasy ............ 105 Figure 4.6  Percentage of participants who sexual fantasies don't involve other people............................................................................................................................................ 106    x List of Abbreviations AIS Asexuality Identification Scale APA American Psychiatric Association ANCOVA Analysis of Covariance ANOVA Analysis of Variance AVEN Asexuality Visibility & Education Network BDI Beck Depression Inventory BDSM Bondage/Discipline, Dominance/Submission, Sadism/Masochism BIDR Balanced Inventory of Desirable Responding BSI Brief Symptom Inventory DSFI Derogatis Sexual Functioning Inventory DSM Diagnostic and Statistical Manual of Mental Disorders FSDS-R Female Sexual Distress Scale-Revised FSFI Female Sexual Function Index HSDD Hypoactive Sexual Desire Disorder ICC Intra-class Correlation Coefficient IIEF International Index of Erectile Function IM Impression Management IIP Inventory of Interpersonal Problems  IIP-SC Inventory of Interpersonal Problems – Short Circumplex form M Mean MANCOVA Multivariate Analysis of Variance NS Non-Significant  xi SCL-90-R Symptom Checklist-90- Revised SD Standard Deviation SDE Self-Deceptive Enhancement SDS Sexual Distress Scale SE Standard Error SIAD Sexual Interest/Arousal Disorder  SFQ Sexual Function Index TAS Toronto Alexithymia Scale TR Text Revision    xii Acknowledgements There are many people I would like to thank for supporting, guiding, and cheering me through my PhD. First, I would like to sincerely thank the many participants who gave their time and careful consideration of lengthy questionnaires to participate in the studies that make up this dissertation. I would also like to acknowledge my dissertation committee for their insightful questions and comments, as well as the Canadian Institutes of Health Research for the financial support of a Doctoral Research Award. I am profoundly grateful to Lori Brotto, for her unwavering encouragement, support and expertise. She is an inspiration and role model, both personally and academically. I am also thankful to Boris Gorzalka, who has been a wonderful guide and source of encouragement throughout my time at UBC. I could not have asked for better supervisors and mentors.  My lab-mates, fellow graduate students, colleagues, and friends have been an unyielding source of commiseration, humour, and friendship. GL, in particular, was a steadfast source of support to me throughout my work on this dissertation. I am deeply grateful to have been able to share the trials and tribulations of life and graduate school with so many wonderful people along the way. Finally, I could not have attained this goal without the support of my family. I am indebted to them for supporting my decision to follow my dreams, no matter what they might look like, or where they take me. Without their unquestioning support and love, I could never have come as far as I have.    xiii Dedication   For my family    1 Chapter 1: Introduction Human asexuality is generally defined as an absence of sexual attraction to anyone at all, although this definition varies somewhat, depending on the source. Estimates from large-scale national probability studies of British residents suggest that between 0.5% (Aicken et al., 2013; Bogaert, 2013) and 1% (Bogaert, 2004; Poston & Baumle, 2010) of the adult population is asexual. Smaller studies suggest that 2% of high school students from New Zealand report being attracted to neither sex (Lucassen et al., 2011), and up to 3.3% of Finnish women (Höglund, Jern, Sandnabba, & Santtila, 2014) report experiencing a lack of sexual attraction in the past year. Although asexuality has appeared sporadically throughout the scientific literature since Kinsey first defined the lack of sexual attraction inherent to asexuality as belonging to category X (Kinsey, Pomeroy, & Martin, 1948), it is not a well-defined construct. A number of different definitions for asexuality have been put forward (Hinderliter, 2009). Prause and Graham (2007) hypothesized that asexuality may be due to low levels of sexual excitation, while Rothblum and Brehony (1993) defined asexuality as a lack of sexual behaviour with others. However, these definitions are problematic; the absence or low level of sexual behaviour or excitation may be due other reasons, such as absence of a sexual partner or sexual trauma history, rather than being due to an intrinsic preference to abstain from sex (Prause & Graham, 2007). More recently, Bogaert (2004, 2006) has defined asexuality as a lack of sexual attraction, and the largest English-speaking online community of asexuality, the Asexuality and Visibility Education Network (AVEN; asexuality.org), supports this definition. In research, however, there has been a tendency to not adopt a single  2 definition, and asexuality has been both defined as a lack of sexual attraction to anyone (Bogaert, 2004) as well as a lack of sexual attraction entirely (i.e., to anyone or anything) (AVEN, 2011). Overall, the lack of sexual attraction is thought to be persistent throughout an asexual individual’s adult life, although this is not a requirement for self-identification as asexual within the asexual community (AVEN). It is important to emphasize that the lack of sexual attraction that seems to be fundamental to asexuality does not necessarily equate to a lack of sexual behaviour, and there is evidence that asexual individuals engage in both partnered and solitary sexual activity (e.g., Brotto, Knudson, Inskip, Rhodes, & Erskine, 2010) for a variety of reasons unrelated to sexual attraction. There are a number of pervasive stereotypes that assume all asexual individuals are aromantic (lacking romantic attraction), non-male, afraid of sex, highly religious, have experienced traumatic relationships or sexual experiences, have low testosterone levels or some other physical problem, or are making a conscious choice to be asexual (e.g., celibacy; NextStepCake, 2011; Sloan, 2006; Walters & Geddie, 2006), and these opinions have also been expressed by clinicians and academics (Sloan, 2006).  The recent emergence of the asexual community, combined with a lack of empirical data on asexuality, has led to much discussion and speculation, both within academic and non-academic communities, on how asexuality should be conceptualized. Asexuality has been described as a sexual orientation by a number of sources (Berkey, Perelman-Hall, & Kurdek, 1990; Bogaert, 2004; Brotto & Yule, 2011; Brotto et al., 2010; Storms, 1978; Yule, Brotto, & Gorzalka, 2014a), and heterosexual and non-heterosexual sexual orientation groups have been used as a comparison to  3 asexual groups in a number of studies (e.g., Nurius, 1983; MacInnis & Hodson, 2012). In contrast to understanding asexuality as a sexual orientation, there has also been speculation (Bogaert, 2012a, 2015) that asexuality could arise from, or be part of, a mental health difficulty, a sexual dysfunction (defined as “a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure”; American Psychiatric Association, 2013), or possibly even a paraphilia. These hypotheses have received very little empirical investigation to date, and are the focus of this dissertation, in an attempt to better understand how to conceptualize asexuality. It is important to consider that self-identified asexual individuals are likely a very diverse group, and that there is not one single explanation that can universally explain their lack of sexual attraction.  Asexuality as a mental health difficulty It is a possibility that asexuality is a symptom of a mental health difficulty, or is itself a mental disorder. There is conflicting evidence regarding the association between asexuality and psychiatric symptoms. In one early study, Nurius (1983) found higher rates of depression and self-esteem problems among asexual individuals (defined as those who chose to not have sex) compared to the other sexual orientation groups. A more recent study found self-identified asexual individuals to have the same rates of depression as population norms (Brotto et al., 2010), but to be more likely to endorse symptoms of Social Withdrawal. In a follow-up qualitative study conducted on a subgroup of asexual individuals who participated in a larger quantitative study, Brotto and colleagues found that nearly half of the participants interviewed believed that they had traits of Schizoid Personality Disorder. Further, several participants in  4 this study speculated that there may be an association between Asperger Syndrome and asexuality, and this has also been discussed at length by members on AVEN.  In order to further investigate these claims, we explored mental health correlates of asexuality, and compared asexual, non-heterosexual (bisexual and homosexual), and heterosexual individuals on aspects of mental health. These data are presented in Chapter 2. Asexuality as a sexual dysfunction Disorders of sexual desire, such as the DSM-IV-TR’s HSDD (American Psychiatric Association, 2000) and the DSM-5’s Female Sexual Interest/Arousal Disorder (FSIAD; American Psychiatric Association, 2013), are similar to asexuality in that they involve a lack of interest in sex. Certainly, it has been conjectured that asexuality is a dysfunction of sexual desire, and represents the lowest end of the sexual desire continuum. However, one crucial difference between asexuality and HSDD or FSIAD is that a diagnosis of the latter requires the individual to experience clinically significant personal distress. Asexual individuals’ lack of sexual attraction does not seem to cause personal distress, and any distress that might be present is likely interpersonal, perhaps in response to navigating a relationship with a (sexual) partner, or to experiencing perceived social condemnation of their lack of sexual attraction, rather than being a personally derived distress. There has been no empirical research to date on this topic. Chapter 3 will explore the similarities and differences between asexual individuals and those meeting diagnostic criteria for HSDD. We will be specifically  5 interested in responses to measures of sexual desire, distress, mood, and sexual behaviour.  Asexuality as a paraphilia A paraphilia is defined as an atypical sexual attraction. On its own, a paraphilia is not considered a disorder. However, if a paraphilic interest is associated with significant personal distress, if the desire or associated behaviour creates distress for someone else, or involves an unwilling partner, it may be diagnosed as a paraphilic disorder (American Psychiatric Association, 2013). There is evidence that asexual individuals masturbate (Bogaert, 2013; Brotto et al., 2010; Poston & Baumle, 2010), and there may be a non-partner oriented sexual desire underlying this behaviour. For example, there may be an underlying atypical sexual interest, or diffuse erotic urges (that are not directed toward others) present. Bogaert (2006) speculated that if this is the case, asexuality may be a form of paraphilia.  A qualitative exploration into the motivations for masturbation found that for some asexual individuals, masturbation is seen as a purely physiological act that does not arise from sexual motivations. Further, some asexual individuals have at least some asexual individuals have described masturbation in emotionally bare terms, such as “cleaning out the plumbing” (Brotto et al., 2010; Prause & Graham, 2007; Scherrer, 2008). Conversely, there is some evidence that asexual individuals engage in sexual fantasy while masturbating (AVEN, 2016). Sexual fantasies are thought to be a more accurate representation of sexual desires or interests than are sexual behaviours, as they are not limited by social or interpersonal constraints (Ellis & Symons, 1990). It seems that there might be a number of motives for masturbation among asexual  6 individuals, with some having a paraphilic component reflected in the content of their sexual fantasy. What asexual individuals fantasize about while masturbating, if anything, is a question that has yet to be explored. The aim of Chapter 4 is to address the hypothesis that asexuality may be a paraphilia, by investigating the content of sexual fantasy among asexual individuals. We will provide a preliminary exploration of sexual fantasy frequency and content among asexual individuals compared to sexual individuals with and without low sexual desire. We will also explore group differences in masturbation patterns and then compare the contents of sexual fantasies among asexual individuals with sexual fantasies of sexual individuals.  Data collection and analyses Internet research The research discussed in this dissertation is entirely Internet based. This method of data collection is necessary due to the nature of the asexual population itself, which has developed around an online platform. While there are known difficulties that arise when conducting this type of research (e.g., asexual individuals who do not belong to AVEN are systematically excluded from research, and there is a strong likelihood that AVEN members differ from those asexual individuals who are not affiliated with AVEN in a number of significant ways, see Brotto & Yule, 2009; Hinderliter, 2009), gaining physical access to a sufficient number of asexual participants is prohibitive (in one study, only seven female asexual participants could be recruited for a study investigating physiological sexual arousal, despite great efforts taken in recruitment; (Brotto & Yule, 2011)). There is evidence, however, that the  7 quality of data provided by Internet research is frequently at least as good as that provided by more traditional paper-and-pencil methods, and may actually provide some important advantages over traditional methods of data collection (Gosling, Vazire, Srivastava, & John, 2004). For example, customary data collection methods often rely on easily accessed samples, such as university students, which are arguably non-representative of the general population. For hard-to-reach samples such as asexual individuals, Internet-based research allows us access to an otherwise inaccessible population. Analysis by gender Asexual individuals have a higher likelihood of eschewing binary gender identities, and identify with a range of genders, including agender, non-gendered, and gender-fluid (Yule, Antczak & Brotto, in preparation). This is problematic for sex research, which has a long-standing tendency to compare men and women to allow for hypotheses about gender to be tested, and which typically excludes individuals that do not endorse one of these two categories. Participants in our research in asexuality over the years have provided feedback that they strongly prefer not to choose one of these two options, as they do not feel that this is an accurate representation of their gender identity. Thus, the traditional “male” and “female” gender categories may create a false dichotomy in asexuality research. Throughout the studies described in this dissertation, we requested that participants select the option that best describes them, in an attempt to compare results with previously published research which is often dichotomized into male and female groups. However, wherever possible, we have analyzed all participants as a single group, rather than differentiating between “male”  8 and “female” participants, and risk excluding up to a quarter of our asexual participants (Yule, Antczak, & Brotto, in preparation). While we recognize that analysis of the entire group may not be ideal, and that subtle differences by gender expression or identity may be masked, the methods we used to capture sex and gender do not allow us to explore these sex and gender nuances fully. Asexuality Identification Scale As discussed briefly above, due to limitations in recruiting sufficiently powered local samples, most studies have relied on recruiting via online web-based asexual communities. This is problematic because it limits the sample to individuals who have already self-identified as asexual, who find community in AVEN, and therefore, may already experience less distress through a sense of "belonging" (Hinderliter, 2009; Brotto & Yule, 2009). Certainly, those belonging to AVEN may be a distinct group within the asexual population, as they have already acknowledged their asexuality as an identity, and they may have different motivating factors to join such an online community (e.g., distress) that make them different from those who are not part of an online community (Brotto et al., 2010). Some AVEN members also acknowledge that the recognition of an asexual identity “enables asexual individuals to form a new self-image” (Radloff, 2008), suggesting that their membership might influence or change the way that an individual lacking sexual attraction might respond to research questions. Very little is known, on the other hand, about the experiences of individuals who lack sexual attraction, but who have not yet “come out” and adopted the label of “asexual”.   9 It is for this reason that we developed the Asexuality Identification Scale (AIS; Yule, Brotto & Gorzalka, 2015; Appendix A) as part of my Master’s thesis. The AIS is a 12-item, sex- and gender-neutral self-report measure of asexuality. The AIS was developed in a series of stages, including development and administration of open-ended questions to sexual and asexual individuals, development of initial multiple choice items, and analysis of these items to facilitate selection of final items. Based on discriminant analytic methods, 12 items were retained in the final AIS. Sexual and asexual participants significantly differed in their AIS total score with high statistical significance. Further, a cut-off score of 40/60 was found to identify 93% of self-identified asexual individuals, while excluding 95% of sexual individuals. This suggests that the AIS is a useful tool for identifying asexuality, and could be used in future research to identify individuals with a lack of sexual attraction.  Psychometric validation on the AIS was conducted for construct validity. Specifically, the total score of the AIS showed excellent ability to distinguish between asexual and sexual subjects (discriminant validity), while showing only moderate correlations with an adaptation of a previously established measure of sexual orientation (approximated incremental validity). When compared to an existing measure of sexual desire, the AIS was found to correlate highly with scores on the Dyadic subscale of the Sexual Desire Inventory, but not with Solitary sexual desire scores. This finding demonstrates the previously recognized and considerable overlap between the constructs of sexual attraction and sexual desire. We believe that the AIS does not depend on one’s self-identification as asexual; rather, it would also capture the individual who scores high on the AIS but has not yet identified themselves as  10 asexual. It is our hope that the AIS will allow for recruitment of more representative samples of the asexuality population. I indicate clearly in the study that follows where the AIS was employed.  Statistical Analyses More detailed information regarding specific statistical techniques employed for each study are provided in the following chapters. In general, the following techniques were used throughout this dissertation. All data were tested to ensure that they met assumptions of normality, linearity, homogeneity of variance, and independence. If the data did not meet these assumptions, corrective techniques were employed to overcome this, and more detail is provided about this in the Method sections of the following chapters. Throughout this dissertation, Student’s t-tests, univariate analysis of variance (ANOVA) tests followed by Tukey's multiple comparison tests, and multivariate ANOVA (MANOVA) tests followed by Bonferroni post hoc tests were used for baseline group comparisons for continuous variables, using age as a covariate where appropriate. In situations where there were high correlations between dependent variables, or there were a large number of outliers, ANOVAs were used in preference to MANOVAs, or outliers were removed (Tabachnick & Fidell, 1983). For categorical variables, baseline group comparisons used chi-square analyses. Significance of findings was determined using either statistical significance or effect size calculations. Effect sizes for all t-tests were calculated using Cohen’s d. The effect was considered small when Cohen’s d was between zero and 0.2, medium between 0.201 and 0.5, and large between .501 and 1. Effect sizes for all analysis of  11 variance tests were calculated using Partial eta-squared (ɳ2), and the effect was considered to be small when Partial eta-squared was between zero and 0.01, medium when between 0.0101 and 0.06, and large between 0.0601 and 0.14. Effect sizes for all chi-squared analyses were calculated using Cramer’s V (φc). The correlation was considered small when φc was between 0.1 and 0.3; medium when φc was between 0.301 and 0.5, and large when φc was between 0.501 and 1.0 (Cohen, 1988). Effect sizes for a logistic linear regression was calculated using odds ratios. Despite these general guidelines, the meaning of the size of an effect size may vary depending on the variable being investigated, and this was taken into account when interpreting each separate variable throughout the following studies.   12 Chapter 2: Mental health and interpersonal functioning in self-identified asexual men and women1  2.1 Introduction  The largest online web-community of asexual individuals, the Asexuality Visibility and Education Network (AVEN, www.asexuality.org), describes asexuality as a sexual orientation or sexual identity, akin to heterosexuality, bisexuality and homosexuality (Jay, 2008). A comprehensive discussion of prevalence and definitions of asexuality is provided on page 15 of this dissertation. This recent trend to examine biological aspects aligns with the position of many online asexual communities which posits that the discovery of an underlying biological explanation might lead to a lessening of the current stigma surrounding asexuality (Brotto et al., 2010). Non-heterosexual (gay, lesbian, or bisexual) sexual orientation has previously been linked to mental health variables (Busseri, Willoughby, Chalmers, & Bogaert, 2008; D'Augelli, Hershberger, & Pilkington, 2001; Sandfort, de Graaf, Bijl, & Schnabel, 2001), including increased prevalence of mood disorders and anxiety, as well as increased substance abuse/dependence (Fergusson, Horwood, & Beautrais, 1999; Sandfort et al., 2001) and suicidality (D'Augelli et al., 2001; Fergusson et al., 1999; Remafedi, 1994; Remafedi, French, Story, Resnick, & Blum, 1998; Remafedi, 1999) among non-heterosexual groups. These problems are thought not to be a direct response to the individual’s sexual orientation per se, but to various external stressors, perhaps including                                                         1 The findings of Chapter 2 have been published. Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2013). Mental health and interpersonal functioning among asexual individuals.  Psychology & Sexuality, 4(2), 136-151. DOI:10.1080/19419899.2013.774162   13 difficulties encountered during the coming-out period, or attempts to negotiate a non-heterosexual sexual identity in a heterosexual society.  Because asexual individuals may face similar social stigma to that experienced by homosexual and bisexual persons, in that they may also experience discrimination and/or marginalization, it follows that asexual individuals might also experience higher rates of psychiatric disturbance. Asexual individuals may, in fact, experience additional stigma, due to the experience of a lack of sexual attraction in a culture that is arguably dominated by sexuality.  Today’s mainstream view on sex is that it is positive, healthy, and desirable, and individuals who are not interested in sexuality may be viewed as having a disorder or something “wrong” with them. Asexuality is also often understood by lay-people as being the result of negative childhood experiences, although there is no evidence for this claim (Brotto et al., 2010). Large-scale studies on mental health issues in gay men and lesbian women (e.g., Busseri et al., 2008; Sandfort et al., 2001) have found evidence that these sexual minorities do have higher rates of mental health problems (e.g., depression, substance abuse) than heterosexual individuals. The causes of such elevated rates in gays and lesbians are unclear and debated, but if asexual people feel similar pressure to other sexual minorities to conform to heterosexual norms, then it is possible that they too may have elevated rates of mental health problems.  In an early study investigating the relationship between sexual orientation and mental health, Nurius (1983) assessed homosexual, bisexual, heterosexual, and asexual (who were defined as those who preferred not to be involved in any sexual activities) college students in the United States, and found asexual participants to demonstrate  14 the highest level of symptoms on measures of depression, self-esteem, and sexual satisfaction, followed by homosexual participants, bisexual participants, and lastly, heterosexual participants. The author questioned to what extent the observed distress was due directly to sexual orientation, as opposed to being an indirect consequence of sexual preference. Nurius suggested the possibility that individuals of non-heterosexual orientations, including asexual individuals, are “paying the price” for breaking social norms (Nurius, 1983).  Thus the experience of the asexual individual, who lacks sexual attraction but exists in a society seemingly focused on sexuality, might lead to distress and perhaps mental health difficulties. In a recent mixed-methods study of asexual men and women (Brotto et al., 2010), there was no evidence to suggest elevated rates of depression or alexithymia (a collection of personality traits that indicates difficulty identifying and describing feeling of others) among asexual individuals. However, there was modest evidence for other psychological difficulties (in that the asexual individuals had elevated scores on a brief measure of personality indicating social withdrawal), as well as scores indicating problems with anger control and suicidal thinking. Asexual individuals had scores that fell just below the clinical cut-off point for moderate personality characteristics of alienation, hostile control, negative affect, health problems, and psychotic features. Additionally, asexual individuals demonstrated elevated scores on a measure of interpersonal problems, including subscales indicating cold/distant and socially inhibited interpersonal styles (Brotto et al., 2010). On the basis of these elevated traits, the authors speculated that asexual individuals may be more likely to show traits consistent with the (former) DSM-IV Cluster A personality disorders, and suggested  15 that Schizoid Personality Disorder (which is characterized by emotional coldness, a lack of desire for close relationships, and a limited capacity to express warmth toward others (APA, 2000), might be more prominent in this population. The latter was explored and confirmed through a series of in-depth qualitative interviews (Brotto et al., 2010).  Previous research investigating asexuality and correlates of mental health is scant, and more direct comparisons, for example, to other sexual minorities, are warranted. This study explored mental health correlates and interpersonal functioning, and compared asexual, non-heterosexual (bisexual and homosexual), and heterosexual individuals on these aspects of mental health. We hypothesized that asexual individuals would differ from heterosexual and non-heterosexual sexual orientation groups on these measures. Due to conflicting findings in the two previous research studies investigating mental health in asexual individuals (Brotto et al., 2010; Nurius, 1983), we did not predict a specific directionality of findings.  Based on the conclusions of previous researchers (Bogaert, 2006; Brotto et al., 2010), we allowed participants to self-identify as asexual, given that, at the time of data collection, our AIS (Yule, Brotto, & Gorzalka, 2015) had not yet been published.  2.2 Method Participants The original sample consisted of 1293 individuals between the ages of 19 and 72, including 317 men and 976 women.  A significant majority of participants identified themselves as Caucasian/White (88% of asexual, 48% of heterosexual, and 71% of non-heterosexual; χ2(2)= 161.24, p < .001; φc = .35, p < .001) and a large proportion  16 (32%) of heterosexual participants identified themselves as East Asian, a significantly greater proportion than the 3% of asexual and 12% of non-heterosexual participants who self-identified as East Asian, χ2(2)= 128.87, p < .001; φc = .32, p < .001.  This discrepancy reflects the large proportion of East Asian participants in the main city of recruitment, a phenomenon that is not reflected in the online asexual community. As observed in previous research, there were significant differences between ethnic groups on measures of mental health (e.g., Vega & Rumbout, 1991).  As the majority of participants were Caucasian, we based the present analysis on Caucasian participants only to avoid differences in ethnic groups obscuring any potential differences in mental health between sexual orientation groups. Data for 806 Caucasian participants between the ages of 19 and 72 were included in the current analysis, including 203 men and 603 women. Participants were asked to select which of four sexual orientation options best described them; heterosexual, homosexual, bisexual, or asexual, resulting in 54 asexual, 110 heterosexual, and 39 non-heterosexual (22 gay and 17 bisexual) men, and 228 asexual, 223 heterosexual, and 152 non-heterosexual (73 lesbian and 79 bisexual) women. This non-representative sample was recruited through several separate and concurrent avenues, including postings on local websites (e.g., Craigslist), on the AVEN online web-community general discussion board, and through a large university’s human subject pool.  The average age of male participants was 27.0 years for asexual men (SD = 10.9), 27.2 years for heterosexual men (SD = 9.9), and 31.3 years for non-heterosexual men (SD = 10.8), and there was no significant group difference in age, F(2,200) = 2.59,  17 p > .05, partial ɳ2 = .025.  The average age of asexual women was 24.6 years (SD = 6.9), 24.8 years for heterosexual women (SD = 8.4), and 31.1 years for non-heterosexual women (SD = 9.6), and there was a significant group difference in age, F(2,600) = 34.72, p < .001, partial ɳ2 = .10. Post-hoc Tukey’s tests revealed non-heterosexual women to be significantly older than both asexual and heterosexual women. Due to this significant age difference, we controlled for age in all subsequent analyses. There were no significant group differences in highest level of education achieved, χ2(2)= 2.47, p > .05; φc = .06, p > .05, with the majority of participants (89% asexual, 92% heterosexual, 88% non-heterosexual) having received at least some post-secondary education. Fifteen percent of asexual, 57% of heterosexual, and 59% of non-heterosexual individuals indicated that they were in a relationship, either committed or non-committed, and these proportions differed significantly, χ2(2)= 135.18, p < .001; φc = .41, p < .001, with asexual participants being least likely to be in a relationship.   Procedure All procedures were approved by UBC's Behavioural Research Ethics Board. Data were collected between September and December 2010 via a web-based survey hosted by SurveyMonkey (Gordon, 2002). We administered measures of physical and mental health, sexual functioning, and sexual behaviours, and the entire questionnaire battery took approximately 60 minutes to complete. The majority of asexual individuals were recruited from AVEN, while heterosexual and non-heterosexual participants were recruited via the UBC Department of Psychology human subject pool, Craigslist, and other targeted websites.    18 Measures Demographic Information.  Participants were asked two questions directly inquiring into their mental health: “do you have a mood disorder such as depression, bipolar disorder, mania or dysthymia?” and “do you have an anxiety disorder such as a phobia, obsessive-compulsive disorder, or a panic disorder?” Response options for these two items were “yes,” “no,” or “I don’t know.” Brief Symptom Inventory The Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) is a 53-item self-report symptom inventory designed to assess psychological symptom status. Created as a shorter version of the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1977), the BSI has nine primary symptom dimensions and three global indices of distress: the Global Severity Index, the Positive Symptom Distress Index, and the Positive Symptom Total. Symptom dimensions include: Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. Responses are collected on a five-point scale ranging from 0 “not at all” to 4 “extremely”. Internal consistency was found to be 0.80 for the Somatic dimension, α = 0.83 for the Obsessive-Compulsive dimension, α = 0.74 for Interpersonal Sensitivity, α = 0.85 for Depression, α = 0.81 for Anxiety, α = 0.78 for Hostility, α = 0.77 for Phobic Anxiety, α = 0.77 for Paranoid Ideation, and α = 0.77 for Psychoticism (Derogatis & Melisaratos, 1983). Test-retest reliability over two weeks was found to be r(60) = 0.68 (Somatization dimension) to 0.91 (Phobic Anxiety dimension). The BSI has convergent validity with the Minnesota Multiphasic  19 Personality Inventory, and factor analytic studies have shown the BSI to have good construct validity. Of the three global indices of distress, the Global Severity Index is thought to be the single best indicator of current distress levels, as it combines information on the number of symptoms, as well as the intensity of perceived distress (Derogatis & Melisaratos, 1983). This index of distress will be used in the current study. Two individual items in the BSI are related to suicidal ideation, and have been used in previous research investigating suicidality (D'Augelli et al., 2001): Question 9 of the BSI asks if, in the past two weeks, the respondent has had “thoughts of ending your life,” and Question 39 inquires about “thoughts of death or dying.” Internal consistency for these two Items in our sample was α = .84. Inventory of Interpersonal Problems  The Short Circumplex form of the Inventory of Interpersonal Problems (IIP-SC; Soldz, Budman, Demby, & Merry, 1995) is a 32-item scale designed to measure interpersonal distress. It is a shorter version of the 64-item IIP Circumplex Form (Alden, Wiggins, & Pincus, 1990), which itself was derived from the original 127-item IIP (Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988). The IIP-SC contains eight subscales: Domineering, Vindictive, Cold, Socially Avoidant, Non-Assertive, Exploitable, Overly Nurturant, and Intrusive, each containing four items. Each item is measured using a five-point Likert scale ranging from 0 “not at all” to 4 “extremely”. The raw scale scores are obtained by summing the items for each scale, and the Total Score is calculated by summing the eight scales (Horowitz, Alden, & Wiggins, 2000). A higher total score indicates greater interpersonal problems experienced by respondents, and has been found to measure general psychopathology. The IIP has been used in studies  20 of interpersonal difficulties in nonclinical populations, and has the ability to distinguish between people who demonstrate characteristics such as differing attachment styles and ability to describe other people (Bartholomew & Horowitz, 1991), as well as between an asymptomatic community sample, a student sample, and a clinical sample (Hansen & Lambert, 1996). The IIP has been demonstrated to have acceptable reliability, validity, and sensitivity to changes that occur during psychotherapy (Horowitz et al., 1988), and the IIP-SC has excellent internal reliability (α = .88) and strong test-retest correlations (α = .83) (Soldz et al., 1995).  Individual subscales similarly had adequate internal reliability: Domineering, α = .72, Vindictive, α = .69, Cold, α = .77, Socially Avoidant, α = .80, Non-Assertive, α = .82, Exploitable, α = .70, Overly Nurturant, α = .78, and Intrusive, α = .83 (Soldz et al., 1995). Statistical Analyses Baseline group comparisons for continuous variables used analysis of variance (ANOVA) followed by Tukey’s multiple comparison tests in cases of an overall significant effect. Given the significant group differences in age, we included age as a covariate (ANCOVA) for all analyses. When the correlation between variables was moderate, multivariate analysis of variance was used for multiple comparisons of continuous variables, using age as a covariate (MANCOVA).  Bonferroni post hoc tests were used with all MANCOVAs to calculate conservative p-values in order to control for the inflated error rate that accompanies multiple comparisons. Effect sizes for all independent ANCOVAs and MANCOVAs were calculated with the partial eta-squared (ɳ2). For categorical variables, baseline group comparisons used chi-squared analyses. Effect sizes for all chi-squared analyses were calculated using Cramer’s V (φc).   21 2.3 Results Asexual individuals were more likely to respond positively to the two items assessing presence of mood or anxiety disorders. Twenty-four percent of asexual men, compared to 10% of non-heterosexual men and 15% of heterosexual men (χ2(4) = 16.08, p < .01; φc = .31) noted that they did have a mood disorder. Follow-up tests indicated that asexual men were significantly more likely to report having a mood disorder than heterosexual men. There was no significant difference between asexual and non-heterosexual men. Thirty percent of asexual women, 34% of non-heterosexual women, and 16% of heterosexual women reported a current mood disorder (χ2(4) = 23.36, p < .001; φc = .22). Again, follow-up tests indicated that asexual women were more likely to report having a mood disorder than heterosexual participants. Non-heterosexual participants were significantly more likely to report a mood disorder than heterosexual participants. Similarly, asexual men and women were significantly more likely to note that they had an anxiety disorder. Twenty-three percent of asexual men, 20% of non-heterosexual men, and 8% of heterosexual men responded positively to the inquiry about anxiety disorders (χ2(4) = 14.03, p < .01; φc = .29). Twenty-three percent of asexual women, 20% of non-heterosexual women, and 15% of heterosexual women reported a current anxiety disorder (χ2(4) = 20.33, p < .001; φc = .20). Follow-up tests revealed both asexual men and women to be significantly more likely to report a current anxiety disorder than heterosexual men and women.  Brief Symptom Inventory Because of the high correlations between subscales of the BSI, univariate ANOVAs were used to compare groups on this measure.  There were significant  22 differences between men and women on mean scores of several BSI subscales: Somatization (F(1,662) = 11.61, p = .001, partial ɳ2 = .017), Interpersonal Sensitivity (F(1,662) = 6.65, p = .01, partial ɳ2 = .010), Anxiety (F(1,662) = 7.06, p < .01, partial ɳ2 = .011), and Phobic Anxiety (F(1,662) = 7.27, p < .01, partial ɳ2 = .011), as well as the Global Severity Index (F(1,662) = 4.15, p < .05, partial ɳ2 = .006). While these differences were small according to our effect size calculations, they were statistically significant, and thus we performed subsequent analyses on men and women separately.  Statistically significant differences were noted between asexual and non-heterosexual men on the Somatization subscale and between asexual and heterosexual men on the Depression subscale (partial ɳ2 = .039 and .043 respectively), and between asexual and both non-heterosexual and heterosexual participants on the Psychoticism subscale, partial ɳ2 = .055. Asexual men had higher scores on the Interpersonal Sensitivity subscale than heterosexual men with a difference approaching statistical significance, and non-heterosexual men had significantly higher scores on the Interpersonal Sensitivity subscale than heterosexual men, partial ɳ2 = .056. Asexual women were noted to have significantly lower scores than non-heterosexual women on the Hostility subscale, partial ɳ2 = .012, and to have significantly higher scores than heterosexual woman on the Phobic Anxiety and Psychoticism subscales, partial ɳ2 = .020 and .022 respectively. Non-heterosexual women similarly had significantly higher scores on the Phobic Anxiety and Psychoticism subscales than heterosexual women (Table 2.1).  23 Table 2.1 Mean scores on the Brief Symptom Inventory (BSI) by sexual orientation for men and women    Variable Men  Asexual   (n=44)  Non-heterosexual  (n=30)  Heterosexual  (n=93)  Partial eta-squared (ɳ2) Women Asexual   (n=195)  Non-heterosexual  (n=108)  Heterosexual   (n=195)  Partial eta-squared (ɳ2) BSI Subscale:  Somatization Obsession/ Compulsion Interpersonal Sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Global Severity Index  Mean (SD) .36 (.62)2 .82 (.76)  .84 (.98)4  1.06 (.92)1 .51 (.69) .56 (.64) .31 (.54) .69 (.81)  .65 (.64)1,2 .66 (.58)   .10 (.19) .55 (.66)  .95 (.95)3  .80 (.77) .36 (.47) .42 (.51) .11 (.20) .39 (.62)  .32 (.44) .44 (.38)   .25 (.40) .84 (.75)  .67 (.72)  .67 (.72) .39 (.52) .50 (.58) .16 (.35) .47 (.56)  .39 (.48) .47 (.44)   .039 .021  .056  .043 .011 .0070 .033 .030  .055 .033   .40 (.56) .93 (.83)  .89 (1.00)  .91 (.94) .60 (.76) .49 (.61)2 .40 (.66)1 .51 (.71)  .54 (.60)6 .64 (.59)   .48 (.64) .88 (.69)  .95 (.96)  .94 (.90)5 .61 (.63) .62 (.68) .37 (.60)3 .57 (.78)  .52 (.61)3 .67 (.58)   .40 (.54) .90 (.76)  .83 (.85)  .73 (.82) .65 (.64) .53 (.60) .23 (.46) .47 (.70)  .37 (.55) .57 (.54)   .0050 .000  .0050  .014 .0040 .012 .020 .003  .022 .0090  1 indicates a significant difference between asexual and heterosexual participants, p< .05 2 indicates a significant difference between asexual and non-heterosexual participants, p<.05 3 indicates a significant difference between non-heterosexual and heterosexual participants, p<.05 4 indicates a difference approaching significance between asexual and heterosexual participants, p=.06 5 indicates a difference approaching significance between non-heterosexual and heterosexual participants, p=.06 6 indicates a significant difference between asexual and heterosexual participants, p<.01 Table 2.1 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2013). Mental health and interpersonal functioning among asexual individuals. Psychology & Sexuality, 4(2), 136-151. Page 143.   24 Suicidality Items There was no significant difference between men’s and women’s responses to the two suicidality items (BSI Item 9, t(663) = .538, p > .05, Cohen’s d = .04; BSI Item 39, t(660) = .048, p > .05, Cohen’s d = 0), thus these items were analyzed in a single group. Responses to the two questions concerning suicidal thinking are shown in Table 2.2.  Results from BSI Item 9 revealed that 26% of asexual individuals had some suicidal thoughts in the past two weeks, compared to 24% of non-heterosexual individuals and 12% of heterosexual individuals. BSI Item 39 revealed that 36% of asexual participants had had some thoughts of death or dying in the previous two weeks, compared to 33% of non-heterosexual participants and 23% of heterosexual participants.   When mean scores of these two items compared, asexual participants had significantly higher scores on Item 9 than heterosexual individuals, partial ɳ2 = .023. Asexual participants similarly had significantly higher scores on Item 39 than heterosexual participants, partial ɳ2 = .020. There were no significant differences in scores between asexual and non-heterosexual participants nor between non-heterosexual and heterosexual participants on either Item.    25 Table 2.2  Suicidal ideation among sexual orientation groups      Inventory of Interpersonal Problems There were significant differences between men and women on several IIP-SC subscales: Non-Assertive F(1,648) = 18.66, p <.001, partial ɳ2 = .028), Exploitable (F(1,648) = 13.24, p < .001, partial ɳ2 = .020), and Overly Nurturant subscales (F(1,648) = 6.90, p < .01, partial ɳ2 = .011). Women scored significantly higher than men on the Non-Assertive, Exploitable, and Overly Nurturant subscales.    Asexual Non-heterosexual Heterosexual Partial Eta-squared (ɳ2) BSI Item 9  “Thoughts of ending your own life” Not at all Slightly Moderately Quite a bit Extremely Mean (SD) 74%  15% 6% 3% 2% .43 (.88)1 76% 16% 3% 4% 1% .38 (.80) 88% 8% 2% 1% 0% .19 (.57)       .023 BSI Item 39 “Thoughts of death and dying” Not at all Slightly Moderately Quite a bit Extremely Mean (SD) 64% 18% 9% 5% 4% .67 (1.090)1 67% 20% 7% 4% 1% .51 (.93) 77% 15% 4% 3% 1% .37 (.80)       .020 1 indicates a significant difference between asexual and heterosexual participants, p< .001   Table 2.2 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2013). Mental health and interpersonal functioning among asexual individuals. Psychology & Sexuality, 4(2), 136-151. Page 144.    26 Sexual orientation groups (asexual, heterosexual, and non-heterosexual) for men and women were then compared separately. Asexual men were noted to score significantly higher than both heterosexual and non-heterosexual men on the Cold subscale, partial ɳ2 = .18, and to score significantly higher than heterosexual men only on the Socially Avoidant, partial ɳ2 = .11, and Non-Assertive subscales partial ɳ2 = .047, as well as on the IIP-SC Total Score, partial ɳ2 = .071.  Asexual women had significantly higher scores than heterosexual participants on the Vindictive subscale, and non-heterosexual women also scored significantly higher than heterosexual participants on this subscale, partial ɳ2 = .020. Asexual women were found to score significantly higher on the Cold, partial ɳ2 = .11, Socially Avoidant, partial ɳ2 = .13, and Non-Assertive, partial ɳ2 = .054, subscales than both their heterosexual and non-heterosexual counterparts, and non-heterosexual women scored significantly higher than heterosexual women on the Cold and Socially Avoidant subscales. Asexual women had significantly higher scores than heterosexual women on the Exploitable subscale, partial ɳ2 = .015, as well as the IIP-SC Total Score, partial ɳ2 = .067.  Non-heterosexual women had significantly higher Total Scores than heterosexual women (Table 2.3).                27  Table 2.3  Mean scores on the Inventory of Interpersonal Problems (IIP) by sexual orientation for men and women   Variable Men   Asexual (n=43)  Non-heterosexual (n=28)  Heterosexual (n=91)  Partial eta-squared (ɳ2) IIP-SC Subscale:    Domineering   Vindictive   Cold   Socially Avoidant   Non-Assertive   Exploitable   Overly Nurturant   Intrusive   Total Score Mean (SD) 2.40 (2.59) 2.74 (3.79) 7.14 (4.30)6,7 7.37 (5.18)6 5.81 (5.49)1 4.49 (4.34) 4.63 (4.06) 3.12 (3.95) 37.70 (24.38)4,5  2.04 (2.20) 1.79 (2.35) 2.39 (3.13) 5.04 (4.26) 3.75 (3.96) 3.36 (3.46) 4.04 (4.24) 3.07 (4.35) 25.46 (4.35)  2.04 (2.33) 2.04 (2.75) 3.14 (4.04) 3.65 (4.30) 3.62 (3.84) 3.67 (3.70) 3.70 (3.88) 2.58 (2.93) 24.45 (19.54)  .0040 .013 .18 .11 .047 .012 .0090 .0050 .071  Women Asexual (n=190)  Non-heterosexual (n=105)  Heterosexual (n=194)  Partial eta-squared (ɳ2) IIP-SC Subscale:    Domineering   Vindictive   Cold   Socially Avoidant   Non-Assertive   Exploitable   Overly Nurturant   Intrusive   Total Score  2.38 (2.56) 2.13 (2.67)1 5.83 (4.62)6,7 7.57 (5.33)5,7 5.67 (5.04)2,6 5.81 (4.25)1 5.34 (4.69) 2.49 (3.41) 39.22 (20.97)6  2.29 (2.35) 2.06 (2.62)3 3.55 (4.19)3 5.45 (4.73)8 5.61 (4.72) 5.13 (3.85) 4.89 (3.88) 3.48 (3.76) 32.45 (19.60)3  2.11 (2.42) 1.45 (2.11) 2.54 (3.64) 3.43 (4.23) 5.08 (4.83) 4.68 (4.20) 4.82 (4.06) 2.95 (3.34) 27.07 (20.29)  .0030 .020 .11 .13 .054 .015 .0030 .011 .067 1 indicates a significant difference between asexual and heterosexual participants, p< .05 2 indicates a significant difference between asexual and non-heterosexual participants, p<.05 3 indicates a significant difference between non-heterosexual and heterosexual participants, p<.05 4 indicates a difference approaching significance between asexual and non-heterosexual participants, p=.06 5 indicates a significant difference between asexual and heterosexual participants, p<.01 6 indicates a significant difference between asexual and heterosexual participants, p<.001 7 indicates a significant difference between asexual and non-heterosexual participants, p<.001 8 indicates a significant difference between non-heterosexual and heterosexual participants, p<.001 Table 2.3 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2013). Mental health and interpersonal functioning among asexual individuals. Psychology & Sexuality, 4(2), 136-151. Page 145.     28 2.4 Discussion Summary of findings Participants completed on-line questionnaires assessing mental health correlates and interpersonal problems. There were significant differences between asexual, non-heterosexual, and heterosexual men and women on multiple psychological symptoms, including anxiety, hostility, phobic anxiety, and psychoticism. More specifically, asexual men scored higher on measures of somatization, depression, and psychoticism than their non-heterosexual counterparts. Asexual women scored higher on measures of phobic anxiety and psychoticism than heterosexual women, and had scores similar to non-heterosexual women on these variables. Notably, asexual men and women scored significantly higher on items assessing suicidality than heterosexual individuals. Further, asexual women scored higher on several interpersonal problem domains, including vindictive, cold, socially avoidant, non-assertive, and exploitable personality styles than heterosexual women. Asexual men had scores indicating greater cold, socially avoidant and non-assertive personality styles compared to heterosexual men, and had higher scores indicating cold personality styles than non-heterosexual men.  Mental Health The effect of external factors on mental health among gay men and lesbian women has been clearly established by a number of studies demonstrating that experience with stigma, prejudice, and discrimination are linked with mental health status (Bradford & Ryan, 1994; Brooks, 1981; Frable, Wortman, & Joseph, 1997; Herek, Gillis, & Cogan, 1997; Herek, Gillis, & Cogan, 1999; Meyer, 1995; Meyer & Dean, 1998;   29 Otif & Skinner, 1996; Ross, 1990; Rotheram-Borus, Hunter, & Rosario, 1994; Safen & Heimberg, 1999; Sandfort et al., 2001). Scherrer (2008) has likened an asexual identity to that of other marginalized sexual groups, and paralleled asexual and queer sexualities, as both have had histories of medicalization and pathologization through inclusion in the DSM. Scherrer also noted that, like sexual minority groups, asexual individuals have been subject to discrimination, a feature often associated with mental and physical health (Conrad & Schneider, 1994). Thus, our finding of increased mental health problems among asexual individuals might be explained by the experience of discrimination due to having a non-heterosexual orientation, or may perhaps even be a consequence of lacking sexual attraction within a social environment that is arguably centered on sexuality.  Asexuality has only been the focus of empirical study within the last eight years, and the asexual community itself has only existed for the past decade or so, fuelled by the growth of Internet exposure, and expanding from its original primary venue (AVEN) to include a multitude of blogspots (e.g., www.asexualexplorations.net; asexualunderground.blogspot.ca), YouTube videos (e.g., Hot Pieces of Ace YouTube channel) and dating websites (e.g., www.asexualitic.com) discussing individuals’ experiences of asexuality. The preceding invisibility of asexuality was not due to a scarcity of asexual individuals, but more likely to the lack of a cohesive group or platform (i.e., the Internet) in which an asexual community could flourish and publicly self-identify as such. Brotto and Yule (2009) noted that asexual communities such as AVEN have been described as an important place in the identification process of asexual individuals. These online communities are represented as places where   30 asexual individuals’ experiences are validated, where they can discuss their lack of sexual attraction, and where they can find a sense of community. Brotto and Yule went on to suggest that those individuals who lack sexual attraction, but have never heard the term “asexuality” are more isolated, distressed, or confused than those individuals who belong to an asexual community. Interaction with such a community, and the recognition of an asexual identity, may perhaps allow an asexual individual a sense of belonging. As the asexual community itself is relatively young, it is likely true that many of its members did not come into contact with the community until well into their adult life. It follows that throughout the majority of their formative years, due to their lack of sexual attraction, these individuals may have felt isolated from those around them, which might have increased symptoms of depression, and other mental health correlates. We note, however, the relatively young age of the sample being investigated. It could be that asexual individuals may experience some difficulty in negotiating a lack of sexual attraction within a society that puts great emphasis on sex and sexuality. While the available research suggests that asexual individuals do not experience distress in direct relation to their lack of sexual attraction, it may be that they do experience some difficulty in response to negotiating their asexuality in a sexual world. In fact, Prause and Graham (2007) found that despite several advantages identified by asexual individuals (i.e., avoiding problems that arise in intimate relationships, decreased health and pregnancy risk, less social pressure to find a suitable partner, and having a greater amount of free time), there were several drawbacks, including difficulties establishing intimate relationships, being unsure   31 what “problem” is causing asexuality, and negative public perception of asexuality. One of the most pervasive assumptions of our society is that all people experience sexual desire (Cole, 1993; Przybylo, 2011). Prause and Graham (2007) noted that asexual individuals may experience pressure to conform to this social norm, and may face challenges that are unrecognized by non-asexual individuals. It follows that distress arising from conflict with social expectations, from concerns that a potential physical abnormality may be causing a lack of sexual attraction, or from unique challenges faced by asexual individuals, could lead to psychological symptoms such as depression or anxiety. Furthermore, in recent qualitative research, asexual individuals expressed a sense of always having “felt different” than others, beginning around the time where their peers began to develop sexual interest (Brotto et al., 2010). A sense of belonging can be crucial in mental health development, and disruption or unrest during formative years has been indicated in several mental health problems, such as social anxiety (Hudson & Rapee, 2000) and depression (Ross & Mirowsky, 1999).  Bisexual individuals have been found to have indications of poorer mental health than homosexual and heterosexual individuals (Jorm, Koren, Rodgers, Jacomb, & Christensen, 2002), and it has been speculated that, in addition to social pressure arising from having a non-majority sexual orientation, having neither a clear homosexual nor heterosexual orientation may pose an additional stressor on the bisexual individual (Jorm et al., 2002). The same may be argued for the asexual individual. Relationship status has been linked to mental health problems (Berry & Worthington, 2001; Holt-Lunstad, Birmingham, & Jones, 2008), and it has been   32 suggested that it may be a mediating factor between non-heterosexual sexual identity and higher prevalence rates of some disorders (Sandfort et al., 2001). Gay and lesbian individuals are less likely to be in a relationship compared to their heterosexual counterpart (perhaps due to unavailability of a suitable partner, or to social stigma and barriers to such a relationship), and Sandfort and colleagues (2001) suggested that this may lead to increased loneliness, which may in turn be linked to increased mental health problems. It follows that the same might be true for asexual individuals, who have consistently been shown to be less likely to be in a relationship compared to sexual individuals (Bogaert, 2004; Brotto et al., 2010; Brotto & Yule, 2011; Yule, et al., 2014), despite expressing interest in romantic relationships through online forum discussions and the existence of asexual dating sites. There has yet to be any academic research on the importance of relationships to asexual individuals. Suicidality Our finding of potentially increased suicidality among asexual individuals is novel and interesting. Lesbian, gay, and bisexual youth have consistently been found to have high suicide attempt rates (D'Augelli & Hershberger, 1993; Grossman & Kerner, 1998; Hammelman, 1993; Jorm et al., 2002; Remafedi et al., 1998). Factors associated with suicide attempts among adolescents, such as psychiatric problems, intense personal stressors and losses, and negative life events (Brent, Bridge, Johnson, & Connolly, 1998; Lewinsohn, Rodhe, & Seeley, 1994; Reinherz et al., 1995) have also been found to predict number of suicide attempts among non-heterosexual youth (D'Augelli et al., 2001). It may be that many of these factors are also intensified among asexual individuals, although this association has yet to be investigated. Evidence   33 indicates that gay male youth who have attempted suicide frequently have not yet established a stable sexual identity (Schneider, Farberow, & Kruks, 1989). Due to the general lack of knowledge regarding asexuality as a sexual identity, an individual who lacks sexual attraction may have additional difficulty in finding a stable sexual identity; especially before coming into contact with the asexual community. This potential difficulty in establishing a sexual identity may in part explain the observed increase in endorsement of items indicating suicidality in this sample.  It is important to note that previous research on suicidality in non-heterosexual individuals reveals that this increased suicidality is not universal, but is linked with several risk factors, including self-identification as non-heterosexual at a younger age, substance abuse, family dysfunction, interpersonal conflict surrounding sexual orientation, and non-disclosure of sexual orientation (Remafedi, 1994). Thus, increased suicide risk seems to be in response to negotiating sexual identity within the larger social picture. It is also noteworthy that much of the research conducted on suicidality and sexual orientation has been done with adolescents, using samples of high school students. This study investigated a wide range of ages and utilized only a cursory measure of suicidality composed of two items embedded within a larger measure. However, this finding should be taken seriously and explored in more depth, particularly in light of previous research examining suicide attempts among gay and lesbian youth (Koureny, 1987).  Interpersonal Problems In addition to the observation that a large proportion of asexual individuals had never engaged in sexual intercourse (Bogaert, 2004; Brotto et al., 2010) or been in a   34 relationship (Brotto et al., 2010), researchers found that asexual individuals exhibited elevated social inhibition and cold/distant scores on a measure of personality problems. This lead the authors to speculate that asexual individuals may have had avoidant attachment styles (according to Bowlby’s (1969) attachment theory) as young children, which in turn might have lead to problems developing intimate relationships later in life (Brotto et al., 2010). Specifically, Brotto and colleagues (2010) wondered whether Schizoid Personality Disorder, which is characterized by disconnection from social relationships and a restricted range of emotions, might be related to asexuality. The qualitative portion of Brotto and colleague’s study confirmed that nearly half of the participants felt that they met criteria for Schizoid Personality Disorder, and that a number of members of AVEN were introverted, and thus had characteristics of Cluster A Personality Disorders.  While the current finding that asexual individuals tended to have a socially avoidant and cold interpersonal style compared to non-heterosexual and heterosexual individuals supports Brotto and colleagues’ (2010) finding, it does not allow us to speculate whether or not Schizoid Personality Disorder underlies asexuality.  This relationship between the current indications of socially avoidant and cold personality styles and asexuality requires more detailed exploration in future studies. Combined, our findings do not provide support for the previous speculation that asexuality is a symptom of, or an expression of an underlying psychiatric disorder. On the other hand, our findings do not allow us to rule out the alternative view, which is that growing up feeling different from one’s peers due to the lack of sexual attraction, and experiencing stigma associated with one’s lack of sexual attraction may lead to   35 difficulties developing social and/or intimate relationships, that might eventually lead the individual to self-identify as asexual. Though this interpretation cannot be entirely ruled out, our findings lend greater support to the other direction, which is that asexuality itself gives rise to others' distress in a manner that might impact psychological symptoms. Limitations Previous researchers have noted that asexual participants have, in the past, felt compelled to curtail their responses to queries about psychiatric symptoms, in an attempt to downplay any potential relationship between asexuality and psychopathology (Brotto et al., 2010). If this were true in the current sample, our significant findings may be under-representative of the severity of mental health issues among asexual participants. Further, this study used an Internet sample recruited from established asexual communities. This may limit our findings to asexual individuals who are members of such a community, as we did not assess individuals who lack sexual attraction, but have not yet come across the term “asexuality” or the asexual community (see Hinderliter (2009) and Brotto and Yule (2009) for a discussion on the limitations of recruiting samples from online asexual communities). Unfortunately, our sample of bisexual participants was not large enough to perform analyses on this group separately from homosexual participants. It would have been interesting to compare bisexual and asexual participants on these measures, and this is an area for future study.   36 2.5 Conclusion This study provided evidence that asexuality may be associated with higher prevalence of mental health and interpersonal problems. These findings support previous research that indicates elevated levels of these mental health correlates among individuals with non-heterosexual identities. Importantly, this research suggests that tendency toward suicidality may be elevated in asexual individuals, warranting further research into this important topic. Clinical implications are considerable, and asexual individuals should be adequately assessed for mental health difficulties and provided with appropriate interventions that are sensitive to their asexual identity. Taken together, however, this study does not support the previous contention that asexuality is a mental health disturbance, or is a symptom of an underlying psychiatric condition.      37 Chapter 3: Asexuality: An extreme variant of sexual desire disorder? 2  3.1 Introduction Human asexuality is generally defined as a lack of sexual attraction to anyone at all. A comprehensive summary of current definitions and conceptualizations of asexuality is provided in page 15 of this dissertation. Given the centrality of sexual attraction as a core feature of being human (Buss, & Schmitt, 1993), critics have argued that asexuality is a manifestation of some underlying psychopathology, and to this end, the research presented in Chapter 2 found elevated rates of depression and anxiety associated with asexuality (Yule, Brotto, & Gorzalka, 2013). However, because membership in a sexually marginalized group may be experienced as stressful and stigmatizing, this may account for the elevated rates of psychopathology found among asexual individuals (Scherrer, 2008) and does not directly support the contention that asexuality may be an expression of a psychiatric illness. There is also evidence of outright discrimination against asexual individuals (MacInnis & Hodson, 2012), which may further contribute to mood symptoms. The evidence for asexuality as a psychiatric disorder is, thus, equivocal at best. In Chapter 2, I addressed whether asexuality might be a symptom of a psychiatric disorder, and concluded that there was not sufficient empirical support for this conclusion. Another proposal classifies asexuality as an extreme variant of the                                                         2 A version of Chapter 3 has been published. Brotto, L. A., Yule, M. A., & Gorzalka,  B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). 646-660. DOI: 10.1111/jsm.12806   38 sexual dysfunction formerly classified as HSDD3, which is characterized by persistent or recurrent low sexual desire or absent sexual fantasies along with clinically significant distress, given that both asexual individuals and those with HSDD share a distinct disinterest in sex. Bogaert (2006) challenged this position, however, on the grounds that: (i) HSDD, but not asexuality, requires the presence of significant distress; (ii) a lack of sexual attraction does not necessarily imply a lack of desire for sex; and (iii) most individuals diagnosed with HSDD have, at some point in their lives, experienced sexual desire whereas most asexual individuals often report a lifelong absence of sexual interest. The goal of this study was to directly test this hypothesis that asexuality might be a type of sexual dysfunction. We did so by exploring the similarities and differences between individuals likely to be asexual and those meeting diagnostic criteria for the former condition, HSDD. We were specifically interested in responses to measures of sexual desire, distress, mood, and sexual behaviour. It has been suggested that asexual individuals may be motivated (e.g., by socially desirable responding) to conceal their sexual (dis)interests (Bogaert, 2006). To explore this, we also included a measure of socially desirable responding. To test the possibility that those with lifelong HSDD may overlap categorically with individuals likely to be asexual, we also compared the latter with a subset of the HSDD group who reported a lifelong pattern of distressing lack of sexual desire. A significant strength of this study pertains to the use of a validated measure of asexuality (Yule, et al., 2015), rather than basing categorization on                                                         3 Note: we did not use criteria for Sexual Interest/Arousal Disorder (SIAD) as in the current DSM-5 (APA, 2013) given that this study was carried out before the DSM-5 was available.    39 individuals’ self-report. The benefit of this method of classification is that those individuals with a nondistressing lack of sexual attraction who have not yet encountered and identified with the label “asexual” could still be included in this asexual group, which we describe as the “AIS > 40” group, allowing us to separate out the impact of self-disclosure on the findings. 3.2 Methods Participants In the previous chapter, asexual individuals were categorized according to their self-identification as being asexual. In this study, we took a different approach in light of published criticisms of this way of categorizing asexuality in research (Hinderliter, 2009; Brotto & Yule, 2009). Placement into the asexual group was based on scores from the AIS (Yule, et al., 2015), a 12-item valid and reliable self-report questionnaire that assesses the degree to which respondents agree with a series of statements from 1 (completely true) to 5 (completely false). Any individual who scored at or above 40 on the AIS was placed into the “AIS > 40” group, and those scoring below 40 were placed into the sexual group and further subcategorized as per the criteria described below. A total of 799 individuals provided consent to participate; however, complete data were obtained from 668 individuals. The age range of these 668 individuals was between 15 and 79 years (mean age 28.0, SD 11.2) and included 162 men, 505 women, and one individual who did not respond to the question about sex. Because the data were positively skewed to a disproportionate number of young participants, and because of the known influence of age on sexual experiences, we corrected for this by including individuals in the AIS > 40 group only if they were older than age 23. Doing   40 this led to n = 193 in the AIS > 40 group (mean 30.9 years, SD 11.1; 79.7% female) and n = 231 in the sexual group (mean 33.9 years, SD 12.3; 68.1% female), with significantly more female than male participants, χ2(1) = 7.21, p = 0.008, and significantly older sexual than AIS > 40 participants (mean difference 3.0 years), t(422) = 2.59, p = 0.010. The sexual group was further classified into control, HSDD, and subclinical HSDD on the basis of their responses to items addressing the HSDD criteria, as outlined by the former DSM, 4th edition, text-revision (APA, 2000) and asking participants to indicate whether the symptom was true or false for them. An individual who endorsed each of the HSDD criteria: criterion A: “I experience persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity”; criterion B: “This deficiency/absence of sexual fantasies and desire causes me marked distress or interpersonal difficulty”; and criterion C: “This deficiency/ absence of sexual fantasies and desire for sexual activity are not better accounted for by a mental health disorder (such as depression), a drug (legal or illegal), or some other medical condition”, was placed into the HSDD group. An additional question asked whether the deficiency/absence of sexual fantasies and desire were lifelong (“I have always had low/no desire”) or acquired (“This low/no desire started after a period of normal sexual functioning”). If a sexual individual endorsed criterion A (lack of desire for sex and low/no fantasies) but not criterion B (distress), they were placed into the subclinical HSDD group. Only individuals who denied all of criteria A, B, and C, and whose AIS scores were < 40 were placed into the control group.   41 This further subcategorization led to 50 individuals categorized as HSDD (mean age 36.5, SD 12.2; 74.0% female), 59 as subclinical HSDD (mean age 36.2, SD 13.2; 66.1% female), and 122 control (i.e., score < 40 on the AIS and no reported difficulties in sexual desire or distress; mean age 31.7, SD 11.5; 66.4% female) participants. Procedure Participants were recruited through several separate and concurrent avenues, including postings on local websites (e.g., Craigslist), on the AVEN online web-community general discussion board, through online and in-clinic postings at the offices of sexual therapists and sexologists, and through our university’s human subject pool. We attempted to recruit participants from a wide range of avenues in order to maximize the opportunity to recruit self-identifying asexual individuals, as well as those who lack sexual attraction but do not yet identify as asexual. UBC's Behavioural Research Ethics Board approved all procedures. Data were collected between September and December 2010 via a web-based survey hosted by SurveyMonkey. Data were collected using questionnaires that assessed demographic, sexual health, sexual behaviour, sexual distress, asexual identity, mood, and social desirability. The questionnaire took 60 minutes to complete online. No remuneration was provided. Main Outcome Measures Demographic Information Apart from sex and education, which were asked in a free-response format, all other demographic questions adopted a forced-choice format. Relevant to the current   42 study, we inquired about sexual orientation, education, ethnicity, presence of sexual concerns and treatment thereof, and relationship status and length. Sexual Functioning The Female Sexual Function Index (FSFI; Rosen et al., 2000) is a 19-item multidimensional self-report scale that assesses key dimensions of sexual response in women. We focused on the two-item desire domain only given that all remaining subscales require the individual to have participated in recent sexual activity (Meyer-Bahlburg, & Dolezal, 2007) and the expected low base rate of this activity among our asexual subsample. The FSFI has good construct validity and reliably discriminates women with and without sexual desire and arousal disorders (Wiegel, Meston, & Rosen, 2005). A cutoff of six or higher on the desire domain reliably distinguishes sexually healthy controls from those with HSDD (Gerstenberger, Rosen, Brewer, Meston, Brotto, Wiegel & Sand, 2010). Cronbach’s alpha on the desire domain for our sample was high at 0.91. The International Index of Erectile Function (IIEF; Rosen, Riley, Wagner, Osterloh, Kilpatrick, & Mishra, 1997) is a 15-item self-report questionnaire that provides a brief assessment of sexual functioning in men. Like the FSFI for women, it assesses five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction; however, we chose to focus only on the two-item sexual desire subscale in the current study given the reliance of the other domain items on recent sexual activity (Yule, Davison, & Brotto, 2011). Unfortunately, cutoffs for the sexual desire domain are not available. Cronbach’s alpha in the current sample was high at 0.93.   43 Sexual Distress Sex-related distress was measured with the Female Sexual Distress Scale-Revised (FSDS-R; Derogatis, Clayton, Lewis-D’Agostino, Wunderlich & Fu, 2008). The gender-neutral language of the FSDS-R allowed us to administer this scale also to male participants without changing any of the item phrasing. This brief 13-item self-report scale quantified sexually related personal distress based on frequency rather than the intensity of distress. Each item was scored on a five-point scale ranging from Never to Always. The results were summed with a score of 15 or more being recommended as a cutoff for determining the presence of personal sexual distress (Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002). The FSDS has been shown to reliably discriminate between women with and without sexual dysfunction and is sensitive to therapeutically induced change. Cronbach’s alpha on our female participants was very high at 0.96 and was similarly high for our male participants at 0.97. Sexual Behaviours The Derogatis Sexual Functioning Inventory (DSFI) Drive Scale (Derogatis, Melisaratos, 1979) is a multidimensional self-report scale that was used to quantify frequency of current sexual behaviours. The first four items assessed the frequency of sexual fantasies, kissing and petting, masturbation, and sexual intercourse. Behaviours were assessed on a nine-point scale from Not at all to 4 or more per day, and a single score was obtained from the sum of these four items. The remaining three items of the DSFI Drive Scale assessed the ideal frequency of intercourse, age of sexual debut, and age at which the individual first became interested in sex. In addition, participants were asked the total number of individuals with whom they have had sexual activity in   44 their lifetime, and the total number of partners with whom they have had a close committed relationship, regardless of whether it involved sexual activity (defined as romantic relationship). Mood and Alexithymia The Toronto Alexithymia Scale (TAS; Bagby, Parker, & Taylor, 1994) is a 20-item self-report measure designed to measure alexithymia. It is based on three factors that characterize alexithymia: difficulty identifying and distinguishing between feelings and bodily sensations, difficulty describing feelings, and externally oriented thinking. Each item is measured on a five-point scale ranging from Strongly Disagree to Strongly Agree. A score of ≥ 61 has been suggested as a cutoff score to identify alexithymic subjects. Internal consistency was moderate for our sample (Cronbach’s alpha = 0.71). The Beck Depression Inventory: Second Edition (BDI-II; Beck, Steer, & Brown, 1996) is a 21-item self-report questionnaire revised from the original BDI and designed to assess severity of depressive symptoms over the past week in clinical and nonclinical samples. The statements are rated on a four-point scale ranging from 0 to 3. A score of ≥15 denotes probable depression. In a sample of college students, the internal consistency of the BDI-II was excellent at 0.90 (Storch, Roberti, & Roth, 2004), and it was similarly high in the current sample at 0.92. Socially Desirable Responding We used the Balanced Inventory of Desirable Responding (BIDR; Paulhus, 1988) to measure socially desirable responding. The BIDR is a 40-item scale in which respondents indicate how true they think a series of statements are that refer to the participants’ behaviours or feelings. Each statement is rated on a seven-item scale   45 ranging from Not True to Very True, and scores are calculated by reversing inversely keyed items and summing the scores across items. Two subscales were calculated: impression management (degree of performing desirable but uncommon behaviours; e.g., “I always obey laws even if I’m unlikely to get caught”) and self-deceptive enhancement (unconscious favorability bias similar to narcissism; e.g., “It’s all right with me if some people happen to dislike me”) with a maximum score of 140 for each scale. Internal reliability for the scales are in the highly satisfactory range for the two domains (Cronbach’s alpha = 0.70–0.86), and it has been shown to have excellent face, discriminant, and convergent validity (Paulhus, 1988). For the current sample, BIDR scores were on the low end for both the impression management (Cronbach’s alpha 0.63) and self-deceptive enhancement (Cronbach’s alpha = 0. 56) domains. Data Analyses Given that the sexually identifying participants were significantly older than those in the AIS > 40 group, F(3,420) = 5.23, p = .001, partial ɳ2 = .036, age was controlled for in all analyses. Participants who scored more than two standard deviations above the group mean for any single end point were excluded from that analysis.    46 3.4 Results Demographic Characteristics Table 3.1 presents the results of a one-way analysis of covariance (ANCOVA) comparing the groups (AIS > 40, control, HSDD, and subclinical HSDD) on age, years education, and relationship length (with the latter two controlling for age), and the results of χ2 analyses for categorical variables, including: sexual orientation, relationship status, whether the individual has children, ethnicity, and whether the individual has been previously treated for a sexual concern. The majority of the participants were white, with no significant group differences. After controlling for age, there was no significant group difference on years of education, F(3,392) = 2.09, p = 0.10, partial ɳ2 = .016. The groups significantly differed on relationship status, χ2(9) = 92.96, p < 0.001, φc = .33, with many more AIS > 40 individuals reporting that they were single (75.9%) compared with the control group (31.4%), the HSDD group (18.0%), and the subclinical HSDD group (46.6%). After for controlling for age, the groups did not differ on relationship length, F(3,186) = 0.91, p = 0.44, partial ɳ2 = .014 (Table 3.1). The groups significantly differed in the proportion who reported having children, χ2(3) = 32.54, p < 0.001, φc = .28, with individuals in the AIS > 40 group being significantly less likely to have children than the other three groups. Participants in the HSDD group were significantly more likely to have received prior treatment of a sexual concern than the other groups, χ2(3) = 17.93, p < 0.001, φc = .21. Among the sexual participants, there were no significant group differences in self-reported sexual orientation, χ2(6) = 6.66, p = 0.354, φc = .12; interestingly, at least a few individuals in the HSDD (n = 3), subclinical HSDD (n = 6), and control groups (n = 3)—all of whom   47 were categorized as “sexual” based on AIS scores < 40—self-identified as asexual (Table 3.1). AIS > 40 participants were significantly more likely to self-identify as asexual than the other three groups, χ2(9) = 240.89, p < 0.001, φc = .44.   48 Table 3.1  Demographic characteristics of participants in the AIS > 40 (n = 193), control (n = 122), Hypoactive Sexual Desire Disorder (HSDD; n = 50), and subclinical HSDD (n = 50) groups   AIS > 40  Controls   HSDD   Subclinical HSDD  p-value Effect Size Age M (SD) 30.92 (11.06)  31.72  (11.54) 36.46  (12.15) 36.15  (13.20) .001 .0361 Self-identified Sexual Orientation*  (%) Heterosexual Bisexual Homosexual Asexual    16.1 3.6 2.1 78.2    70.5 18.0 9.0 2.5    68.0 20.0 6.0 6.0    67.8 18.6 3.4 10.2  < .001    .122   .442 Relationship status* (%) Single Casual dating Long-term relationship Other   75.9 1.6 20.4  2.1   31.4 5.8 60.3  2.5   18.0 10.0 70.0  2.0   37.9 3.4 50.0  0   < .001   .332 Have children* (%)  9.4  22.1  42.0  29.3  < .001  .282 Ethnicity (%) Euro-Caucasian East/South Asian African American Aboriginal/First Nation Hispanic Other  90.5 4.2 0.5 0  1.6 3.2  79.5 9.8 4.1 0  1.6 4.9  78.0 10.0 4.0 2.0  2.0 2.0  72.4 6.9 6.9 1.7  5.2 6.9  ns  .152 Treated for sexual concern (%)†  7.8  9.0  28.0  16.9  < .001  .212 Years education M (SD)   14.34  (4.81)  13.68 (4.85)  13.21 (5.41)  12.73 (5.65)  ns  .0161 Relationship length in years M (SD)  8.48 (9.65)  6.77 (8.00)  9.62 (8.69)  7.90  (7.79)  ns  .0141 AIS M (SD)* 50.65 (5.68) 20.82  (7.14) 27.10  (6.62) 27.46  (7.29) < .001 .811  *AIS > 40 individuals significantly different from other groups; † HSDD group significantly different from other groups; 1 Partial eta-squared (ɳ2);  2 Cramer’s V (φc) AIS = Asexuality Identification Scale Table 3.1 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 651.   49 Asexual Identification AIS scores, by definition, differed between the groups and are presented in Table 3.1. Sexual Behaviours After excluding the data from five outliers (individuals who reported more than 100 sexual partners), a multivariate analysis of covariance (MANCOVA) examining the total number of romantic and sexual partners revealed a significant overall effect, F(6,784) = 9.85, p < 0.001, partial ɳ2 = .061. Univariate analyses revealed a significant effect for number of past sexual partners, F(3,392) = 20.54, p < 0.001, partial ɳ2 = .14, such that those in the AIS > 40 group had the fewest past sexual partners (Table 3.2).    50 Table 3.2  Sexual activity frequency by group. Data represent means and standard deviations  AIS > 40  Controls  HSDD  Subclinical HSDD p-value Effect Size Total sexual partners1 M (SD) 2.55 (5.03) 10.94  (14.29) 15.57  (19.26) 14.09 (18.05) < .001 .145 Total romantic partners1 M (SD) 1.71 (2.51) 3.84 (9.16) 5.02  (4.16) 3.85  (3.33) .001 .0465 Ratio of sexual to romantic partners2 1.36  (3.58) 4.54  (6.67) 7.15  (15.39) 3.80  (3.70) < .001 .0655 Intercourse frequency (%) Not at all < 2/month 1-3/week > 4/week   78.2 16.5 5.3 0   24.2 37.5 30.8 7.5   12.2 49.0 34.7 4.1   45.6 35.1 14.0 5.3  < .001  .356 Masturbation (%) Not at all < 2/month 1-3/week > 4/week  27.0 39.2 23.8 10.0  5.1 23.7 41.5 29.7  12.2 49.0 32.7 6.1  15.8 40.4 26.3 17.5  < .001  .246 Kissing and Petting (%) Not at all < 2/month 1-3/week > 4/week   63.8 20.7 8.0 7.4   17.6 22.7 16.0 43.7   8.2 30.6 28.6 32.7   33.3 24.6 15.8 26.3  < .001  .326 Sexual fantasies (%) Not at all < 2/month 1-3/week > 4/week  38.0 39.0 12.8 10.2  4.2 26.7 30.0 39.2  16.3 40.8 22.4 20.4  15.8 35.1 10.5 38.6  < .001  .296 Age of first interest in sexual activity3  M (SD)  15.36 (4.53)  12.80 (3.43)  14.04 (3.62)  13.30 (3.09)  < .001  .0775 Age of first intercourse4 M (SD) 18.84 (4.78) 18.54 (3.98) 18.43 (6.42) 17.13 (3.42) ns .0185 Note: 1Excluding individuals who have had more than 100 romantic or sexual partners 2Excluding individuals who have had at least one romantic partner but no sexual partners, or at least one sexual and no romantic partners. Those with neither romantic nor sexual partners received a zero score 3After excluding individuals who reported never being interested in sexual activity.  4After excluding individuals who reported never having engaged in sexual intercourse.  5 Partial ɳ2;  6 Cramer’s V (φc) ns = nonsignificant; SD = standard deviation. Table 3.2 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 652.   51  There was also a significant univariate effect on total number of past romantic partners after controlling for age, F(3,392) = 5.61, p = 0.001, partial ɳ2 = .046 , with the AIS > 40 also having the fewest past romantic partners (Table 3.2). We also examined the proportion of sexual to romantic partners across groups, controlling for age. For this analysis, we coded as missing any individual who reported a zero for either sexual or romantic partners; however, we retained data from individuals who reported having neither sexual nor romantic partners (and coded these as zero). From the AIS > 40 group, this led to 86 being excluded on sexual partners and 83 being excluded on romantic partners; for the HSDD group, this led to one individual being excluded on sexual and one on romantic partners; for the subclinical HSDD group, this led to one being excluded on past sexual partners and seven being excluded on romantic partners; and for the control group, this led to four being excluded on past sexual and eight being excluded on past romantic partners. The univariate ANCOVA was significant, F(3,356) = 8.20, p < 0.001, partial ɳ2 = .065 with those in the AIS > 40 group having the lowest ratio of sexual to romantic partners (Table 3.2). Significantly, more participants in the AIS > 40 group reported never having engaged in any type of sexual activity (including kissing, petting, and intercourse) compared with the other three groups, χ2(3) = 16.03, p = 0.001, φc = .20, (AIS > 40: 7.9%; controls: 0%; HSDD: 2.0%; subclinical HSDD: 0%). Each of the DSFI behaviour items were examined separately. As detailed in Table 3.2, those in the AIS > 40 group were significantly less likely to currently be engaged in sexual intercourse, χ2(21) = 156.25, p < 0.001, φc = .35, masturbation,  χ2(24) = 72.53, p < 0.001, φc = .24, kissing   52 and petting behaviours, χ2(24) = 127.73, p < 0.001, φc = .32, and sexual fantasies, χ2(24) = 108.37, p < 0.001, φc = .29. DSFI item 2 assessed participants’ ideal intercourse frequency and again found a significant difference between groups, χ2(21) = 309.68, p < 0.001, φc = .52, with 83.9% of the AIS > 40 group stating that they would prefer not to have sexual intercourse at all compared with 3.6% of the control group, 6.8% of those with HSDD, and 9.4% of those with subclinical HSDD. DSFI item 3 assessed age of first interest in sexual activity and significantly more AIS > 40 individuals (37.7%) reported never having any interest in sexual activity compared with those in the control (1.7%), HSDD (0%), and subclinical HSDD (0%) groups. After excluding those who reported never having an interest in sexual activity, we carried out a univariate ANCOVA controlling for age and found a significant main effect of group, F(3,321) = 8.96, p < 0.001, partial ɳ2 = .077, such that the AIS > 40 group were significantly older when they first experienced any interest in sexual activity compared with the remaining three groups. On DSFI item 4 (age of sexual intercourse debut), after excluding those who had never experienced sexual intercourse (50.6% of the AIS > 40 group, 7.7% of the control group, 2.0% of the HSDD group, and 10.3% of those with subclinical HSDD), an ANCOVA failed to reveal a statistically significant group difference, F(3,289) = 1.73, p = 0.16, partial ɳ2 = .018. The mean age for sexual intercourse debut, across groups, was 18.36 years (SD 4.62; Table 3.2). Sexual Desire Difficulties and Distress Those in the AIS > 40 group were significantly less likely to report having any current sexual concerns compared with the other three groups, χ2(3) = 35.75, p <   53 0.001, φc = .29, with individuals in the HSDD and subclinical HSDD groups more often reporting a low sex drive as their sexual concern, and some individuals in the control group reporting discrepant desire with a partner, erectile and ejaculatory issues, pain with sex, and dissatisfaction with the frequency of sexual contact. Moreover, individuals in the HSDD group were significantly more likely to have been treated by a professional for a sex-related concern, χ2(3) = 17.93, p < 0.001, φc = .21 (Table 3.3). Table 3.3  Reported sexual difficulties and distress across groups  AIS > 40 (n = 191) Controls  (n = 121) HSDD  (n = 50) Subclinical HSDD  (n = 58) p-value Effect Size Current sexual concerns1 (%)  20.9  28.9  64.0  36.2  < .001  .297 Ever received treatment for a sexual difficulty2 (%)  7.8  9.0  28.0  16.9  < .001  .217 FSFI Desire3 M (SD) 2.62 (1.34) (n = 145) 5.93 (1.92) (n = 75) 3.30 (1.70) (n = 33) 4.44 (2.42) (n = 32) < .001 .436 IIEF Desire4 M (SD) 3.00 (1.62) (n = 36) 6.62 (2.28) (n = 37) 5.80 (2.74) (n = 10) 5.20 (2.24) (n = 15) < .001 .386 SDS5 M (SD) Men Women  9.59  (16.00) 10.47  (13.21)  15.49 (13.07) 17.62 (11.43)  31.60 (11.24) 27.79 (13.04  27.79 (16.15) 21.86 (13.98)  < .001  .176  Note: SDS = sexual distress scale. SD = standard deviation. 1AIS > 40 significantly different from other groups; 2HSDD group significantly different from other groups; 3significant effect of age and group; 4significant main effect of age 5significant group difference after controlling for age; 6 Partial ɳ2;  7 Cramer’s V (φc) FSFI = Female Sexual Function Index; IIEF = International Index of Erectile Function; SDS = Sexual Distress Scale Table 3.3 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 653.    54 The desire domain of the FSFI was examined with a univariate ANCOVA controlling for age on female participants only. There was a significant main effect of group, F(3,280) = 69.35, p < 0.001, partial ɳ2 = .43. Controls had the highest levels of desire followed by the other three groups (Table 3.3). Moreover, scores in the control group nearly approached the threshold for women without sexual desire difficulties previously published (Gerstenberger, et al., 2010), whereas women in the HSDD, subclinical HSDD, and AIS > 40 groups scored in the range similar to previous samples of women with HSDD. Data were available for 98 male participants on the IIEF desire domain. A univariate ANCOVA controlling for age found a significant main effect of group, F(3,93) = 19.20, p < 0.001, partial ɳ2 = .38, with those in the control group having the highest level of desire and those men in the AIS > 40 group having the lowest scores (Table 3.3). The FSDS-R was examined in both sexes using a univariate ANCOVA exploring effects of group and sex (as independent factors) after controlling for age. The group by sex interaction was not significant, F(3,357) = 1.07, p = 0.360, partial ɳ2 = .0070. The main effect of sex was not significant, F(1,357) = 0.81, p = 0.369, partial ɳ2 =, but the main effect of group was significant, F(3,357) = 23.71, p < 0.001, partial ɳ2 = .17, such that men and women in the AIS > 40 group had the lowest levels of sex-related distress, and those in the HSDD group had the highest scores on sex-related distress (Table 3.3).      55  Alexithymia, Mood, and Desirable Responding We carried out a MANCOVA controlling for age using TAS, BDI-II, BIDR-Self-Deceptive Enhancement, and BIDR-Impression Management Scores. We found a significant multivariate main effect of group, F(12,1113) = 5.87, p < 0.001, partial ɳ2 = .059. Follow-up univariate analyses indicated significant group differences on symptoms of depression (BDI-II scores), F(3,372) = 4.15, p = 0.007, partial ɳ2 = .032, with individuals in the subclinical HSDD group having the highest BDI-II scores followed by those with HSDD. Those in the AIS > 40 group had the lowest BDI-II scores (Table 3.4). The univariate ANCOVA was also significant for BIDR Impression Management scores, F(3,372) = 14.82, p < 0.001, partial ɳ2 = .097, and those in the AIS >40 group had the highest levels of impression management (Table 3.4). The univariate ANCOVA was not significant for BIDR Self-Deceptive Enhancement, F(3,372) = 0.66, p = 0.58, partial ɳ2 = .005, nor for alexithymia, F(3,372) = 2.20, p = 0.09, , partial ɳ2 = .017.     56  Table 3.4  Alexithymia (TAS), depressive symptoms (BDI-II), self-deceptive enhancement (BIDR-SDE), and impression management (BIDR-IM) across groups. Data represent means and standard deviations.  AIS > 40 (n = 177) Controls  (n = 112) HSDD  (n = 42) Subclinical HSDD  (n = 46) p-values Partial Eta-Squared (ɳ2) TAS 47.63 (13.42) 45.12 (13.07) 44.95 (13.96) 50.48 (14.74) ns .017 BDI-II 10.88 (10.51) 11.88 (9.91) 13.50 (10.29) 17.22 (12.52) .007 .032 BIDR-SDE 82.60 (13.90) 80.38 (12.01) 81.74 (12.54) 82.65 (16.97) ns .005 BIDR-IM 86.99 (15.60) 75.20 (16.43) 80.55 (14.40) 77.35 (13.38) < .001 .097   Note: TAS = Toronto Alexithymia Scale. BDI = Beck Depression Inventory. BIDR = Balanced Inventory of Desirable Responding. SDE = self-deceptive enhancement.  IM = impression management; ns = nonsignificant Table 3.4 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 653.      57 Logistic Regression Predicting HSDD vs. AIS > 40 Group A binary logistic regression was used to assess predictors of group membership in HSDD (n = 42, coded as 1) over and above AIS > 40 group (n = 166, coded as 0) groups. Interest focused on three sets of variables: set 1 (demographics: relationship status, age); set 2 (sex-related: sexual distress, sexual desire, and DSFI total sexual behaviour score); set 3 (psychiatric: BDI-II, BIDR, and TAS). Comparisons of nested logistic regression fits were based on the likelihood ratio χ2 test, and the significance of individual regression coefficients was assessed using Wald tests. Step 1 was significant, χ2(2) = 46.75, p <  0.001 with both relationship status (p <  0.001) and age (p =  0.04) being significant predictors (Table 3.5). Partnered individuals were more likely to be in the HSDD compared with the AIS > 40 group, and single individuals were less likely to be in the HSDD group. Older individuals were more likely to be in the HSDD group. Step 2 was also statistically significant, χ2(3) = 34.02, p <  0.001, and 94.0% of those in the AIS > 40 group and 59.5% in the HSDD group being correctly classified based on these predictors. Specifically, sexual distress scores (p < 0.001) and sexual desire scores (p = 0.008) were significant predictors, whereas sexual behaviours did not significantly predict to the HSDD group (p = 0.103). With each unit increase in FSDS-R scores, participants were 1.06 times more likely to be in the HSDD group, and with each unit increase in sexual desire scores they were 1.78 times more likely to be in the HSDD group. The addition of the psychological variables (BIDR, BDI-II, and TAS) also led to an overall significant model, χ2(4) = 11.58, p = 0.021; however, only the TAS scores significantly predicted to the HSDD group (p = 0.017) such that with every unit   58 increase in TAS scores, participants were 0.94 times less likely to be in the HSDD group.  Table 3.5  Logistic regression predicting to HSDD group over AIS > 40 group  Correct predictions to group         AIS > 40 HSDD β SE(B) Wald F2 Odds Ratio  95% CI p-value Step one 93.4% 23.8%   46.75    <.001 Age   0.03 .016 4.24 1.03  1.00–1.07 .04 Relationship Status    1.13   0.20   32.48  3.11  2.10–4.59 < .001 Step two 94.0% 59.5%   34.02    <.001 Sexual desire   0.577 0.22s 7.03 1.78  1.16–2.73 .008 Sex-related distress   0.054 0.016 12.165 1.06  1.02–1.09 < .001 Sexual behaviours   .098 0.060 2.66 1.10  0.98–1.24 .103 Step three 96.4% 64.3%   11.58    .021 BDI-II   -0.012 0.029 0.176 0.99  0.93–1.05 ns TAS   -0.062 0.026 5.675 0.94  0.89–0.99 .017 BIDR-SDE   0.009 0.023 0.153 1.01  0.96–1.06 ns BIDR-IM   -0.021 0.017 1.527 0.98  0.95–1.01 ns  Note: Data were coded as 0 = asexual individuals, 1 = HSDD. BDI = Beck Depression Inventory. TAS = Toronto Alexithymia Scale. BIDR = Balanced Inventory of Desirable Responding. SDE = Self-Deceptive Enhancement. IM = Impression Management  ns = nonsignificant Table 3.5 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 654.      59 Comparison of Lifelong HSDD and Asexuality Among our sample of individuals with HSDD, 14 indicated that their absent sexual desire and sexual fantasies had been lifelong. Given speculation that individuals with lifelong HSDD may overlap the most with asexuality since both groups experience a lifelong lack of sexual desire/attraction, we conducted an exploratory analysis to compare these 14 individuals with lifelong HSDD to the sample of 193 individuals in the AIS > 40 group. Because the two groups differed substantially in sample size, and an independent samples Mann–Whitney U-test revealed that the two groups had different distributions, we used independent samples median tests to assess whether the median scores of several variables were the same between the two groups. As expected, AIS scores were significantly higher in the AIS > 40 group compared with the lifelong HSDD group (p < 0.001). The DSFI sexual behaviour scores did not differ between the AIS > 40 group compared with the lifelong HSDD group (p = 0.10), and neither FSFI sexual desire scores (p = 0.82) nor IIEF sexual desire scores (p = 0.95) significantly differed between the two groups. Sex-related distress was three times higher in those with lifelong HSDD (p = 0.006) (Table 3.6).     60 Table 3.6  Comparison of those in the AIS > 40 group and those with Lifelong HSDD. Data represent means and standard deviations  AIS > 40 (n = 193) Lifelong HSDD (n = 14) p-value AIS 50.65 (5.68) 27.21 (7.65) .001 DSFI Sexual Behaviours Score 8.93 (3.86) 12.36 (6.55) ns FSFI Desire 2.62 (1.34) 2.57 (1.13) ns IIEF Desire 3.00 (1.62) 5.40 (3.85) ns SDS  10.30 (13.75) 30.83 (14.24) .006  AIS = Asexuality Identification Scale; DSFI = Derogatis Sexual Functioning Inventory; FSFI = Female Sexual Function Index; IIEF = International Index Of Erectile Function; ns = nonsignificant; SDS = sexual distress scale Table 3.6 has been reproduced with permission from the publisher © Brotto, L. A., Yule, M. A., & Gorzalka, B. B. (2015). Asexuality: An extreme variant of sexual desire disorder? Journal of Sexual Medicine, 12(3). Pg. 654.   3.5 Discussion Summary of Findings The aim of this study was to test the hypothesis that asexuality might be a type of sexual dysfunction, by comparing individuals who fell into the "asexual domain" on a validated measure of asexuality (AIS > 40), to individuals who met diagnostic criteria for HSDD, to individuals with low sexual desire without distress, and to a sexually healthy control group. Unlike the previous study where we categorized asexual individuals as those who self-identified as asexual, here we classified those in the AIS > 40 group according to scores on a validated measure of asexuality (Yule, et al., 2015). This approach has the advantage of overcoming the limitations associated with relying on self-identification for group comparisons (Brotto & Yule, 2009). Both asexual individuals and those with HSDD share a lack of desire for sex, though these groups are conventionally distinguished based on the lack of concurrent   61 distress among asexual individuals and the clinically significant levels of distress in those with HSDD. In addition to comparing groups on sexual desire and distress, we also compared the groups on other variables of interest that have been speculated as differentiating low desire with and without distress. The impetus for this study emerged from voiced skepticism of the existence of asexuality as a discrete sexual orientation, and the position that asexuality represents an extreme form of low sexual desire. Although our study does not allow us to rule out the possibility that some individuals who initially meet criteria for HSDD might subsequently be classified as asexual, we believe that this study represents a first step in describing the unique areas of overlap and distinction between these populations.  Overall, our findings suggested that asexual individuals were less likely to have ever engaged in a number of sexual behaviours, such as sexual intercourse, sexual fantasies, kissing, or petting than all other groups. Asexual individuals were also less likely to experience distress relating to sex than those with HSDD. Participants with HSDD and subclinical HSDD exhibited higher symptoms of depression than other groups, while there were no group differences on measures of alexithymia or desirable responding. A binary logical regression revealed that relationship status, sexual desire, sex-related distress, and lower alexithymia were the best predictors of group membership to the HSDD or AIS > 40 groups. We limited our analyses to individuals in the AIS > 40 group who were older than 23 years of age in an effort to match the ages of the groups and reduce the possibility that observed group differences in demographic characteristics and sexual behaviours may be an artifact of older age in the sexual samples. Although the AIS > 40   62 sample was still significantly younger than the other three groups, the difference in their ages was minimal (3 years), and age was used as a covariate in all analyses. We found no significant group differences in years of education, which is inconsistent with previous research that found low levels of education to be associated with asexuality (Bogaert, 2004, 2012a; Poston & Baumle, 2010), although one other study did find asexual individuals to have higher levels of education than other group (Prause & Graham, 2007). The equivocal findings on the association between asexuality and level of education may be related, at least in part, to the sources of recruitment. Because our study used a combination of recruitment sources, this may account for the difference between our AIS > 40 participants level of education compared with controls vs. those found in other studies. Not surprisingly, even after controlling for age, AIS > 40 individuals were significantly less likely to be in a relationship (75.9%) compared with the control group (31.4%), the HSDD group (18.0%), and the subclinical HSDD group (46.6%), and the mean number of total sexual and romantic partners were significantly less in the AIS > 40 group compared with the other three groups. These findings highlight that, despite their low desire for sex, individuals with HSDD in this study did not differ significantly from controls in mean sexual or romantic partners, yet individuals identifying as AIS > 40 differed on both these variables. Romantic attraction varies widely among asexual individuals, with some desiring the same nonsexual benefits of partnership declared by sexual individuals (Brotto et al., 2010) and others self-defining as “aromantic,” or in other words, desiring neither a sexual nor a romantic partner. After excluding those with either no history of romantic or sexual partners, we next   63 compared the proportion of sexual with romantic partners across the groups and found those in the AIS > 40 group to have a significantly lower ratio compared with the other three groups. This finding suggests that the AIS > 40 participants were more likely to have romantic relationships that did not include sexual activity whereas those in the other groups (who had higher ratios) were more likely to have sexual encounters outside of a romantic partnership. Having HSDD did not seem to impact this proportion and suggests that a comparison of the ratio of romantic with sexual partners might be one means of differentiating those with HSDD from asexual individuals. The diagnostic criteria for HSDD (APA, 2000) focus on the lack of desire for sex and absent sexual fantasies. On the desire domain of the FSFI, there was an expected linear relationship between group and desire such that the control group had significantly higher scores, followed by the HSDD and subclinical HSDD groups, which did not significantly differ from one another, followed by the AIS > 40 group. The range of scores for our control and HSDD samples were comparable with other published data on women with and without HSDD (Gerstenberger et al, 2010), and FSFI desire scores in the AIS > 40 group were comparable with previously published data on asexual samples of women (Brotto & Yule, 2011). IIEF desire scores among the men in this study showed a similar pattern with men in the AIS > 40 group showing the lowest IIEF desire scores followed by the HSDD group and then the control group. The desire scores for our AIS > 40 men were comparable with another recruited sample of asexual men (Brotto et al., 2010) and scores for our control group were similar to other published data on sexually healthy men (Rosen et al., 1997). Our findings suggest that   64 although asexual individuals and those with HSDD share a similar disinterest in sexual activity, the groups can still be differentiated based on the finding that those in the AIS > 40 group reported even lower levels of desire than those with a sexual desire dysfunction. Criteria for HSDD in the DSM-IV-TR also required deficient or absent sexual fantasies; in this study, we found that significantly more participants in the AIS > 40 group (38.0%) compared with the other groups (4.2–16.3%) reported never having experienced a sexual fantasy. These findings mirror another recent large study that found 40% of asexual individuals have never experienced a sexual fantasy (Yule, Brotto & Gorzalka, 2014b). Interestingly, although a reduced frequency of fantasy is part of the diagnostic criteria for HSDD, it is notable that at least 85% of the HSDD and subclinical HSDD participants have experienced sexual fantasies, and nearly half of those with HSDD currently experience at least one sexual fantasy per week. These data suggest that AIS > 40 and HSDD participants may be differentiated on the basis, at least in part, of their sexual fantasy frequency. Although 62% of the AIS > 40 participants did report experiencing sexual fantasies, we did not explore the contents of their fantasies in this study. Bogaert (2012b) speculated that asexual person’s fantasies are somewhat “identity-less”—or involving characters unknown to the individual or perhaps even fictional characters. If Bogaert’s speculation is correct, we might hypothesize that at least some of the fantasies among this subsample of AIS > 40 who do fantasize may depict scenes that do not involve other persons. Future research employing qualitative stories that invite asexual persons to describe their fantasies might illuminate this further, and this will be undertaken in Chapter 4. Taking the sexual desire and sexual fantasy findings   65 together, our findings suggest that asexual individuals and those with HSDD can be differentiated on the basis of sexual desire and sexual fantasy frequency. Asexual individuals maintain that their lack of sexual interest and attraction evokes no sexual distress for them personally, although it may result in distress in a relationship. A diagnosis of HSDD also requires the presence of clinically significant distress. There was a significant group difference in sex-related distress after controlling for age, and no differences between male and female participants. Those in the HSDD group had the highest levels of distress and fell above the clinical threshold on the FSDS. Those in the control group had significantly lower levels of distress, and scores in the AIS > 40 group were even lower. Population based studies do find that approximately 10% of men and women experience sex-related distress (Mitchell et al. 2013), so the finding that participants in the control group had higher distress than AIS > 40 participants is perhaps not surprising. The HSDD sample had the highest rates of sex-related distress, even in the absence of any specific sexual symptom. The significantly higher levels of distress in the HSDD group may also be associated with this group’s higher frequency of having previously sought treatment by a sex therapist (28.0% vs. 7.8–16.9% in the other three groups). Our findings provide strong support for the low levels of personal sex-related distress reportedly experienced among asexual individuals (Brotto et al., 2010; Scherrer, 2008; Bogaert, 2008) and further support distress as a distinguishing feature of these two groups. Qualitative research has shown that when asked whether they would accept an effective treatment for improving their sexual desire, asexual individuals were unanimous in their rejection of this option (Brotto et al., 2010). When distress does arise for asexual individuals, it   66 seems that it may be related to the impact of one’s asexuality on a relationship when that individual is partnered with a sexual individual (Brotto et al., 2010). It is also possible that distress arises before an asexual has discovered an asexual community and experienced validation from others who can relate to their experiences. Data obtained from the DSFI show significantly lower rates across all sexual activities in the AIS > 40 group, and no significant differences between the HSDD and control groups. These findings suggest that their lack of sexual attraction translates also to a lack of sexual behaviour among those asexually identified, whereas those in the HSDD group continue to engage in sexual activity despite their distressing low desire. Notably, however, approximately 20% of AIS > 40 individuals were in a relationship at the time of the study, and 16.1% reported an ideal sexual intercourse frequency greater than zero. Although we did not explore the nature of their relationships, or specifically the characteristics of their partners (i.e., whether they were sexual or asexual), it is possible that some of our partnered AIS > 40 participants were in a relationship with a sexually identified partner who desired ongoing sexual activity. Negotiating sexuality in an asexual–sexual partnership has been a topic of interest and the focus of qualitative science, and sexual activity in these relationships has been described as consensual but undesired (Brotto et al., 2010)—akin to descriptions among sexual samples recently studied (O’Sullivan & Allgeier, 1998). One notable difference between our AIS > 40 and HSDD samples was that despite their common lack of interest in sex, many of the HSDD participants reported a wish for sexual intercourse and other sexual behaviours. Specifically, 83.9% of AIS > 40 individuals reported that they would prefer not to engage in sexual intercourse,   67 whereas the comparable figure was significantly lower for the control group (3.6%), the HSDD sample (6.8%), and those with subclinical HSDD (9.4%). The reduced desire for sex seen among our AIS > 40 participants was also evident in nongenital sexual activities. There was an overall greater proportion of individuals in the AIS > 40 group who reported never having engaged in any type of sexual activity (7.9%; including kissing, petting, and intercourse) compared with the other three groups (range from 0% to 2%). Rates did not differ between the HSDD and control samples, suggesting that the desire for nonsexual physical intimacy may not differ between controls and those with HSDD, whereas these groups differ from rates seen among asexual individuals. Unlike many individuals with low desire who report a reduction from a previous higher level of desire, asexual individuals have described a more lifelong pattern of no sexual attraction or desire, or feeling like they “could not relate” to friends who described sexual desire and attractions during adolescence (Brotto et al., 2010). Indeed, we found that age of first interest in sex significantly differed between the groups with the AIS > 40 group being more likely (37.7%) to report never having had an interest in sex compared with those in the control (1.7%), HSDD (0%), and subclinical HSDD (0%) groups. Among those in the AIS > 40 group who did recall having an interest in sex at least at some point in their lives, it occurred at a significantly older age than in the other three groups. Interestingly, however, age of intercourse debut did not significantly differ between the groups. We might conclude that whereas interest in sex may differentiate asexual individuals from those with HSDD, age of intercourse debut does not reliably distinguish the groups, and may be   68 influenced by a multitude of factors that do not reflect one’s motivation/desire for sex (Meston & Buss, 2007). Indeed, asexual individuals have reported “trying out” intercourse as a way of testing their lack of sexual attraction in a similar manner to same-sex attracted individuals trying out sex with opposite-sex partners. On our measured domains of psychological functioning, there were no group differences in alexithymia scores, and scores among our sample of AIS > 40 participants were the same as previously published data using the same measure with asexual men and women (Brotto et al., 2010). There was a significant group difference in depressive symptoms with the AIS > 40 sample showing the lowest rates and the HSDD and subclinical HSDD groups showing the highest rates, equivalent to a mild level of depressive symptoms. Given the strong association between mood and sexual desire (Dennerstein, Lehert, Guthrie, & Burger, 2007; Shifren, Monz, Russon, Segreti & Johannes, 2008), it is not surprising that our samples with clinical symptoms of low desire had significantly higher rates of depressive symptoms. Interestingly, our findings in Chapter 2 suggested that asexual men scored higher on a measure of depression than non-heterosexual men, and that asexual individuals scored significantly higher on items assessing suicidality than heterosexual individuals. Thus, it may be that the distress experienced by those men who meet diagnostic criteria for low sexual desire in the current study might influence higher depressive scores, and that this distress might be over-and-above distress arising from perceived social stigma experienced by asexual individuals.  On a measure of desirable responding, there were significant group differences in impression management (i.e., lying) but not in self-deceptive enhancement (i.e., overconfidence). Specifically, those in the AIS > 40   69 group endorsed more items reflecting a higher need for impression management compared with the other groups. This finding suggests that there may be a potential bias in this group wanting to appear favorable to the research team, and this may have impacted their responses on other items. Predictors of HSDD vs. Asexuality We carried out a three-stage binary logistic regression with demographic variables in stage 1, sexual desire, distress, and behaviour in stage 2, and psychological variables in stage 3. Here we found (older) age, (partnered) relationship status, higher distress scores, and higher sexual desire scores significantly predicted to the HSDD group above and beyond prediction to the AIS > 40 group. Level of sexual behaviour, depression, and social desirability scores did not significantly predict to group. Alexithymia scores did significantly predict to group such that a one unit increase in TAS scores decreased the odds of being in the HSDD group markedly. These findings suggest that, during an assessment of considering whether one may have HSDD vs. an asexual orientation, it may be important to consider the individual’s relationship status, level of desire, their sex-related distress, and characteristics of alexithymia, but examining their sexual behaviours only may not be a useful predictor. Differences and Similarities Between Lifelong HSDD and Asexuality As an exploratory analysis, we also compared the lifelong HSDD (n = 14) and AIS > 40 (n = 193) groups in order to explore whether those with a lifelong pattern of never desiring sex may overlap more with the AIS > 40 group than the entire group of HSDD individuals, which mostly included those with an acquired desire disorder. To explore this, we were specifically interested in four variables: AIS scores, sexual desire,   70 sex-related distress, and overall sexual behaviour. We found that those with lifelong HSDD had significantly lower AIS scores and significantly more sex-related distress; however, the groups did not differ on total sexual behaviours or on sexual desire. These findings illustrate potentially more overlap between lifelong HSDD and sexuality given that the groups could not be differentiated on the basis of behaviour or desire. We cannot rule out the possibility, however, that some individuals with asexuality may in fact have lifelong HSDD or that some diagnosed with lifelong HSDD may end up self- identifying as asexual, particularly because self-identification was not used as a basis of group classification in this study and because an in-person clinical assessment was not administered. That we found 6% of our HSDD sample self-identified as asexual, despite having AIS scores that did not meet the threshold for asexuality, suggests that there is likely overlap between some individuals with HSDD and asexuality. This group should be the focus of research in the future given that most research on low desire has focused on individuals who have acquired HSDD. Limitations There are limitations to this study that must be considered. First, although our sample was large and we attempted to recruit from a variety of sources, we had a proportionately small number of HSDD individuals, and a very small subsample of those with lifelong HSDD. Second, there were markedly more female than male participants, thus, we were unable to include sex as a factor in most analyses. Previous studies of asexuality, however, have failed to find significant sex differences for most correlates of asexuality. Third, we did not use a clinical interview to assign individuals to HSDD group. We did advertise for the study in the waiting rooms of sex therapists   71 who treat loss of sexual desire, however, only a series of self-report dichotomous questions were used to determine the extent to which participants met criteria for HSDD. Another limitation relates to the possibility of respondent fatigue. Although 799 individuals provided consent and started to take part in the online questionnaire, complete data were received by 668 participants (83.6%). Because AIS data were not available for these 131 individuals, a respondent fatigue by group interaction cannot be ruled out. 3.6 Conclusion The aim of this study was to address the hypothesis that asexuality might be an extreme version of a sexual desire disorder. However, we found notable differences between AIS > 40 individuals (those likely to identify as asexual) and those who meet diagnostic criteria for HSDD. Although a face-to-face clinical interview was not used to designate individuals to the HSDD group, we used diagnostic criteria based on the DSM-IV-TR, similar to the questions used in the Decreased Sexual Desire Screener (Clayton, Goldfischer, Goldstein, DeRogatis, Lewis-D’Agostino, & Pyke, 2009); thus, it is likely that our sample classified as HSDD would have met diagnostic criteria if a full clinical interview were performed. Nonetheless, we acknowledge the lack of a clinical interview as a weakness in our study design. We found that sexual desire, sexual distress, relationship status, and alexithymia were significant predictors to the AIS > 40 group over and above the HSDD group, and these variables may be important to assess in the clinical setting when differentiating between HSDD and asexuality. It is notable that level of engagement in sexual behaviours as well as age of intercourse debut do   72 not discriminate the groups, suggesting that in instances of making a classificatory decision between asexuality vs. a sexual dysfunction, the interviewer must assess a broad range of sex-related domains and not focus exclusively on sexual behaviour (in)frequency. Our findings also lend support for the use of the AIS in categorizing individuals as asexual and support the clinical cutoffs determined in psychometric analyses (Yule, et al., 2015). AIS scores significantly differentiated the groups, and even the lifelong HSDD from AIS > 40 groups (the latter two arguably having the most overlap), and thus, future researchers may consider implementing this measure in asexuality research. In conclusion, these data add to the growing literature on the correlates and characteristics of asexuality and suggest that asexuality is a category distinct from a sexual desire dysfunction. To this end, the most recent edition of the DSM, the DSM-5 (APA, 2013) explicitly includes a statement cautioning the clinician against making a diagnosis of low sexual desire in the case where the presenting individual is identifying as asexual. That said, we found significantly more overlap between those with lifelong low sexual desire and asexuality, which may ultimately prove invaluable for gaining a greater understanding of the processes that underlie the development of romantic vs. sexual attraction, and lack thereof.        73 Chapter 4: Sexual fantasy and masturbation among asexual individuals 4.1 Preliminary study on sexual fantasy and masturbation4 4.1.1 Introduction Approximately 1% of the population is thought to be asexual (Bogaert, 2004), and a general discussion of the definition and conceptualizations has been provided on page 15 of this dissertation. Chapter 2 of this dissertation provided evidence that asexuality is likely not due to a mental health difficulty, and Chapter 3 concluded that asexuality is a category distinct from a dysfunction of low sexual desire. The current chapter will explore the possibility that asexuality may be a paraphilia. One might assume that the low level of sexual interest experienced by asexual individuals would be associated with a complete lack of or infrequent masturbation. However, research suggests that a substantial proportion of asexual individuals masturbate at rates similar to (Brotto et al., 2010; Poston & Baumle, 2010) or less than (Bogaert, 2013) sexual individuals. This indicates that while a significant proportion of asexual individuals appear to have a low sex drive or lack sexual interest (Bogaert, 2006), some degree of desire for masturbation remains. Brotto and colleagues (2010) speculated that masturbation among asexual individuals may be motivated by non-sexual reasons, such as tension release or as a means of getting to sleep, rather than from intrinsic sexual desire or sexual excitement. Bogaert (2012b) hypothesized an identity-less                                                         4 A version of Section 4.1 has been published. Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409    74 masturbation pattern characterized by a need for physical release without engaging in sexual fantasy or thoughts/images of sexual partners. However, it may be that asexual individuals who masturbate have some sort of sexual interest of paraphilia that is reflected in the content of their sexual fantasies. This has not been explored to date, and is the focus of this Chapter.   (Barclay, 1973; Crepault & Coutoure, 1980; Knafo & Jaffe, 1984) and it has been hypothesized that fantasies more accurately reflect sexual desires than do sexual behaviours which may be constrained by social norms and pressures (Ellis & Symons, 1990).  Ellis and Symons suggest that gender differences in sexual fantasies may be a consequence of natural selection during the course of human evolution. In sum, according to this perspective, sexual fantasy is a fundamental aspect of human sexuality, developed to facilitate sexual activity, and is thought to be ubiquitous and universally experienced (Leitenberg & Henning, 1995).  As might be expected, men tend to fantasize more frequently than women, both throughout the day, and during masturbation and partnered sexual activity (Leitenberg & Henning, 1995). One study found that heterosexual men averaged approximately 7.2 fantasies per day, compared with about 4.5 for women (Jones & Barlow, 1990). A content analysis revealed the most common sexual fantasies to focus on the behaviours that people actually engaged in (Hsu et al., 1994). There are some gender differences in content, however, with men tending to be more exploratory in their fantasies (frequently fantasizing about behaviours they had never engaged in) than women (who tend to fantasize about sexual behaviours they have experienced) (Hsu et al., 1994). Compared to sexually-healthy controls, women with low sexual   75 desire did not masturbate less often or have fewer orgasms during masturbation (Nutter & Condron, 1983). They did, however, fantasize less than normal controls during foreplay and intercourse, masturbation, and general daydreaming. In a separate study, Nutter and Condron (1985) found that men with low sexual desire had less frequent sexual fantasies than a control group of men with erectile dysfunction.  The fantasy content of these groups was similar (Nutter & Condron, 1985). To more fully examine the speculative association between asexuality and sexual desire disorders, we sought to assess fantasy frequency and content among self-identified asexual individuals.  The aim of the current study was to provide a preliminary exploration of sexual fantasy frequency and content among asexual individuals compared to sexual individuals with and without low sexual desire. By increasing our understanding of sexual fantasies among asexual individuals, we hope to gain a greater understanding of motivations behind masturbation among asexual individuals as well as deepen our understanding of the (lack of) sexual attraction experienced by asexual people. We also explored group differences in masturbation patterns. 4.1.2 Method Participants A total of 1230 individuals provided consent to participate; however, only 924 participants completed data on sexual fantasy and masturbation. The age range of these 924 individuals was between 15 and 79 years (mean age 27.90, SD 10.81), and included 153 men, 533 women, and 238 individuals who did not respond to the query about sex. As in Chapter 2, participants were categorized as asexual if they self-  76 identified as such. Among the total sample, 534 were classified in the self-identified asexual group (mean age = 24.38, SD = 8.09), 87 as HSDD (mean age = 35.19, SD = 12.38), 78 as subthreshold HSDD (mean age = 32.90, SD = 12.38) (defined below), and 187 as normative (mean age = 30.72, SD = 11.25) (i.e., identified as sexual, and no reported difficulties in sexual desire or distress). There was a significant group difference in age, F(3,887) = 51.81, p < .001, partial ɳ2 = .15, with asexual participants being significantly younger than the sexual groups, p < .001 and the sexual comparison group being significantly younger than participants who met diagnostic criteria for HSDD, p < .01.  There were no significant differences in highest level of education achieved, Χ2(3) = 5.65, p > .05, φc = .081, with the majority of the participants (87% asexual, 88% HSDD, 80% low desire, 89% comparison) having received at least some post-secondary education. Eighteen percent of asexual individuals, 70% of those who met diagnostic criteria for HSDD, 51% of those with low sexual desire without distress, and 66% of the sexual comparison group indicated that they were currently in a relationship, either committed or non-committed, and these proportions differed significantly Χ2(3) = 198.68, p < .001, φc = .48.  Participants reported their ethnicity as: Caucasian/White, East Asian (Chinese, Japanese, or Korean), South Asian, African American/Canadian, First Nations/Aboriginal, Hispanic, or “other” with the majority identifying as Caucasian, χ2(18) = 40.38, p = .002, φc = .12 (Table 4.1). All ethnicities were included in the following analyses, as, as far as we know, there is no published evidence to date that sexual fantasies differ between these ethnic groups.   77     Table 4.1  Ethnicity of participants   Asexual (n=532) Low Sexual Desire (n=76) HSDD (n=87) Sexual Comparison Group (n=186) Caucasian/White 83% 78% 80% 74% East Asian (Chinese, Japanese, Korean) 3% 1% 7% 8% South Asian 2% 3% 3% 6% African American 2% 4% 1% 4% First Nation/Aboriginal 0% 1% 2% 1% Hispanic 2% 8% 2% 3%  Table 4.1 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409. Pg. 91.      78 Measures  Asexual identification Sexual orientation was assessed with the following question: “Which option below best describes your sexual orientation?” and response options were: asexual, heterosexual, bisexual, and homosexual. Individuals endorsing “asexual” were classified in the asexual group and those endorsing any of the other three options were placed into the “sexual” group. Asexuality was further assessed with the AIS (Yule, et al., 2014b), a 12-item self-report questionnaire that assesses the degree to which respondents agree with a series of statements from 1 (completely true) to 5 (completely false). The AIS has been found to significantly differentiate asexual from sexual individuals, and a score of 40 out of 60 was found to capture 93% of individuals who self-identified as asexual.  Hypoactive Sexual Desire Disorder (HSDD) Among those participants placed into the “sexual” category, participants were further classified into control, HSDD, and subclinical HSDD using the same methodology employed in Chapter 3 (see page 57 of this dissertation).  Masturbation and sexual fantasy Participants were asked about masturbation frequency in a forced-choice format using the query “Are you sexually active with yourself (i.e., masturbation)?”. Possible responses included “No” and several options ranging from “Yes (few times/year)” to “Yes (more than once/day)”. Contents of sexual fantasy were assessed using the query “Which of the following best describes your sexual fantasies (either involving yourself or involving others) from puberty until now?” with possible   79 responses including a range of options including opposite-sex and same-sex fantasies, as well as the options “I have never had a sexual fantasy” and “my sexual fantasies do not involve other people.” Procedure UBC's Behavioural Research Ethics Board approved all procedures. Data were collected between September and December 2010 as part of a larger study (data published elsewhere; Brotto, Yule & Gorzalka, 2015) via a web-based survey hosted by SurveyMonkey (Gordon, 2002). Participants were recruited through several separate and concurrent avenues, including postings on local websites (e.g., Craigslist), on the AVEN online web-community general discussion board, through online and in-clinic postings at the offices of sexual therapists and sexologists, and through our university’s human subjects pool. Data were collected using questionnaires that assessed demographic variables, sexual health, sexual behaviour, sexual distress, asexual identity, mood, and social desirability. The questionnaire battery took 60 minutes to complete. No remuneration was provided. Statistical Analysis Chi-square analyses were used to compare the groups on demographic variables. Because of the large number of participants who did not indicate a sex (e.g., male or female), as well as the wide range of genders that asexual individuals may identify with (e.g., androgyne, neutrois, genderqueer, pangendered, etc.) (see asexuality.org for a discussion of this), we did not conduct analyses by sex or gender and instead carried out analyses on the full group of participants (independent of their reported sex or gender).   80 4.1.3 Results  Masturbation Fifty-six percent of asexual participants reported masturbating at least monthly, as did 75% of individuals who met diagnostic criteria for HSDD, 65% of those with non-distressing low sexual desire, and 82% of the sexual comparison group. A 2 (at least monthly masturbation, less than monthly masturbation) x 4 (asexual, subclinical HSDD, HSDD, comparison) chi-square test revealed an overall significant effect, Χ2(3, n= 881) = 47.62, p < .001, φc = .23. A series of 2 x 2 chi-square tests revealed asexual individuals to be significantly less likely to masturbate at least monthly than those who met diagnostic criteria for HSDD and the sexual comparison group, Χ2(1, n = 617) = 11.31, p < .01, φc = .14, and Χ2(1, n = 715) = 41.81, p < .001, φc = .24, respectively. Participants reporting non-distressing low sexual desire were similarly less likely to report monthly masturbation than the sexual comparison group Χ2(1, n = 264) = 8.91, p < .01, φc =  .18 (Figure 4.1).     81 Figure 4.1  Percentage of participants who masturbate at least monthly   ** asexual individuals significantly less likely to masturbate than those with HSDD, p < .01, φc = .14 *** asexual individuals significantly less likely to masturbate than those in the comparison group, p < .001, φc = .24 low desire individuals less likely to masturbate than those in the comparison group, p < .01, φc = .18  Figure 4.1 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409. Pg. 92      0102030405060708090Asexual(n=529) Low Desire(n=78) HSDD(n=87) SexualComparison(n=186)% who masturbate at least monthlyGroup§ *****§   82 Sexual Fantasy   Forty percent of asexual individuals reported never having had a sexual fantasy, as did 8% of those who met diagnostic criteria for HSDD, 1% of those with low sexual desire without distress, and 2% of the sexual comparison group. A 2 (never had fantasy, fantasy-experienced) x 4 (asexual, subclinical HSDD, HSDD, comparisons) chi-square test revealed an overall significant effect, Χ2(3, n = 878) = 147.41, p < .001, φc = .41. A series of 2 x 2 chi-square tests revealed asexual participants to be significantly less likely to have had a sexual fantasy than those who met diagnostic criteria for HSDD, those with low sexual desire without distress, and the sexual comparison group, Χ2(1, n = 615) = 32.60, φc = .23, p < .001, Χ2(1, n = 606) = 44.03, p < .001, φc = .27, and Χ2(1, n = 713) = 91.58, p < .001, φc = .36, respectively. There was no statistically significant difference between any of the other groups on this measure (Figure 4.2).       83 Figure 4.2  Percentage of participants who have had a sexual fantasy  *** asexual individuals significantly less likely to have had a sexual fantasy than all other groups, p < .001, φc = .41 Figure 4.2 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409. Pg. 92.   0102030405060708090100Asexual(n=520) Low Desire(n=76) HSDD(n=86) SexualComparison(n=185)Percent who have had a sexual fantasyGroup***  84  Eleven percent of asexual participants reported that their sexual fantasies did not involve other people, compared to none of the participants in the HSDD group, 1% of participants in the subclinical HSDD group, and 0.5% of the sexual comparison group.  A 2 (sexual fantasies include other people, sexual fantasies do not involve other people) x 4 (asexual individuals, subclinical HSDD, HSDD, comparisons) chi-square test revealed an overall significant effect, Χ2(3, n = 878) = 36.71, p < .001, φc = .20. A series of 2 x 2 chi-square tests revealed asexual participants to be significantly more likely to have fantasies that do not involve other people than those who met diagnostic criteria for HSDD, those with low sexual desire without distress, and the sexual comparison group, Χ2(1, n = 615) = 10.75, p < .001, φc = .13, Χ2(1, n = 606) = 7.46, p < .01, φc = .11, and Χ2(1, n = 713) = 20.10, p < .001, φc = .17, respectively. There was no statistically significant difference between any of the other groups on this measure (Figure 4.3).        85 Figure 4.3  Percentage of participants whose fantasies do not involve other people   *** asexual individuals significantly more likely to have had a sexual fantasy that does not involve other people than all other groups, p < .001, φc = .20 Figure 4.3 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409. Pg. 93.  -113579111315Asexual(n=528) Low Desire(n=78) HSDD(n=87) SexualComparison(n=185)Percent whose fantasies are not about other peopleGroup***  86   These data combined indicated that 20% of asexual participants neither masturbated nor had sexual fantasies, and that 19% of asexual participants masturbated but did not report having sexual fantasies. Fifty percent of asexual participants reported both masturbating and having sexual fantasies, compared to 80%, 83%, and 92% of participants with low sexual desire, those who met diagnostic criteria for HSDD, and the sexual comparison group, respectively (Table 4.2).  Table 4.2  Patterns of masturbation and sexual fantasy  Asexual (n=523) Low Sexual Desire  (n=78) HSDD (n=87) Sexual Comparison Group (n=184) No Masturbation or Sexual Fantasy 20.2% 0% 4.6% 2.2% Masturbation but no Sexual Fantasy 19.4% 1.3% 3.4% 0% Sexual Fantasy but no Masturbation 10.5% 19.2% 9.2% 6.0% Masturbation and Sexual Fantasy 49.9% 79.5% 82.8% 91.8%  Table 4.2 has been reproduced with permission from the publisher © Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (2014). Sexual fantasy and masturbation among asexual individuals. Canadian Journal of Human Sexuality, 23(2), 89-95. DOI: 10.3138/chjs.2409. Pg. 94.     87 4.1.4 Discussion  Summary of Findings The overall aim of this study was to explore the speculation that asexuality might be a type of paraphilia. We attempted to gain insight into this question by directly studying masturbation and sexual fantasy attributes among asexual individuals. We found that asexual individuals were significantly less likely to masturbate monthly than individuals who met diagnostic criteria for HSDD and the sexual comparison group.  Asexual individuals were also more likely to report never having had a sexual fantasy than any of the other sexual groups.  Specifically, 40% of asexual participants noted that they have never had a sexual fantasy compared to 7% of sexual participants. Further, some asexual individual’s fantasies did not involve other people, while nearly all sexual individuals described their sexual fantasies as involving other people.  Sexual Fantasy and Masturbation The current results supported the recent finding (Bogaert, 2013) of a lower rate of masturbation among asexual individuals compared to sexual individuals. While previous research based on convenience samples has found that asexual individuals masturbate at frequencies similar to their sexual counterparts (Brotto et al., 2010; Prause & Graham, 2010), a more recent study based on a large national probability sample found that 42% of asexual individuals had masturbated in the past month (Bogaert, 2013), which was significantly lower than the percentage of sexual people in the sample (70%) and comparable to our finding that 56% of asexual participants reported masturbating at least monthly.    88 It has been suggested that a proportion of asexual individuals masturbate for physical pleasure or release of tension without the concurrent use of sexual fantasies or images of a sexual partner (Bogaert, 2012b; Brotto et al, 2010) and this is supported by our findings.  Nineteen percent of asexual participants reported masturbating but noted that they had never had a sexual fantasy, which raises the possibility that this group may be focusing on physical sensations instead of erotic images during self-touch. Narratives by asexual individuals in a qualitative study (Brotto et al., 2010) revealed that their masturbation was motivated by physical needs (akin to an itch needing to be scratched) rather than triggered by innate sexual desire or arousal. That asexual individuals experienced an urge to masturbate but did not experience sexual attraction toward anyone or anything has been termed ‘non-directed masturbation’ (Bogaert, 2012a). It seems to be the case that some asexual individuals experience sexual desire or sexual urges but do not direct this desire toward anyone or anything, and this deserves further exploration in future research. Overall, a far greater number of asexual individuals reported never having had a sexual fantasy compared to sexual participants.  Further, while participants who reported having low sexual desire reported masturbating less than the sexual comparison group, nearly all of them reported having sexual fantasies of some sort. This indicates that, even when sexual desire is low among sexual individuals, masturbation may continue; whereas this practice is overall less frequent among asexual individuals. Given that sexual fantasies are thought to be important to the development of sexual scripts and are generally understood to depict individuals’ underlying attractions, that some asexual individuals report never having had a sexual   89 fantasy supports their lack of sexual interest (Ellis & Symons, 1990). It has been previously observed that a fundamental difference between asexual individuals and those with low sexual desire is that the latter experience sexual attraction while asexual individuals do not (Brotto et al., 2010).  Thus, it follows that, since fantasies are assumed to be an implicit representation of underlying sexual desire, that asexual persons should not fantasize about anything at all, and the current data suggest that this is true for at least some of our asexual participants. Bogaert (2012) has recently identified a type of paraphilia he termed ‘autochorissexuality’ or identity-less sexuality, which he defines as “a disconnect between an individual’s sense of self and a sexual object or target” (Bogaert, 2012, p. 1513). This might be conceptualized as a separation between subjective and physiological sexual interest, in that the person’s subjective sexual attraction is not directed toward anyone, whereas they may still find a particular person or thing physiologically sexually arousing. Thus, it is possible that some asexual individuals will be autochorissexual in that they are not subjectively sexually attracted to anyone or anything, but may nonetheless require explicit stimuli to facilitate masturbation to orgasm. Bogaert hypothesizes that the physiological body of these individuals may have a sexual orientation (such that they have a preference for sexual stimuli involving other people or things), but that the identity of these individuals does not have a sexual orientation. Put another way, despite having sexual fantasies that involve other people or things, these individuals do not experience subjective sexual attraction, where the ‘subjective’ aspect refers to the sense of ‘me’ or ‘I’ of their identity.  If this identity is not   90 itself attracted to anyone or anything, then the individual is ‘asexual’ as it has been defined in the literature to date. Chivers’ (Chivers, Seto & Blanchard, 2007; Chivers, Seto, Lalumière, Laan & Grimbos, 2010) elegant series of studies reveals women’s sexual arousal in response to erotic films depicting sexual activities performed by a variety of actors (including solitary masturbation, nude exercise, heterosexual sexual activity, homosexual sexual activity, and sexual activity between bonobo chimpanzees). These studies indicate that heterosexual and bisexual women may become genitally aroused to films depicting sexual activity of any sort, regardless of the sexual orientation of the viewer. This has been termed ‘target-nonspecificity,’ in that women become genitally aroused to any type of sexual stimuli, regardless of their stated sexual preferences (Chivers et al., 2007).  It may be that asexual individuals experience similar target non-specific genital arousal, in that their body responds to sexual stimuli or sexual fantasy, without being sexually attracted to the subject of the fantasy (Brotto & Yule, 2011). Finally, approximately 11% of asexual individuals reported having sexual fantasies that did not involve other people, and this was far higher than the proportion of sexual individuals who reported this. The current study did not investigate the content of participants’ fantasies, however, there has been some discussion of this on online web-communities such as AVEN (Jay, 2008). According to these discussions, some asexual individuals engage in aesthetic fantasies involving images such as fairies or mountains, fetish-type fantasies, miscellaneous fantasies (such as the mating habits of beetles), or role-plays and fictional characters. Bogaert recounted an interview with one asexual individual who described his sexual fantasies such that “I almost invariably   91 think of sexual characters. My thoughts have never involved people I know, and they never involved myself” (Bogaert, 2012a, p. 115).  This glimpse into fantasies that do not involve other people underscores the wide variety of sexual fantasies that are experienced by asexual individuals, and this topic merits a much more detailed analysis in future research. A large number of asexual participants did not indicate a sex (e.g., male or female) despite being asked to choose which sex best described them. The sample size of participants who did indicate that they were male was relatively small, which did not allow us to analyze men and women separately. We acknowledge this as a serious limitation of the study.  It may well be the case that patterns of sexual fantasy differ between men and women, especially as previous writings have suggested that natural selection may have differentially influenced the development of sexual fantasy in men compared to women (Ellis and Symons, 1990). This topic deserves greater emphasis in future research. We also did not investigate the specific contents of sexual fantasies in this study, and this is the subject of the following section.     92  4.2 Sexual fantasy and masturbation among asexual individuals: An in-depth exploration5 4.2.1 Introduction One characteristic that has both shed light on the correlates of asexuality (which is described in more detail on page 15 of this dissertation) as well as raised doubt about the truly asexual nature of asexuality is masturbation. There is conflicting evidence as to the frequency of masturbation among asexual individuals. Two studies provide evidence that asexual women and men masturbate at frequencies similar to sexual women and men (Brotto et al., 2010; Poston & Baumle, 2010). Specifically, Brotto and colleagues (2010) found that 80% of asexual men and 73% of asexual women had engaged in masturbation, and these frequencies were comparable to that reported in a British national probability sample of sexual individuals (Gerressu, Mercer, Graham, Willings, & Johnson, 2008). Other findings suggest that asexual individuals masturbate at a lower frequency than their sexual counterparts (Bogaert, 2012a; Yule, et al., 2014b), which is more aligned with what we might predict. Despite these inconsistent findings, the observation that a considerable number of asexual individuals do masturbate is somewhat paradoxical, as the lack of sexual attraction that is fundamental to an asexual identification seems to be intuitively in conflict with their demonstrated masturbatory behaviour.                                                          5 A version of Section 4.2 has been accepted for publication. Yule, M. A., Brotto, L. A., & Gorzalka, B. B. (Provisionally Accepted). An in-depth exploration of sexual fantasy among asexual individuals. Archives of Sexual Behaviour.    93 Early research conducted in the 1950s found that nearly all men and 60% of women surveyed in the general population reported that they had masturbated at least once in their life (Kinsey et al., 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953) and this has been confirmed by more recent, arguably better-sampled, studies (Laumann, Gagnon, Michael & Michaels, 1994) which suggested that nearly all men and approximately 75% of women had masturbated. The most common cited motivations for masturbation were to seek pleasurable sensations or physical release of sexual tension, while additional reasons such as body exploration, to get to sleep, or to reduce boredom or loneliness were also common (Carvalheira & Leal, 2013; Clifford, 1978). Non-sexual motivations for masturbation are reflected in the comments of two (presumably sexual) female participants in an early study on masturbation (Clifford, 1978). One participant reported that: “masturbation is not an emotional arousal, when I cross my legs and do that, and that thing happens. I feel very asexual most of the time, except when I’m with someone I really like.” Another participant noted: “To me, masturbation is not that sexual. To me, it doesn’t have that much connection to intercourse.” (Clifford, 1978, p. 570).  The motivation for masturbation among asexual individuals is not entirely clear. Brotto and colleagues (2010), in a mixed-methods study, hypothesized that masturbation among asexual individuals might arise for non-sexual reasons, such as release of tension or getting to sleep, while Bogaert (2012b) introduced the idea of an identity-less masturbation pattern, in which individuals experience a sense of detachment between their sense of self and a sexual object or target, which allows for physical release without engaging with sexual partners even in sexual fantasy.    94 Sexual fantasies are generally defined as any thought, mental image, or imagined scenario that is experienced as erotic or sexually arousing to the individual (Leitenberg & Henning, 1995). It has been generally accepted that sexual fantasy is a common experience for most men and women (Barclay, 1973; Crepault & Coutoure, 1980; Knafo & Jaffe, 1984). Leitenberg and Henning’s (1995) review of the sexual fantasy literature suggest that between 77% and 100% of women and men report ever having had a sexual fantasy when not engaged in sexual activity, and also provide evidence that approximately 86% of men and 69% of women report fantasizing during masturbation. Sexual fantasies, it has been argued, are very important to revealing an individual’s sexual orientation and sexual attraction, even more than are sexual behaviours or sexual identity. This is because behaviours are constrained by social norms and by the (potential or desired) sexual partner, and thus are necessarily more inhibited than what can be imagined (Ellis & Symons, 1990). The received view is that sexual fantasies are not subject to such compromises, and reflect the desires or wants of the fantasizer (Ellis & Symons, 1990; Leitenberg & Henning, 1995). However, there is evidence that sexual fantasies based on themes that the individual would not wish to experience in real life, such as fantasies of erotic reluctance, or “rape fantasies” (Bivona, Critelli & Clark, 2012; Clifford, 1978; Critelli & Bivona, 2008), are common among women (as high as 57%), which is in direct contrast to the widely accepted view of sexual fantasy as reflection of one's underlying desire.   Previous research comparing self-identified asexual individuals to two groups of sexual individuals, those who did and those who did not meet diagnostic criteria for hypoactive sexual desire disorder (APA, 2000), found that asexual participants were   95 significantly more likely to report never having had a sexual fantasy, with 40% of asexual participants reporting no sexual fantasy compared to 1% and 8% of participants in the sexual groups, respectively (Yule, et al., 2014b). Interestingly, of asexual individuals who have had a sexual fantasy, 11% reported that these fantasies were not about other people, compared to 1.5% of sexual individuals. This study suggested that there are notable differences in patterns of sexual fantasy between asexual individuals and sexual individuals with and without low sexual desire, with asexual individuals more likely not to have had a human protagonist featured in the fantasy. However, it did not provide any clarity into what, exactly, asexual individuals fantasize about. The current study expands on previous research into sexual fantasies among asexual individuals. In addition to investigating reasons for masturbation, this study aimed to explore and compare the contents of sexual fantasies among asexual individuals with sexual fantasies of sexual individuals. We hope that by exploring the contents of asexual individuals' fantasies in more depth that this will provide evidence as to whether asexuality is, in fact, a paraphilia, and may contribute towards a larger effort at considering how asexuality best be classified.  4.2.2 Method Participants  Those who took part in the study responded to a recruitment advertisement asking for participants of “all sexual orientations (asexual, heterosexual, homosexual, or bisexual)” to complete an online survey. It was explicit in the advertisement that the questionnaires would ask about sexual fantasy, masturbation, and sexual behaviours. A   96 total of 1285 individuals provided consent to participate; however, 490 of these did not complete the majority of the items (i.e., they read the consent form and indicated that they consented to the study, but did not complete any items, or they provided some data, but discontinued the survey at some point), leaving 795 participants with usable data. Data from participants under 19 years old were excluded (n = 56) leaving 739 participants. The age range of these 739 participants was between 19 and 70 years (M 30.83, SD 10.81).  In response to the query “what is your sex?”, 217 participants identified themselves as male, 482 as female, two as intersex, and 38 left this item blank or indicated that they preferred not to respond, or that their sex was not relevant to this study. In a later query worded: “The following pages are sex specific. We realize that the following categories do not accurately describe some individuals. However, for the purposes of this study we ask that you please choose the option below that best describes you in order to be directed to the most appropriate questionnaires: Which of the following best describes you?”, 226 indicated that they were male, and 513 indicated that they were female.  Asexuality was assessed with the AIS (Yule, et al., 2015), which is described in more detail on page 23 of this dissertation. Any participant who scored at or above 40 on the AIS was placed into the “AIS > 40/asexual” group, and those scoring below 40 were placed into the sexual group. Among the total sample, 388 (52.5%) were classified in the sexual group (mean age = 34.34, SD = 11.20), and 351 (47.5%) were classified in the AIS > 40/asexual group (mean age = 25.99, SD = 8.42), with the sexual group being significantly older than the AIS > 40/asexual group, t(713.8) = 11.52, p <   97 .001, Cohen’s d = .94. The AIS > 40/asexual group will be hereafter referred to as the “asexual” sample. There were 292 asexual women, 221 sexual women, 59 asexual men, and 167 sexual men in the final group. There were no significant differences between asexual and sexual individuals in highest level of education achieved, Χ2(1) = 5.60, p > .05, φc = .088, with the majority of the participants (85% asexual, 88% sexual) having received at least some post-secondary education. Twenty percent of asexual individuals and 64% of sexual participants indicated that they were currently in a relationship, either committed or non-committed, and these proportions differed significantly Χ2(1) = 170.81, p < .001, φc = .48. Participants reported their ethnicity as: Caucasian/White, East Asian (Chinese, Japanese, or Korean), South Asian, African American/Canadian, First Nations/Aboriginal, Hispanic, or “other” with the majority identifying as Caucasian (Table 4.3). All ethnicities were included in the following analyses, as, as far as we know, there is no published evidence to date that sexual fantasies differ between these ethnic groups.     98 Table 4.3  Ethnicity of participants  Asexual Female (n=290)  Male (n=59) Sexual Female (n=221)  Male (n=166) Caucasian/White  81% 69% 80% 81% East Asian (Chinese, Japanese, Korean) 3% 2% 5% 2% South Asian 0% 0% 3% 9% African American 3% 0% 5% 4% First Nation/Aboriginal 0% 0% 1% 1% Hispanic 4% 8% 1% 5% Other 9% 10% 6% 1%     99 Measures Participants were queried about masturbation frequency, motivations for masturbation, and whether or not they had sexual fantasies at the beginning of the questionnaire battery. Sexual Fantasy Questionnaire (SFQ) The SFQ is a 62-item questionnaire developed by Bogaert, Visser, and Pozzebon, (2015) in order to assess a level of sexual interest in a number of sexual fantasies, including group sex, voyeurism, and BDSM-style themes. Participants were instructed to evaluate how exciting they would find each of the 62 sexual fantasies listed from 1 (not at all exciting) to 7 (extremely exciting).   Open-ended Exploration of Sexual Fantasies Following completion of the SFQ, participants were provided with the instruction: “In the space below, please provide a description of any sexual fantasies that you have regularly that were not included in the previous list. You can provide as much or as little detail as you wish. You may include your feelings, desire, and activities at each stage of the fantasy – that is, what events and feelings led up to the encounter and what events and feelings occurred during the encounter? Please include any and all information that is important in making your fantasy arousing. You may describe up to four sexual fantasies.” This instruction is similar to that used in previous research (Bogaert et al., 2015). Procedure The University of British Columbia Behavioural Research Ethics Board approved all procedures. Data were collected between February and November 2015   100 via a web-based survey hosted by SurveyMonkey (Gordon, 2002). Participants were recruited through several separate and concurrent avenues, including postings on local websites (e.g., Craigslist, Mechanical Turk), on the AVEN online web-community general discussion board (www.asexuality.org), and through online and in-clinic postings at the offices of sexual therapists. Data were collected using questionnaires that assessed demographic variables, sexual health, sexual behaviour, sexual distress, asexual identity, mood, and social desirability. The questionnaire battery took 60 minutes to complete. Participants were entered into a draw for one of two $50 gift certificates. Statistical Analyses Chi-square analyses were used to compare the groups (asexual vs sexual) on demographic variables, and also to compare asexual participants to sexual participants on measures of sexual fantasy. A univariate analysis of variance (ANOVA) was used to compare the groups on SFQ scores. Fantasy content was coded based on commonly used thematic analysis protocols (e.g., Lodi-Smith, Geise, Roberts, & Robins, 2009; Visser, DeBow, Pozzebon, Bogaert, & Book, 2014). Neither coder was blind to the study hypothesis, but both coded the fantasies without knowledge of the participants’ demographic information (including sexual vs. asexual group or gender) or scores on other variables. Upon first looking at the data, each of the coders identified a number of themes (n=75 and n=102). Upon discussion, both coders agreed that there was some overlap between themes (i.e., specific types of fetish (e.g., feet, breeder, feeder, vore, etc.), BDSM themes (e.g., being restrained, humiliation), or feeling wanted in some way (e.g., feeling attractive, feeling desired)), and these were grouped together into over-  101 arching themes (i.e., “fetish”, “BDSM”, and “object-desire self-conscious”(Bogaert & Brotto, 2014)). We included a wide range of themes under the BDSM category, as one recent study showed that a number of sexual behaviours and fantasies such as spanking, humiliation, and inflicting pain are all subsumed under the overarching category of BDSM (Dunkley & Dang, in preparation).   Once these items were grouped together, both coders agreed upon a more parsimonious list of 49 themes (See Tables 6 & 7). Each coder then independently coded each fantasy into one or more themes (minimum of one theme and maximum of 11 themes per fantasy) and inter-rater reliability (as assessed using intra-class correlation coefficients, ICC) was high (ICC range = .86 to .98). Comparative analyses were then carried out on these data.  4.2.3 Results Masturbation  Seventy-one percent of asexual women and 91% of asexual men reported masturbating at least monthly, compared to 94% of sexual women and 95% of sexual men. Asexual women were significantly less likely to masturbate at least monthly than sexual women Χ2(1) = 40.96, p < .001, φc = .30, as well as asexual men Χ2(1) = 10.68, p < .001, φc = 14. There were no significant differences between asexual men and sexual men in masturbation frequency (Figure 4.4). Among asexual individuals, asexual women who reported that they did not masturbate scored significantly higher on the AIS than did asexual women who reported that they masturbated at least monthly, t(290) = 3.61, p < .001, Cohen’s d = 0.47. The AIS scores of asexual men who did and did not masturbate did not significantly differ.     102  Figure 4.4  Percentage of participants who masturbate at least monthly    *** Asexual women significantly less likely to masturbate than sexual women and asexual men, p < .001, φc = .30 and .14 respectively    Asexual women were much less likely than their sexual counterparts to report masturbating for sexual pleasure or for fun, and asexual men were less likely to report masturbating for sexual pleasure than were sexual men. Asexual women were more likely to endorse the statement “I feel that I have to” masturbate, and were less likely to masturbate to “relieve tension” than were sexual women. Asexual men were similarly likely to sexual men to report masturbating to relieve tension. Asexual men, but not 0102030405060708090100Asexual Sexual% who masturbate at least monthlyGroup.WomenMen******  103 women, were much more likely to state that they had “other” reasons for masturbating than their sexual counterparts. “Other” reasons for masturbation that asexual men provided included: “procrasturbation” (i.e., masturbating as a form of procrastination), “habit”, being bored, wanting to fall asleep, relaxation, and functional beliefs about masturbation (such as “apparently it works against epididymitis”), whereas asexual women cited reasons such as: having an uninterested/unavailable partner, loneliness, stress relief, and “needing to practice” (Table 4.4).  Table 4.4  Motives for masturbation among asexual individuals who engage in masturbation    Women Men  Asexual (n=292) Sexual (n=221) X2 p Asexual (n=59) Sexual (n=167) X2 p Sexual pleasure 30% 80% 127.28 < .001 27% 84% 65.59 < .001 Relieve tension 48% 57% 4.14 < .05 52% 64% 2.44 > .05 For fun 20% 46% 40.51 < .001 32% 46% 3.45 > .05 I feel that I have to 13% 5% 4.72 < .05 25% 15% 3.27 > .05 Other 15% 11% 1.94 > .05 24% 8% 10.54 < .01      104 Sexual Fantasy Asexual men were significantly more likely than sexual men to report having never had a sexual fantasy Χ2(1) = 31.56, p < .001, φc = .39. Similarly, asexual women were significantly more likely than sexual women to report never having had a sexual fantasy Χ2(1) = 77.97, p < .001, φc = .41. Asexual women were significantly more likely to have never had a sexual fantasy than asexual men Χ2(1) = 4.11, p < .05, φc = .17. There was no significant difference between sexual women and sexual men on this variable (Figure 4.5). Among asexual individuals, asexual women who reported that they had never had a sexual fantasy scored significantly higher on the AIS than did asexual women who reported that they had had a sexual fantasy, t(222.18) = 6.41, p < .001, Cohen’s d = 0.81. Asexual men who had never had a sexual fantasy similarly scored higher on the AIS than asexual men who had had a sexual fantasy, although this difference approached rather than achieved statistical significance despite a relatively large effect size, t(50) = 2.00, p = 0.051, Cohen’s d = 0.69.     105 Figure 4.5  Percentage of participants who have never had a sexual fantasy  *** Asexual women and men significantly more likely to have never had a sexual fantasy than sexual women and men, p < .001, φc = .41 and , φc = .39 respectively * Asexual women significantly more likely to have never had a sexual fantasy than asexual men, p < .05, φc = .17   0510152025303540Asexual Sexual% who have never had a sexual fantasyGroup.WomenMen*******  106 Of those participants who have had a sexual fantasy, 12% of asexual men and 14% of asexual women endorsed the response “my fantasies do not involve other people” compared to 0% of sexual men and 0.5% of sexual women, Χ2(1) = 20.25, p < .001, φc = .23, and Χ2(1) = 37.45, p < .001, φc = .43, respectively (Figure 4.6).  Figure 4.6  Percentage of participants who sexual fantasies don't involve other people   *** Asexual women and men significantly more likely than sexual women and men to have sexual fantasies that don’t involve other people, p < .001, φc = .23 and .43 respectively   0246810121416Asexual Sexual% whose fantasies don't involveother peopleGroup.WomenMen*** ***  107  A 2 (Sex) x 2 (Group: Asexual vs. Sexual) ANOVA was conducted for mean SFQ scores. There was a significant Sex x Group interaction, F(1, 588) = 11.89, p < .001, partial η2 = .020  as well as a significant main effect for Sex, F(1, 588) = 8.62, p < .01, partial η2 =  .42, and for Group, F(1, 588) = 721.62, p < .001, partial η2 =  .98, suggesting that, overall, sexual participants found the sexual fantasies listed on the SFQ much more sexually exciting than did the asexual participants. Sexual participants (both women and men) demonstrated higher scores than asexual participants on each of the SFQ items, with a significance of p < .001. The effect size of these differences was most frequently very large (defined to be a Cohen’s d score of > 1.0 for this study). Overall, asexual women and men scored higher on the three items related to romantic or emotional content relative to the other SFQ items. For asexual women, the two items that mention love without sex had relatively small effect sizes, suggesting that asexual women’s scores were more similar to sexual women’s scores on these items. Overall, asexual individuals, both men and women, were significantly more likely to score the items on the SFQ as “not exciting” (i.e., from 1 = "not at all exciting” to 3 on the seven point Likert scale), whereas sexual participants were significantly more likely to score the items on the SFQ in the “exciting” range of the Likert scale (i.e., from 5 to 7 = "extremely exciting”) (Tables 4.5 & 4.6).   108 Table 4.5  Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual women SFQ Item # Item Score  Mean (SD)  Effect Size (Cohen’s d)   Asexual Women (n=292) Sexual Women (n=219)  9 A special person is devoted to me and showers me with love and attention. 3.24 (2.19) 5.07 (1.91) 0.89 54 Feeling affection and emotional connection while having sex. 2.82 (2.12) 5.78 (1.59) 1.58 40 I am devoted to a special man or woman and shower him or her with love and devotion 2.66 (2.09) 4.68 (2.01) 0.96 2 My partner telling me how good-looking and sexy I am. 2.40 (1.67) 5.18 (1.76) 1.62 13 Being passive and submissive to someone who wants my body. 1.91 (1.64) 4.50 (2.17) 1.35 4 Imagining that I observe myself or others having sex. 1.91 (1.46) 4.16 (1.96) 1.30 19 My partner showing me how much s/he desires my body. 1.89 (1.52) 5.53 (1.68) 2.27 11 My partner tells me what s/he wants me to do to him or her during sex 1.80 (1.40) 4.95 (1.90) 1.89 7 Being forced to surrender to someone who is overcome with lust for me 1.73 (1.48) 3.95 (2.43) 1.10 43 My partner tells me what s/he wants to do to me during sex. 1.70 (1.39) 5.04 (1.94) 1.98 28 Exerting dominance and control over a partner who is highly attracted to me 1.69 (1.49) 3.08 (2.11) 0.76 62 Pretending that I am doing something wicked or forbidden. 1.68 (1.43) 4.10 (2.19) 1.31 52 Having sex with my current partner. 1.68 (1.40) 5.30 (1.95) 2.13 31 Being passive and submissive to someone whose body I want. 1.67 (1.40) 3.97 (2.29) 1.21 50 A man or woman sweeps me off my feet and teaches me all about romance and sex 1.66 (1.41) 3.79 (2.14) 1.18 55 Exerting dominance and control over a partner who finds me very desirable 1.64 (1.42) 3.16 (2.17) 0.83 58 Telling my partner how good-looking and sexy s/he is. 1.63 (1.29) 4.57 (1.96) 1.77 22 Being overpowered or forced to surrender because I am so irresistible 1.62 (1.42) 3.56 (2.43) 0.97    109 Table 4.5 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual women 38 Having sex in a different place like a car, hotel, beach, woods. 1.62 (1.21) 4.91 (1.90) 2.07 53 Watching my partner undress. 1.59 (1.23) 4.69 (1.99) 1.87 57 Taking the initiative and dominant role while having sex. 1.58 (1.34) 3.67 (2.07) 1.20 23 Dressing in sexy, transparent underwear for my partner. 1.58 (1.32) 4.16 (2.14) 1.45 15 Exerting dominance and control over a partner who I am highly sexually attracted to 1.57 (1.35) 3.40 (2.07) 1.05 39 Exerting dominance and control over a very desirable partner. 1.57 (1.34) 3.04 (2.09) 0.84 16 Showing off my body to tease and arouse onlookers who lust after me 1.57 (1.29) 3.35 (2.13) 1.01 35 Undressing for my partner. 1.57 (1.21) 4.17 (2.00) 1.57 48 Teasing a man or woman (or men or women) until s/he is consumed with sexual desire for me 1.56 (1.38) 4.15 (2.17) 1.42 3 Having sex with two or more very attractive partners at the same time 1.55 (1.22) 4.13 (2.27) 1.42 33 Being forced to surrender to someone while I'm overcome with lust for him or her 1.51 (1.31) 3.82 (2.38) 1.20 6 I imagine that an older, experienced partner is attracted to me because of my youthful appearance. 1.51 (1.25) 3.45 (2.13) 1.11 56 Having sex without making eye contact. 1.49 (1.18) 2.57 (1.89) 0.69 24 Having sex with two or more partners, who are very attracted to me, at the same time 1.46 (1.14) 4.03 (2.30) 1.42 60 Being forced to sexually pleasure attractive men or women. 1.41 (1.17) 2.83 (2.25) 0.79 26 Talking dirty to my partner. 1.41 (1.07) 4.22 (2.12) 1.67 1 Having sex with a very attractive stranger. 1.41 (1.02) 4.40 (2.07) 1.83 38 Having sex in a different place like a car, hotel, beach, woods. 1.62 (1.21) 4.91 (1.90) 2.07 37 Being an exotic dancer. 1.40 (1.13) 2.31 (1.82) 0.60 46 Showing my partner how much I desire his or her body. 1.40 (1.01) 4.71 (1.92) 2.16 12 Lusting after a hot guy or girl who is teasing and arousing me with his or her body 1.39 (1.05) 4.22 (2.01) 1.76   110 Table 4.5 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual women 61 Imagining my partner in sexy underwear. 1.38 (1.05) 3.50 (2.18) 1.24 44 I imagine that I am attracted to a sexual partner because of his or her greater age and experience 1.37 (1.04) 3.12 (2.09) 1.06 5 Having casual sex with a person who I just met and who finds me irrisistible 1.36 (1.00) 4.01 (2.17) 1.57 29 Teasing a man or woman (or men or women) until I can no longer contain my sexual desire for him/her 1.35 (1.10) 4.07 (2.17) 1.58 51 Having anal intercourse. 1.34 (1.00) 3.10 (2.22) 1.02 10 Overpowering or forcing another to surrender because he or she is so irresistible. 1.34 (.98) 2.59 (1.96) 0.81 27 Revealing my body to an attractive stranger. 1.33 (1.02) 3.25 (2.10) 1.16 8 Dating an exotic dancer. 1.33 (1.00) 2.13 (1.58) 0.61 49 Having an attractive stranger reveal his or her body to me. 1.32 (1.02) 3.41 (2.10) 1.27 45 Men or women talk about how sexy and irresistible I am before forcing me to sexually pleasure them 1.31 (1.01) 3.02 (2.23) 0.99 21 Having sex with a stranger who is very attracted to me. 1.31 (.91) 3.73 (2.12) 1.48 20 I sweep a man or woman off his or her feet and teach them all about romance and sex 1.31 (.88) 2.92 (1.91) 1.08 36 Using force or humiliating a person who I desire. 1.29 (1.02) 1.72 (1.43) 0.35 42 Receiving sexual pleasure from many people. 1.29 (.88) 3.45 (2.32) 1.23 17 Using force or humiliating a person who desires me. 1.28 (.97) 1.69 (1.37) 0.34 59 Reliving a previous sexual experience. 1.27 (.83) 4.03 (2.18) 1.67 30 Being the centre of attention while having group sex. 1.26 (.96) 2.85 (2.12) 0.97 34 Being a promiscuous person who attracts the attention of many partners with my irresistibility 1.25 (.93) 2.90 (2.11) 1.01 18 Pleasuring many other people while having group sex. 1.25 (.91) 2.80 (2.06) 0.97 25 Giving sexual pleasure to many people. 1.22 (.84) 2.89 (2.09) 1.05    111 Table 4.5 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual women 47 Having sex with many men or women, all of whom are very attractive. 1.21 (.84) 3.01 (2.13) 1.11 32 Having sex with many men or women, all of them overcome with lust for my body 1.21 (.78) 2.90 (2.15) 1.04 14 Being a promiscuous person who has many irresistible sexual partners 1.21 (.74) 3.00 (2.04) 1.17 41 Having casual sex with a person I just met and find irresistible. 1.21 (.72) 3.66 (2.14) 1.53  Items are sorted by asexual women’s SFQ scores, from highest to lowest All item scores differ between asexual and sexual women at a statistical significance of p < .001                 112 Table 4.6  Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual men  SFQ Item # Item Score  Mean (SD)  Effect Size (Cohen’s d)   Asexual Men (n=59) Sexual  Men (n=167)  9 A special person is devoted to me and showers me with love and attention. 2.80 (2.02) 5.07 (1.67) 1.61 54 Feeling affection and emotional connection while having sex. 2.52 (1.90) 5.60 (1.58) 1.76 40 I am devoted to a special man or woman and shower him or her with love and devotion 2.47 (1.95) 4.90 (1.83) 1.29 4 Imagining that I observe myself or others having sex. 2.00 (1.53) 4.59 (1.84) 1.53 2 My partner telling me how good-looking and sexy I am. 1.93 (1.32) 5.14 (1.56) 2.21 13 Being passive and submissive to someone who wants my body. 1.92 (1.45) 4.23 (2.09) 1.28 19 My partner showing me how much s/he desires my body. 1.90 (1.32) 5.51 (1.53) 2.53 43 My partner tells me what s/he wants to do to me during sex. 1.88 (1.45) 5.29 (1.72) 2.79 11 My partner tells me what s/he wants me to do to him or her during sex 1.88 (1.23) 5.50 (1.51) 2.63 53 Watching my partner undress. 1.81 (1.36) 5.56 (1.40) 2.72 61 Imagining my partner in sexy underwear. 1.71 (1.25) 5.11 (1.73) 2.25 7 Being forced to surrender to someone who is overcome with lust for me 1.68 (1.21) 4.10 (2.18) 1.37 50 A man or woman sweeps me off my feet and teaches me all about romance and sex 1.64 (1.45) 4.22 (2.01) 1.47 52 Having sex with my current partner. 1.64 (1.20) 5.46 (1.59) 2.71 48 Teasing a man or woman (or men or women) until s/he is consumed with sexual desire for me 1.64 (1.10) 4.64 (2.00) 1.86 51 Having anal intercourse. 1.63 (1.33) 4.32 (2.18) 1.49 62 Pretending that I am doing something wicked or forbidden. 1.63 (1.27) 4.34 (2.05) 1.59 38 Having sex in a different place like a car, hotel, beach, woods. 1.63 (1.19) 5.15 (1.73) 2.37   113 Table 4.6 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual men  31 Being passive and submissive to someone whose body I want. 1.62 (1.36) 3.91 (2.09) 1.30 49 Having an attractive stranger reveal his or her body to me. 1.62 (1.24) 5.16 (1.88) 2.22 22 Being overpowered or forced to surrender because I am so irresistible 1.59 (1.34) 3.57 (2.16) 1.10 15 Exerting dominance and control over a partner who I am highly sexually attracted to 1.56 (1.16) 4.38 (2.09) 1.67 6 I imagine that an older, experienced partner is attracted to me because of my youthful appearance. 1.56 (1.15) 3.98 (2.12) 1.42 55 Exerting dominance and control over a partner who finds me very desirable 1.56 (1.12) 4.05 (2.20) 1.43 1 Having sex with a very attractive stranger. 1.54 (1.15) 5.59 (1.68) 2.81 58 Telling my partner how good-looking and sexy s/he is. 1.53 (1.01) 4.95 (1.72) 2.42 3 Having sex with two or more very attractive partners at the same time 1.51 (1.12) 5.57 (1.96) 2.54 39 Exerting dominance and control over a very desirable partner. 1.47 (1.00) 3.93 (2.16) 1.46 24 Having sex with two or more partners, who are very attracted to me, at the same time 1.46 (1.15) 5.21 (2.04) 2.26 12 Lusting after a hot guy or girl who is teasing and arousing me with his or her body 1.45 (.96) 5.21 (1.75) 2.66 33 Being forced to surrender to someone while I'm overcome with lust for him or her 1.44 (1.16) 3.67 (2.24) 1.25 28 Exerting dominance and control over a partner who is highly attracted to me 1.44 (.92) 3.95 (2.18) 1.50 57 Taking the initiative and dominant role while having sex. 1.44 (.86) 4.48 (1.89) 2.07 60 Being forced to sexually pleasure attractive men or women. 1.42 (1.09) 3.68 (2.26) 1.27 45 Men or women talk about how sexy and irresistible I am before forcing me to sexually pleasure them 1.41 (1.02) 4.01 (2.22) 1.51 59 Reliving a previous sexual experience. 1.41 (.99) 4.51 (1.86) 2.08 20 I sweep a man or woman off his or her feet and teach them all about romance and sex 1.37 (1.07) 4.42 (2.13) 1.81   114 Table 4.6 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual men  56 Having sex without making eye contact. 1.37 (1.05) 2.84 (1.77) 1.01 17 Using force or humiliating a person who desires me. 1.37  (.96) 2.43 (1.92) 0.67 16 Showing off my body to tease and arouse onlookers who lust after me 1.37  (.95) 3.56 (2.00) 1.40 5 Having casual sex with a person who I just met and who finds me irresistible 1.36  (.78) 5.25 (1.93) 2.64 35 Undressing for my partner. 1.36 (.77) 4.08 (1.92) 1.86 10 Overpowering or forcing another to surrender because he or she is so irresistible. 1.34 (.78) 3.31 (2.21) 1.19 29 Teasing a man or woman (or men or women) until I can no longer contain my sexual desire for him/her 1.34 (.76) 4.16 (1.89) 1.96 25 Giving sexual pleasure to many people. 1.31 (.99) 4.25 (2.21) 1.72 8 Dating an exotic dancer. 1.31 (.92) 3.74 (2.08) 1.51 44 I imagine that I am attracted to a sexual partner because of his or her greater age and experience 1.31 (.86) 3.71 (2.12) 1.48 46 Showing my partner how much I desire his or her body. 1.29 (.74) 5.12 (1.70) 2.92 41 Having casual sex with a person I just met and find irresistible. 1.29 (.72) 4.83 (2.05) 2.30 36 Using force or humiliating a person who I desire. 1.27 (.87) 2.28 (1.86) 0.69 18 Pleasuring many other people while having group sex. 1.25 (.92) 3.78 (2.23) 1.45 21 Having sex with a stranger who is very attracted to me. 1.24 (.68) 5.14 (1.96) 2.66 37 Being an exotic dancer. 1.22 (.70) 2.20 (1.64) 0.78 23 Dressing in sexy, transparent underwear for my partner. 1.21 (.64) 3.16 (2.12) 1.25 27 Revealing my body to an attractive stranger. 1.21 (.55) 3.80 (2.01) 1.76 42 Receiving sexual pleasure from many people. 1.19 (.57) 4.55 (2.16) 2.13 30 Being the centre of attention while having group sex. 1.19 (.54) 3.72 (2.23) 1.56 47 Having sex with many men or women, all of whom are very attractive. 1.15 (.61) 4.70 (2.13) 2.66   115 Table 4.6 Continued… Sexual Fantasy Questionnaire (SFQ) scores for asexual and sexual men  26 Talking dirty to my partner. 1.15 (.41) 4.57 (1.95) 2.43 14 Being a promiscuous person who has many irresistible sexual partners 1.14 (.47) 4.06 (2.09) 1.93 32 Having sex with many men or women, all of them overcome with lust for my body 1.12 (.46) 4.28 (2.20) 1.99 34 Being a promiscuous person who attracts the attention of many partners with my irresistibility 1.12 (.46) 3.95 (2.07) 1.89 34 Being a promiscuous person who attracts the attention of many partners with my irresistibility 1.12 (.46) 3.95 (2.07) 1.89   Items are sorted by asexual men’s SFQ scores, from highest to lowest  All item scores differ between asexual and sexual men at a statistical significance                  116 These data combined indicated that sexual women and men were significantly more likely to engage in both sexual fantasy and masturbation than their asexual counterparts. Asexual women and men were significantly more likely to have neither sexual fantasy nor masturbation, or to masturbate but to have no sexual fantasy, than were sexual women and men. Asexual women were significantly more likely to engage in sexual fantasy without masturbation than were sexual women, but this was not the case for asexual and sexual men (Table 4.7).  There was no significant difference in AIS scores between asexual men who engaged in neither masturbation nor sexual fantasy, masturbated but reported no sexual fantasy, reported sexual fantasy but no masturbation, or engaged in both masturbation and sexual fantasy. However, there was a significant difference in AIS scores of asexual women such that asexual women who reported engaging in both sexual fantasy and masturbation had significantly lower AIS scores than women who reported neither masturbating nor sexual fantasy, and those who reported masturbating but denied engaging in sexual fantasy.      117 Table 4.7  Patterns of masturbation and sexual fantasy     Women Men  Asexual (n=292) Sexual (n=221) X2 p Asexual (n=59) Sexual (n=167) X2 p No Masturbation or Sexual Fantasy 16% 1% 33.60 < .001 6% 0% 11.53 < .001 Masturbation but no Sexual Fantasy 19% 1% 40.95 < .001 15% 1% 18.60 < .001 Sexual Fantasy but no Masturbation 35% 10% 40.30 < .001 4% 4% 0.07 > .05 Masturbation and Sexual Fantasy 51% 93% 104.50 < .001 75% 95% 20.30 < .001   118  Based on responses to the open-ended exploration of sexual fantasies, there were a number of similarities and differences in the themes of sexual fantasies of asexual women and men compared to sexual women and men (Tables 4.8 & 4.9). Both asexual men and women were significantly more likely to report having sexual fantasies that do not involve themselves. Further, asexual women were significantly more likely to report having sexual fantasies that involved fictional human characters. Both asexual women and men were less likely to fantasize about group sex compared to their sexual counterparts. Asexual women were also less likely than sexual women to fantasize about a number of topics such as public sex.  Of note, asexual women were significantly more likely than sexual women to report engaging in fantasies that focused on emotions or on romantic, non-sexual, intimacy such as cuddling. These, as well as other non-sexual fantasy content such as “being cared for/managed/cared for” “sensory, “monogamy or poly,” and “involving commitment or relationship,” have been separated from sexual fantasies by presenting them at the ends of Tables 4.8 and 4.9 in order to create a clear distinction between sexual and non-sexual content.  Interestingly, there was a large amount of overlap between asexual and sexual participants on most of the sexual fantasy themes identified. Specifically, asexual women and asexual men respectively were just as likely to fantasize about 77% and 85% of the sexual topics that sexual women and men described. For example, both asexual women and men were just as likely to fantasize about BDSM or fetish themes than their sexual counterparts. Reporting of fantasy themes such as erotic reluctance or fantasies involving voyeurism were also similar in frequency between asexual and   119 sexual groups.   120 Table 4.8  Sexual fantasy comparisons between asexual women and sexual women Theme % Asexual Women (n=122) % Sexual Women (n=84) X2 p Asexual women significantly  more likely to fantasize about:     Don't involve me 32.79 8.33 16.89 < .001 Fictional Human Characters/Not real people 27.87 4.76 17.66 < .001 Asexual women significantly  less likely to fantasize about:     Group Sex 4.1 30.95 28.06 < .001 Public Sex 1.64 15.48 14.11 < .001 *Having an affair/Extramarital sex 0 9.93 5.16 < .05 Sex w/ celebrity 0.82 2.38 10.55 < .01 Memories of actual past sexual encounters 0 3.57 4.42 < .05 Cuckold fantasy 0 3.57 4.42 < .05 Sex with Ex 0 3.57 4.42 < .05 Asexual women just as likely to fantasize about:     BDSM (including humiliation) 32.79 32.14 0.0094 > .05 Observing Homosexual encounters (when the other gender)/Sex w/ other gender (or same gender if gay) 16.39 14.29 0.17 > .05 Other (anything that comes up only once and doesn't fit into any other category) 16.39 16.67 0.0027 > .05 Fetish (feeder, breeder, vore, feet, etc.) 10.66 7.14 0.039 > .05 Rape Fantasy/Non consent/Erotic Reluctance  9.84 11.9 0.2232 > .05 Sex toys 8.2 3.57 1.8 > .05 Voyeurism (watching others or being watched) 8.2 11.9 0.78 > .05 Sex with power figure (e.g., teacher) 5.74 10.71 1.72 > .05 Making out/foreplay 5.74 2.38 1.34 > .05   121 Table 4.8 Continued… Sexual fantasy comparisons between asexual women and sexual women  Masturbation 5.74 5.95 0.0042 > .05 Sex while drugged/Mind Control/Hypnosis 4.1 0 3.53 > .05 Risky/Forbidden sex 4.1 7.14 0.91 > .05 Engaging in sexual activity as the other sex 4.1 2.38 0.45 > .05 Involving older partners 4.1 4.76 0.05 > .05 Transvestism/Changing genders or genitalia/Forced feminization 3.28 0 2.81 > .05 Don’t involve (sex with) other people 3.28 0 2.81 > .05 Pleasing a partner 3.28 7.14 1.61 > .05 Fantasies aren’t sexually arousing (although they may be physically arousing) 3.28 1.19 0.92 > .05 Sex in context of larger story 3.28 2.38 0.14 > .05 Roleplay (furries, cosplay) 2.46 8.33 3.72 > .05 Object-desire self-consciousness/Teasing 2.46 7.14 2.61 > .05 Incest 2.46 4.76 0.8 > .05 Sex with stranger/Anonymity 2.46 4.76 0.8 > .05 Anal play/Anal intercourse 2.46 4.76 0.8 > .05 Sex w/ non-human creatures (non-beastiality) 2.46 4.76 0.8 > .05 Oral Sex 2.46 2.38 0.0013 > .05 Rough Sex (not BDSM) 2.46 2.38 0.0013 > .05 Sex with animals 1.64 1.19 0.7 > .05 Sex with friend 0.82 1.19 0.071 > .05 Sex w/ sleeping partner or vice versa 0 2.38 2.93 > .05 Sex with/as virgin 0 1.19 1.46 > .05 *Sex with Current Partner 0 2.13 0.28 >.05 Involving younger partners 0 0 n/a n/a Cum Play 0 0 n/a n/a   122 Table 4.8 Continued… Sexual fantasy comparisons between asexual women and sexual women  Fantasies that focus on non-sexual content     Focusing on emotions 18.03 5.95 6.37 < .05 Romantic (non-sexual) (e.g., cuddling) 14.75 1.19 10.93 < .001 No Sexual or Romantic Content 7.38 0 6.48 < .01 Sensory (smell, sight, taste, sound) 5.74 1.19 2.76 > .05 Monogamy or Poly, involving commitment or relationship 4.1 1.19 1.6 > .05 Being cared for/Managed/caring for others 1.64 2.38 0.14 > .05  * Fantasies about current partner and engaging in extramarital sex or affairs were analyzed for participants who were in a relationship only. Asexual n = 62, Sexual n = 141     123 Table 4.9  Sexual fantasy comparisons between asexual men and sexual men  Theme % Asexual Men (n=27) % Sexual Men (n=64) X2 p Asexual men significantly  more likely to fantasize about:     Don't involve me 18.52 0 12.54 < .001 Object-desire self-consciousness/Teasing 11.11 0 7.35 < .01 Asexual men significantly  less likely to fantasize about:     Group Sex 3.7 39.06 11.63 < .001 Asexual men just as likely to fantasize about:     Fetish (feeder, breeder, vore, feet, etc.) 37.04 28.13 0.71 > .05 BDSM (including humiliation) 14.81 29.69 2.22 > .05 Other (anything that comes up only once and doesn't fit into any other category) 14.81 26.56 1.48 > .05 Voyeurism (watching others or being watched) 14.81 18.75 0.2 > .05 Masturbation 11.11 3.13 2.33 > .05 Transvestism/Changing genders or genitalia/Forced feminization 11.11 9.38 0.064 > .05 Rape Fantasy/Non consent/Erotic Reluctance  7.41 9.38 0.092 > .05 Sex in context of larger story 3.7 0 2.4 > .05 Don't involve (sex with) other people 3.7 0 2.4 > .05 Observing Homosexual encounters (when the other gender)/Sex w/ other gender (or same gender if gay) 3.7 10.94 1.24 > .05 Oral Sex 3.7 9.38 0.86 > .05 Risky/Forbidden sex 3.7 9.38 0.86 > .05 Anal play/Anal intercourse 3.7 7.81 0.52 > .05 Fictional Human Characters/Not real people 3.7 1.56 0.41 > .05   124 Table 4.9 Continued… Sexual fantasy comparisons between asexual men and sexual men  Engaging in sexual activity as the other sex 3.7 1.56 0.41 > .05 Rough Sex (not BDSM) 3.7 6.25 0.14 > .05 Public Sex 0 12.5 3.7 > .05 Involving younger partners 0 12.5 3.7 > .05 Sex with power figure (e.g., teacher) 0 7.81 2.32 > .05 Cuckold fantasy 0 7.81 2.32 > .05 Sex with friend 0 7.81 2.32 > .05 Involving older partners 0 6.25 1.77 > .05 Making out/foreplay 0 4.69 1.31 > .05 Sex with Ex 0 4.69 1.31 > .05 Cum Play 0 4.69 1.31 > .05 Sex w/ sleeping partner or vice versa 0 4.69 1.31 > .05 Incest 0 3.13 0.86 > .05 Sex with/as virgin 0 3.13 0.86 > .05 Sex with stranger/Anonymity 0 7.81 0.52 > .05 Roleplay (furries, cosplay) 0 7.81 0.52 > .05 Memories of actual past sexual encounters 0 1.56 0.43 > .05 Pleasing a partner 0 1.56 0.43 > .05 Sex toys 0 1.56 0.43 > .05 Sex w/ non-human creatures (non-beastiality) 0 1.56 0.43 > .05 Sex w/ celebrity 0 1.56 0.43 > .05 *Sex with Current Partner 0 1.89 0.13 > .05 *Having an affair/Extramarital sex 0 17.92 0.44 > .05 Fantasies aren't sexually arousing (although they may be physically arousing) 0 0 n/a n/a Sex while drugged/Mind Control/Hypnosis 0 0 n/a n/a Sex with animals 0 0 n/a n/a   125 Table 4.9 Continued… Sexual fantasy comparisons between asexual men and sexual men  Fantasies that focus on non-sexual content     No Sexual or Romantic Content 22.22 4.69 6.55 < .01 Focusing on emotions 3.7 1.56 0.41 > .05 Romantic (non-sexual) (e.g., cuddling) 3.7 3.13 0.02 > .05 Being cared for/Managed/caring for others 3.7 0 2.4 > .05 Sensory (smell, sight, taste, sound) 3.7 0 2.4 > .05 Monogamy or Poly, involving commitment or relationship 0 1.56 0.43 > .05  * Fantasies about current partner and engaging in extramarital sex or affairs were analyzed for participants who were in a relationship only. Asexual n = 7, Sexual n = 106   126 For example, one asexual participant noted:  I do have sexual fantasies but most of the time they do not involve me or any real person. I sexually fantasize about fictional male couples and their romantic & sexual relationships and events. They are all monogamous relationships where they are faithful to one another (no affairs). With fictional male couples, my sexual fantasies can involve many and varying sexual preferences and fetishes. Please do know that these are my specific sexual fantasies and they do not apply to others' sexual fantasies (female, 19 years old)  Another participant described their fantasies as follows:  I don't put myself into my fantasies. That is thoroughly unappealing to me. Instead, I imagine other people in sexual situations, and focus on their thoughts and feelings for a sort of vicarious arousal. I don't want to do anything sexual with any of the people I imagine, and by themselves, they don't turn me on. I think it's because I'm not capable of feeling sexual attraction or lust, so I mentally conjure up people who are and empathize with them (though my ideas of how they experience lust are, since I'm asexual, awfully vague in some ways and probably way off base in others) (female, 32 years old) Another asexual participant reported:  I enjoy watching other people enjoy their sexuality.  I like the role of being strictly a voyeur but I love being the cause of them enjoying their sexuality.  Although I am very excited by these situations I wouldn't call it sexual excitement.  Although my body is clearly aroused by it, I have no desire to attend to that arousal.  I very much enjoy being the one who does not physically engage in sexual behaviour   127 while being the one who provokes it in others.  I like to see my romantic partner endure unpleasant situations that I've created because I feel that his willingness to sacrifice his comfort is an expression of his devotion to me.  I like to see a partner insensible with excitement or pleasure because of my interaction with them.  This makes me feel very emotionally enticed and engaged but sexually I feel disengaged and disinterested even though my body is aroused. (female, 35 years old) Both asexual women and men were significantly more likely to report engaging in fantasies that did not include any sexual or romantic content. One example of such a fantasy was described as “being able to stop time and mess with people and things without their awareness. Often not sexual” (female, 27 years old). Another asexual participant described a fantasy that did not involve sexual or romantic content: This one is a bit, like, diffuse or inchoate, but magic and adventure. Imagining myself in a situation where the laws of nature are suspended, or I get a glimpse of a world that underlies our own, or I am in a desert hut with a girl from an unfamiliar tribe. Or even just an old country house with the wind whistling. Not only xenophilia, but just the idea that we can be different and feel different things and learn and have experiences we never imagined. An art studio on the lower east side in 1976. A girl wizard. A blood moon. Does this make sense? (male, 34 years old).     128 4.2.4 Discussion Summary of Findings This study was an in-depth exploration of masturbation and sexual fantasy among asexual individuals. We found that asexual women were significantly less likely to masturbate at least monthly than sexual women and asexual men. Asexual women were less likely to report masturbating for sexual pleasure or fun than their sexual counterparts, and asexual men were less likely to report masturbating for sexual pleasure than sexual men. Asexual women and men were significantly more likely to report that they had never had a sexual fantasy than sexual women and men, and of those who have had a sexual fantasy, asexual women and men were significantly more likely to endorse the response “my fantasies do not involve other people” compared to sexual participants.  It is interesting to note that a substantial proportion of asexual individuals in the current study did report engaging in sexual fantasy (65% of asexual women and 80% of asexual men), and a large number (51% of asexual women and 75% of asexual men) engaged in both sexual fantasy and masturbation, despite reporting a lack of sexual attraction. Further, there was a large amount of overlap in the content of sexual fantasy of asexual and sexual participants, including themes such as BDSM, fetishes, and fantasies of non-consent. Because sexual fantasies are thought to be an indicator of an individual’s true sexual interest, this raises questions about the meaning of these sexual fantasies for the construct of asexuality, which is based on the idea that an individual lacks sexual interest.   129 On a sexual fantasy questionnaire, asexual participants (both women and men) consistently scored each sexual fantasy as being less sexually exciting than did sexual participants. When given the opportunity to share their sexual fantasies using an open-ended format, there were a few fantasy themes that were more common among asexual participants compared to sexual participants, particularly the tendency to have fantasies about sexual activities that did not involve themselves. Asexual participants were less likely to fantasize about topics such as group sex, public sex, and having an affair. There was a large amount of overlap between sexual fantasies of asexual and sexual participants. This overlap in sexual fantasy content was unexpected, and perhaps one of the most interesting findings of the current study. Notably, both groups (both men and women) were equally likely to fantasize about topics such as BDSM and fetishes such as podophilia (feet; Weinberg, Williams & Calhan, 1994), feeder (sexual pleasure derived from feeding other people) (Terry & Vasey, 2011), maieusiophilia/breeder (sexual pleasure derived from getting pregnant or getting others pregnant) (Dean, 2009), and vorarephilia (the erotic desire to be consumed by, or to consume, another creature) (Lykins & Cantor, 2013). Masturbation The current findings suggest that significantly fewer asexual women masturbate than do sexual women, but that asexual men masturbate at rates similar to sexual men. Previous findings on masturbation frequencies among asexual individuals have also been mixed.  There has been some research indicating that asexual individuals (both women and men) masturbate at frequencies similar to their sexual counterparts (Brotto et al., 2010). However, the one available study based on data from a national   130 probability sample found that, of those asexual individuals (women and men combined) who reported sexual experience with a partner, 42% had masturbated in the past month, which was significantly lower than 70% of sexually-identified participants (Bogaert, 2013), and this finding has been supported by a recent study using convenience sampling in which 56% of asexual participants (again, both women and men together) reported masturbating at least monthly (Yule, et al., 2014b).  One early study on the development of masturbation among young, college aged women, found that masturbation is more likely to occur when it is found to be rewarding and pleasurable (Clifford, 1978) and this has been supported by more recent research (Carvalheira & Leal, 2013). The current study queried motives for masturbation. Asexual women and men were both significantly less likely to cite sexual pleasure as a reason for engaging in this behaviour, and asexual women (but not men) were less likely to report “for fun” as a reason for masturbation, which raises the question of how asexual men are differentiating sexual pleasure from fun. Rather, asexual women were more likely to endorse “I feel that I have to [engage in masturbation]”, and were less likely to cite “to relieve tension” compared to sexual participants as a reason for masturbation. Asexual men, but not women, were significantly more likely to endorse “other” reasons for masturbation, such as: needing to fall asleep, boredom, health reasons, or procrasturbation.  The findings reported above support earlier, anecdotal, findings that some asexual individuals’ primary motives for masturbation are non-sexual (Brotto et al., 2010), in that wishing to fall asleep or to alleviate boredom were viewed as non-sexual motivations. Further, our findings align with Bogaert’s (2012a, 2012b) notion of “non-  131 directed masturbation”, a term reflecting the presence of sexual desire and urge to engage in masturbation, but desire that is not directed toward anyone in particular. The wide range of reasons for masturbation endorsed by asexual individuals is a testament to the diversity of asexuality and asexual individuals. The use of masturbation as a purely physical release or as a tool to relieve tension might seem somewhat detached and devoid of emotion, and thus seem detached from sexuality and sexual activity. In fact, it is possible to have physiological sexual arousal in the form of erection, vaginal vasocongestion, lubrication, and even orgasm, without having any desire to engage in sexual activity with others.  Sexual Fantasy Overall, a much larger proportion of asexual participants, both men and women, reported never having had a sexual fantasy compared to sexual participants. Approximately 35% of asexual women and 20% of asexual men in the current sample denied ever having had a fantasy, compared to very few of the sexual participants. Previous research revealed a similar finding, such that 40% of the asexual sample (both women and men) noted that they had never had a sexual fantasy (Yule, et al., 2014b) compared to almost none of the sexual participants, including those who met diagnostic criteria for a sexual desire disorder. The current findings strongly suggest that sexual fantasies are not, in fact, ubiquitous, as previous writings have suggested (e.g., Leitenberg & Henning, 1995).  Interestingly, those asexual individuals in the current study who reported having never engaged in a sexual fantasy scored higher (i.e., had more “asexual” features) on the AIS than did asexual individuals who have had sexual fantasies,   132 providing some evidence for previous speculations (Bogaert, 2012a) that asexuality exists on a continuum, with a lack of behaviours such as engaging in sexual fantasy and/or masturbation occurring more frequently among a subgroup of asexual individuals.  Previous research found that 19% of asexual participants reported masturbating (Yule, et al., 2014b) but reported never having had a sexual fantasy, and this was replicated in the current study. Yule and colleagues (2014b) speculated that this group might be focusing on physical sensations during masturbation rather than eliciting a sexual fantasy during masturbation. In the current study, a greater proportion of asexual women and men did endorse focusing on tactile stimulation when engaging in sexual fantasies than sexual women and men, however this difference was not significant, so it remains unclear whether this explanation accounts for those who report masturbating but not engaging in sexual fantasies. It may be that if a focus on physical sensations is not considered to be a “sexual fantasy” and thus might not have been noted by participants in the open-ended sexual fantasy questions. Further studies should focus on how asexual individuals understand sexual fantasy, perhaps employing face-to-face qualitative interviews. Fourteen percent of asexual women and 12% of asexual men in the current sample reported having sexual fantasies that did not involve other people, compared to less than one percent of sexual women, and none of the sexual men in the sample. This replicates previous research that found that 11% of asexual individuals (both women and men) had sexual fantasies that did not involve other people (Yule, et al., 2014b). This finding points to at least some asexual individuals perhaps fitting the category of   133 analloeroticism, a term coined by Blanchard (1989) which describes individuals who are not attracted to other people but continue to experience sexual drive and/or sexual activities such as masturbation. Analloeroticism was first described in the context of autogynephilia (Blanchard, 1989), but the term is now used interchangeably with the term “libidoist” by some self-identified asexual individuals (http://www.asexuality.org/en/topic/78181-libidoist-what-is-it/), and may describe a subset of asexual individuals. The possibility for asexual subtypes, with some fitting the category of analloerotic should be the focus of future research.  Asexual women in the current study were much more likely to endorse fantasies that focus on fictional human characters, rather than focusing on another person. In fact, there are at least some self-identified asexual individuals who also identify as “fictosexual” or “fictoromantic” (http://www.asexuality.org/en/topic/135747-what-counts-as-fictosexual/?hl=fictosexual). However, there were no significant differences between the asexual and sexual participants (women or men) in the frequency of endorsing fantasies that involved non-human animals/creatures, scenic imagery, or fetishes, in any proportion that was significantly more than that of sexual individuals. We did not ask specifically about schediaphilia (also known as toonophilia; Griffiths, (2012)), or sexual attraction to animated cartoon or anime characters. While there is very little academic writing on this topic, it has some presence on the Internet and there are claims that some individuals are sexually and/or romantically attracted to particular cartoon characters. Elucidating the difference between those who are attracted to   134 human, non-human, and animated fictional characters will be important to consider in future asexuality research. Asexual women were more likely than sexual women to report engaging in fantasies that focused on emotions or on romantic, non-sexual, intimacy such as cuddling. While these “romantic fantasies” arguably do not provide insight into “sexual” attraction or orientation, it is of interest that asexual women may have experienced these as sexual, particularly since they answered a question asking about contents of a "sexual" fantasy.  It may be that these asexual women more clearly identify with a romantic identity (i.e., heteroromantic or homoromantic) than with a sexual identity, and that this might be influencing the content of what they identify to be a sexual fantasy. Since we did not assess participants' romantic orientation in this study, the extent to which their romantic attractions influenced these responses is not clear. However, the 2014 AVEN Census (Ginoza, Miller, & AVEN Survey Team, 2014) highlighted the diversity of different romantic orientation subtypes among asexual participants. Future research should seek to explore whether an asexual individual's romantic orientation impacts their experience of sexual fantasy, and what implications this has for understanding the nature of sexual and romantic attraction development.  The largest distinguishing feature between fantasies of asexual individuals compared to sexual individuals was the former's increased likelihood of having sexual fantasies that didn’t involve them. This provides evidence for Bogaert’s (2012b) identification of a phenomenon he coined “autochorissexuality”, or identity-less sexuality, defined as “a disconnect between an individual’s sense of self and a sexual object or target” (Bogaert, 2012b, p. 1513). Autochorissexual individuals view   135 themselves as being separate from the sexual acts they are viewing or fantasizing about, thereby allowing for detachment between their sense of self and masturbation and sexual fantasies. In support of Bogaert's (2012b) speculation that some asexual individuals may identify as autochorissexual, we interpret the present data as asexual individuals using explicit stimuli as a vehicle to facilitate their sexual arousal and subsequent orgasm (Yule, et al., 2014b). Put another way, despite having sexual fantasies that involve other people or things, these individuals do not experience subjective sexual attraction, where the ‘subjective’ aspect refers to the sense of ‘me’ or ‘I’ of their identity.  If this identity is not itself attracted to anyone or anything, then the individual is ‘asexual’ as it has been typically defined to date. This raises the possibility that subjective sexual attraction might represent another dimension of sexual orientation, with (some) asexual individuals being at the non-subjective polar end of a subjective/non-subjective orientation dimension.  Asexual women were less likely to fantasize about a number of topics, including group sex and public sex. These sexual fantasies arguably include content that is highly sexualized and focuses on sex with another person (interpersonal sex), rather than on topics that might be less focused on genital content (e.g., BDSM content such as humiliation) or sexual interaction with oneself or not directly with another person (intrapersonal sex; e.g., voyeurism, masturbation, use of sex toys, etc.). Asexual women in a relationship were less likely than sexual women in a relationship to fantasize about extramarital sex.     136 Paraphilic Interest Paraphilic interest is commonly defined as a sexual interest in an atypical object, person, or activity, whereas a paraphilic disorder is defined as arising when the person “feels personal distress about their interest, not merely arising from society’s disapproval”, or the sexual interest causes another person’s distress in some way (APA, 2013). It is very unlikely that the majority of asexual individuals have paraphilias for two main reasons (Bogaert, 2012a); even those with extreme paraphilias maintain some level of sexual interest in other people, and the majority of asexual people are women and paraphilias tend to be rare among women (Cantor, Blanchard, & Barbaree, 2009).  Nonetheless, Bogaert (2012a) has speculated that asexual individuals, while experiencing a lack of sexual attraction for other people, might experience unusual sexual attractions, or paraphilias. Following from this, it may be that an underlying paraphilic interest is what motivates an asexual individual's masturbation and sexual fantasy behaviour. Further, a substantial proportion of our asexual sample reported being in a relationship and, according to our thematic analysis of sexual fantasy, did indicate some level of sexual interest in people. It is possible that some of our asexual participants are displaying paraphilic interest, although this should be investigated further in future research. Limitations Our sample of men was small and may have been underpowered, such that it was difficult to detect significant differences between sexual and asexual men on sexual fantasy themes. Further, our study relied on a convenience sample of asexual participants recruited from the AVEN website, which may not be representative of the   137 asexual population, as those who frequent the website (and participate on studies posted there) may tend to be more liberal and perhaps more curious about sexuality and sexual behaviours than those asexual individuals who are not on the website. Another limitation is that we did not assess how frequently participants experienced each of their types of fantasies. It may be that for some of them, the described fantasy was experienced in isolation, whereas other types of fantasy tend to be elicited on a more regular basis. 4.2.5 Conclusion While there are a number of differences between asexual and sexual groups in terms of patterns of masturbation and sexual fantasy, as well as in contents of sexual fantasy, the similarity between the groups on several of these measures is striking. For example, nearly half of asexual women and three quarters of asexual men reported both experiencing sexual fantasy and masturbating, despite reporting a lack of sexual attraction to other people and identifying as asexual. Further, there was significant overlap in the sexual fantasies experienced by participants, regardless of their asexual or sexual status. Sexual fantasies have long been thought to reveal an individual’s innermost desires. However, the current data suggest that if this is true, individuals do not necessarily act on these desires. An asexual individual does not experience sexual attraction, and may not wish to engage in sexual activity, but can continue to engage in sexual fantasy, perhaps to facilitate physiological sexual arousal and masturbation. The sexual fantasies do not appear to be reflections of innate sexual wants or desires. More research will be needed to ascertain whether this is because the individual cannot act on these desires (in the case of being attracted to fictional characters), because social   138 constraints prohibit them from doing so, or because there is a disconnect between their subjective sense of self in relation to sexual targets. Further, these findings suggest that sexual fantasies are not, in fact, ubiquitous, as previous writings have suggested. What makes one individual have sexual fantasies, and whether they appear spontaneously or deliberately, versus another individual not having fantasies, is a fascinating area of inquiry that may also inform the debate on whether lack of sexual fantasies should be a marker of a sexual desire disorder (Brotto, 2010).  The current findings strongly suggest that self-identified asexuality might comprise a highly heterogeneous group. There are likely a large number of variations in how (lack of) sexual attraction is experienced that might lead a person to identify as asexual, including a total lack of sexual attraction, autochorissexuality, analloeroticism, and some types of paraphilic tendencies. It will be essential for researchers to take these variations into account when conducting future investigations into asexuality. Finally, the current findings further suggest that it is important to be aware of the difference between self-identified asexuality and a more stringent definition of asexuality that includes a lack of sexual attraction to anything at all, when we are using these definitions for research purposes. While self-identification as asexual might provide asexual individuals with a community and way to describe their experience in the context of navigating an arguably sexualized society, we must be very careful when utilizing these definitions and self-identities for quantitative empirical research investigating the source of the corresponding lack of sexual attraction. Self-identification as asexual is a legitimate, and arguably very important, aspect of asexuality. However, in the context of sexuality (and sexual orientation) research, it   139 must be acknowledged that the umbrella term “asexual” might not accurately describe the entirety of all self-identified asexual individual’s experience. Further investigations of the topic should be careful to clearly define what is meant by terms such as “asexual”, and be thorough in the questions that are posed to identify participants as such for research purposes. Of course, it is a different, and very important, question entirely to conduct research on self-identified asexual individuals and the communities that develop around this self-identification. We must be clear in the distinction and in defining our terms.        140 Chapter 5: Conclusion Asexuality as a mental health difficulty The research presented in Chapter 2 provided additional evidence that asexuality may be associated with higher prevalence of mental health and interpersonal problems, however, I conclude, based on these findings, that asexuality should not be classified as either a mental illness, or be conceptualized as a symptom of a psychiatric condition. Asexual individuals were more likely to endorse symptoms of Social Withdrawal on a self-report screener for personality symptoms, and to report more interpersonal difficulties in general. Asexual individuals were also more likely to report symptoms of anxiety, and to endorse more symptoms of suicidality compared to non-asexual participants. Brotto and colleagues (2010) found that asexual individuals reported traits of Schizoid Personality Disorder, and indicated an association between Asperger Syndrome and asexuality. Further support of potential association between asexuality and autism spectrum disorder (ASD) comes from a study by Ingudomnukul et al. (2007), who found that 17% of asexual women met criteria for an ASD, and conversely, there is evidence of a higher rate of asexuality among individuals on the autism spectrum compared to a community control group (Gilmour, Schalomon, & Smith, 2012). This figure is in comparison to approximately 14.7 per 1000 children in the general population meeting criteria for an autism spectrum condition (Developmental DMNSY & 2010 Principal Investigators, 2014). While there is some general discussion on AVEN endorsing the link between asexuality and the Autism spectrum, large scale studies on this topic are necessary.   141 Although this study does provide evidence for higher rates of psychiatric symptoms in asexual individuals, there is evidence that these symptoms may be explained by increased experience of stigmatization and dehumanization by asexual individuals. One study found that college students evaluated asexual individuals most negatively compared to different sexual orientation groups, and asexual individuals were seen to be the least likely to possess “human nature traits” (MacInnis & Hodson, 2012). Participants in this study were most likely to report wanting to avoid future contact with asexual individuals compared to the other sexual orientation groups, over and above the greater likelihood for asexual individuals to be single. This is similar to the experiences of individuals of non-heterosexual orientations (e.g., D’Augelli & Hershberger, 1993; Toomey, Ryan, Diaz, Card, & Russell, 2010). It is likely that the distress and psychological symptoms experienced by asexual individuals is secondary to their experience of prejudice and discrimination, rather than asexuality being the result of an underlying psychological disturbance.   These findings strongly suggest that increased experience of distress and associated mental health difficulties should not be used to pathologize asexual individuals (Bogaert, 2006), and that asexuality should not be classified as a psychiatric diagnosis, nor be seen as a symptom of one. It remains a possibility that, for those asexual individuals who do have symptoms of autism spectrum disorder, distress arises from these mental health conditions, rather than from the asexuality itself. This group is understudied, and much more research needs to be done to understand this further.     142 Asexuality as a sexual dysfunction The findings from Chapter 3 suggest that asexuality is not a sexual dysfunction, at least not of sexual desire. One earlier study found that asexual individuals did not find their sexual desire to be problematic, and, if given the choice, they did not wish to speak with a health care provider about it (Prause & Graham, 2007). Further, and as Bogaert (2006) points out, most individuals diagnosed with HSDD have, at some point in their lives, experienced sexual desire whereas most asexual individuals report a lifelong absence of sexual interest. It remains a possibility that at least some of the individuals diagnosed with lifelong HSDD might be better classified as asexual, given our finding that there lifelong HSDD and asexual individuals were similar on measures of sexual behaviour and sexual desire. This overlap between lifelong HSDD and asexuality may be due to the fact that this is one homogeneous group, aside from self-reported distress. The delineation between lifelong HSDD and asexuality requires further investigation. Overall, however, this research suggests that there are fundamental differences between the lack of sexual attraction experienced by asexual individuals, and the distressing low desire that defines HSDD. There is previous evidence that asexuality is not a disorder of physiological sexual arousal (at least among women). One recent study compared genital sexual arousal between asexual and heterosexual and homosexual women in response to erotic films. There was no significant difference in genital sexual arousal, as measured by a vaginal photoplethysmograph, between groups. However, the asexual women differed from the sexual women in that they reported no increase in desire for sex after viewing the erotic films (Brotto & Yule, 2011). Whether genital arousal patterns of   143 asexual men differ from other sexual orientation groups is unknown, and is currently the subject of at least two ongoing studies at the University of British Columbia and Northwestern University. There are important clinical implications of these findings. The goal in treatment for the person with a sexual desire or arousal disorder is to increase their interest in sex, whereas, based on the current evidence, an asexual person in therapy would be more likely to benefit from a focus on self-acceptance (Hinderliter, 2013), or on developing skills around navigating relationships, especially if their partner was sexual and motivated to have sex. In the DSM-5, the accompanying text for the sexual desire disorders (both FSIAD in women and HSDD in men) explicitly mentions asexuality as an exclusion criterion (American Psychiatric Association, 2013).  Asexuality as a paraphilia In Chapter 4, I found that asexual individuals reported being much less likely to masturbate for reasons such as sexual pleasure than for more functional reasons, such as to relieve tension, which supports previous evidence that for some asexual individuals, masturbation is a physiological act rather than being sexually motivated (Brotto et al., 2010). Our finding that at least half of the asexual participants did engage in sexual fantasy as well as masturbation supports the hypothesis that there may be a paraphilic component to asexuality for some asexual individuals. Bogaert, in his 2006 discussion of asexuality and paraphilias, noted that the likelihood of all asexual individuals being paraphilic was low. Firstly, paraphilias without any human interest is rare, and more frequently occurs in men (Bogaert, 2004, 2013), while asexual individuals are more frequently women (Bogeart, 2004; Brotto et al., 2010). However,   144 Bogaert (2012b) did wonder whether some asexual individuals might have a particular type of paraphilia, autochorissexuality. Autochorissexuality, or “identity-less sexuality” is discussed in some detail in Chapter 4 (pg. 108 and 154). This research provides some empirical support for autochorissexuality among asexual individuals, as they are much more likely to report having sexual fantasies that do not involve them than are sexual individuals. The earlier finding of significantly higher rates of alexithymic traits in asexual individuals compared to sexual participants provides additional support for this (Brotto et al., 2010). It is possible that there is an underlying connection between the lack of emotional attachment in alexithyimia and the potential autochorissexuality in asexuality. Future research is needed to explore this more fully.  It may be that asexual individuals experience erotic target location errors (e.g., Lawrence, 2009), defined as the erroneous location of a preferred erotic target an external location or inanimate object (Blanchard, 1991). Some asexual individuals in the current research reported having sexual fantasies that involve fictional characters or scenes, rather than other humans. This requires further study, as the queries put forward in research to date have been imprecise, and do not allow us to elucidate whether the focus of fantasy is functioning as a focus of attention to facilitate sexual arousal and orgasm, or is actually an “imagined self” of the individual.  While it is a possibility that some asexual individuals do experience paraphilic interest, it is important to note that there is recent evidence that a large number of sexual individuals engage in sexual fantasy that might once have been considered paraphilic, in that they were thought to be non-normative. (Ahlers et al., 2011; Ogas & Gaddam, 2011). This evidence suggests that it is relatively common for non-paraphilic   145 individuals to have sexual fantasies that are non-normative, and that the content of sexual fantasies is not necessarily an indicator of an individual’s primary erotic preference. The majority of sexual fantasies of a truly paraphilic individual would likely contain paraphilic content, whereas a non-paraphilic individual may have paraphilic fantasies on occasion. Thus, the frequency of paraphilic fantasy content must be assessed in future research in order to discern whether they are reflective of the majority of an individual’s sexual interest. Further, queries into preferred sexual behaviour, as well as sexual fantasy content, would allow greater understanding between these two constructs. Asexuality as a sexual orientation Sexual orientation is thought to be a largely undefined internal mechanism that directs a person’s sexual interest, with varying degrees, towards men, women, or both (LeVay & Baldwin, 2012), and asexual advocates maintain that asexuality is a unique sexual orientation, alongside heterosexuality, homosexuality, and bisexuality. It may be more accurate to conceptualize asexuality as a lack of sexual orientation, in that this internal mechanism is not directed toward anyone or anything, or might not exist at all. It may also be that the same processes that guide the direction of sexual attraction to men, women, or both, might be involved in the development of a lack of sexual attraction. By investigating markers previously associated with sexual orientation development, such as age of menstruation, shorter stature, and increased number of health problems (Bogaert, 2004, 2013a), and potential biological markers of prenatal environment such as handedness and number of older siblings (Yule, et al., 2014a), researchers have provided evidence that the same processes that influence these   146 markers of sexual orientation may be associated with development of the lack of sexual attraction characteristic of asexuality (Bogaert, 2006; Bogaert, 2012a; Brotto, et al., 2010; Brotto & Yule, 2011; Yule, et al., 2014a).  For these reasons, we argue that asexuality be conceptualized as a unique sexual orientation rather than the absence of one (see Brotto & Yule (In Press) for a more in-depth exploration of this issue). Defining asexuality A number of different definitions were used throughout the studies presented in this dissertation, and this is a reflection of the lack of a unified definition of asexuality in general. Two of the studies (mental health and preliminary sexual fantasy study) classified participants as asexual if they self-identified as such, while the other two studies (sexual dysfunction and sexual fantasy content-analysis) utilized the AIS (Yule, Brotto, & Gorzalka, 2015) in order to identify those who lack sexual attraction. The AIS was not available for use at the time recruitment took place in the mental health study. We chose not to use the AIS for data analysis of individuals in the preliminary sexual fantasy study because much of the data we had regarding sexual fantasies among asexual individuals was anecdotal (via the AVEN website), and thus we decided to conduct analyses on self-identified participants in order to maximize the range of experiences our study captured. In subsequent analyses (i.e., the sexual dysfunction study and the sexual fantasy content analysis) we decided to use the AIS in order to utilize a more stringent definition of asexuality. Overall, we feel that allowing participants to self-identify as asexual is an appropriate technique for studies investigating characteristics of the asexual community, but when used to describe individuals who lack sexual attraction, and may not be a member of the asexual   147 community, a more objective tool (such as the AIS) might be more appropriate. It is true, however, that the vast majority of our asexual participants are recruited through the AVEN website, and thus there is likely a large amount of overlap between self-identified participants and those who were identified using the AIS (as demonstrated in the similarity of results between the two sexual fantasy studies). Further, the AIS itself was developed largely based on responses from participants recruited from AVEN. The AIS will likely be of benefit to very large-scale studies, in which there is a higher likelihood that participants who identify as sexual might actually lack sexual attraction. Limitations Because we relied heavily on the AVEN website for recruitment of our asexual participants, there is a possibility that the same individuals have participated a number of times in our studies over the years. We have no way to assess this potential confound, however, data collected by the webmasters of the AVEN website suggest that there is an overall trend of individuals participating as active members on the AVEN forums (where our studies are posted) when they initially join the AVEN community, and then become less active over time, eventually leaving the community after approximately two years (David Jay, personal communication, October 2014). If this is true, it would suggest that, overall, participants in the studies presented in this dissertation would likely not overlap. Further, the asexual community itself is quite large (approximately 120,000 members), and the most recent AVEN community census (Ginoza, Miller & Members of the AVEN Survey Team, 2014) received a total of 10,880 responses, suggesting that there is a large pool of asexual participants on the   148 AVEN website who are willing to participate in research. This again diminishes the likelihood that we are seeing repeated participation between our studies. Overall, the asexual participants discussed throughout this dissertation should be considered to have been recruited from asexual community websites. Thus, they may have different features and experiences than those individuals who lack sexual attraction but are not (yet) members of an online community. Overarching Conclusions Kinsey first defined the lack of sexual attraction inherent to asexuality as belonging to category X (Kinsey, Pomeroy, & Martin 1948), yet rigorous empirical research on this category has emerged only over the past decade. Research employing a variety of methodologies, and drawn from many different disciplines, has examined the nature of asexuality, with a focus on how to best conceptualize it. The current findings call into question the inclination to adopt a single theory explaining asexuality, and underscore the diversity among the asexual population. The most widely accepted definition of asexuality is a “lack of sexual attraction”. The logical conclusion of this statement is that there is a lack of sexual attraction toward anyone or anything at all. However, the current research suggests that there may be some sexual attraction present among some asexual individuals. Even if it is not directed toward another person, it may be directed toward themselves (i.e., automonosexuality) or to a character, object, or activity (i.e., BDSM). Autochorissexuality (identity-less sexuality) might also be a unique, heretofore yet unexplored, sexual orientation that is relatively common under the self-identified asexual umbrella.    149 The current findings further suggest that it is important to clearly differentiate between self-identified asexuality and a more stringent definition of asexuality (that focuses on a lack of sexual attraction to anything at all) when we are using these definitions for research purposes. We must be very careful when utilizing the self-identification that makes up asexual communities when conducting quantitative empirical research, as this may include a wide range of experiences that far outside the scope of a more rigorous academic definition of a complete lack of sexual attraction. Self-identification as asexual is a legitimate, and arguably very important, aspect of asexuality. However, in the context of sexuality (and sexual orientation) research, it must be acknowledged that the umbrella term “asexual” might not accurately describe the entirety of all self-identified asexual individual’s experience. Further investigations of the topic should be careful to clearly define what is meant by terms such as “asexual”, and be thorough in the questions that are posed to identify participants as such for research purposes. Of course, it is a different, and very important, question entirely to conduct research on self-identified asexual individuals and the communities that develop around this self-identification. We must be clear in the distinction and in defining our terms. This might be particularly important in studies comparing asexual individuals with those who meet diagnostic criteria for HSDD, especially those with a lifelong presentation. It may well be that there is significant overlap between individuals in these two groups if terms are not defined and distress not assessed carefully. Further, in future research investigating sexual fantasy among asexual individuals, it is essential that we are very clear and thoughtful in the way that we ask questions in such a way   150 that teases apart various dimensions (such as self/other, or involvement/non-involvement within a fantasy), of an asexual individual’s experience and fantasy. This dissertation addressed the possibility that asexuality is a psychiatric disorder (or a symptom of one), or that it is a sexual dysfunction. We conclude that there is not sufficient evidence to support either of these classifications for asexuality. 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Journal of Sex & Marital Therapy, 37, 255– 69.     170 Appendix A – Items on the Asexuality Identification Scale (AIS)  Yule, M. A., Brotto, L. A. & Gorzalka, B. B. (2015). A validated measure of no sexual attraction: The Asexuality Identification Scale. Psychological Assessment, 27(1). 148-160. doi.org/10.1037/a0038196   Number Item Response Range (on a 5-point Likert scale) 1. I experience sexual attraction towards other people 1 = Completely true  5 = Completely false 2. I lack interest in sexual activity 1 = Completely false  5 = Completely true 3. I don’t feel that I fit the conventional categories of sexual orientation such as heterosexual, homosexual, or bisexual  1 = Completely false  5 = Completely true 4. The thought of sexual activity repulses me 1 = Completely false  5 = Completely true 5. I find myself experiencing sexual attraction towards another person 1 = Always  5 = Never 6. I am confused by how much interest and time other people put into sexual relationships 1 = Completely false  5 = Completely true 7. The term ‘non-sexual’ would be an accurate description of my sexuality 1 = Completely false  5 = Completely true 8. I would be content if I never had sex again 1 = Completely false  5 = Completely true 9. I would be relieved if I was told that I never had to engage in any sort of sexual activity again 1 = Completely false  5 = Completely true 10. I go to great lengths to avoid situations where sex might be expected of me  1 = Completely false  5 = Completely true 11. My ideal relationship would not involve sexual activity  1 = Completely false  5 = Completely true 12. Sex has no place in my life  1 = Completely false  5 = Completely true 

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