"GLOBAL SEXUAL FUNCTIONING": A SINGLE SUMMARY SCORE FOR NOWINSKI AND LOPICCOLO'S SEXUAL HISTORY FORM (SHF)

Laura Creti, Catherine S. Fichten, Rhonda Amsel, William Brender,
Leslie R. Schover, Dennis Kalogeropoulos, Eva Libman
SMBD - Jewish General Hospital, McGill University, Concordia University, Dawson College, The Cleveland Clinic Foundation

The Sexual History Form (SHF: Nowinski & LoPiccolo, 1979; Schover & Jensen, 1988) is a widely used "multiple choice" questionnaire evaluating the frequency of sexual activity, sexual function relating to desire, arousal, orgasm, and pain, and overall sexual satisfaction for men and women. Originally developed for clinical use and to provide standardized data for diagnosis and research (Schover, Friedman, Weiler, Heiman, & LoPiccolo, 1982), the Sexual History Form has been widely used in sex therapy clinics, in clinical studies of sex therapy outcome (Schover & LoPiccolo, 1982; Trudel, Ravart, & Matte, 1993; Fichten, Libman, Takefman, & Brender, 1988), and in longitudinal assessments of the impact of chronic illness on sexuality (Schover, Fife, & Gershenson, 1989; Schover, Novick, Steinmuller, & Goormastic, 1990; Schover, Yetman, Tuason, Meisler, Esselstyn, Hermann, Grudfest-Broniatowski, & Dowden, 1995).

In its present format, the Sexual History Form provides a very detailed self-report assessment of sexual behavior and function. It has been used in an item-by-item fashion to describe sexual problems in a particular population or to compare sexual function before and after a medical intervention. A limitation of the Sexual History Form for research has been the lack of a reliable and valid global score that could measure differences in overall sexual function between groups or across time.

To enhance the utility of the Sexual History Form, we developed a new scoring system which generates a single summary score: Global Sexual Functioning (Creti, Fichten, Libman, Amsel, & Brender, 1988; Creti, Fichten, Libman, Kalogeropoulos, & Brender, 1987). The Global Sexual Functioning Score is easy to calculate and concisely and accurately reflects overall level of sexual functioning. The single score also permits results from different investigations to be more readily compared.

Description

The SHF is a self-report sexual history measure. The original version consisted of 28 items; the latest version has 46. The format of the measure is "multiple choice"; items have variable numbers of response options and different response scales [e.g., item #1 has 9 options, with 1= more than once a day and 9 = not at all; item #18 has 6 options, with 1 = never and 6 = nearly always (over 90% of the time)]. Response options are numbered from 1 to 4, 1 to 5, 1 to 6, or 1 to 9 and have a verbal descriptor corresponding to each number. The measure is typically scored on an item-by-item basis, resulting in 46 variables. Normative data for most items are presented in Schover and Jensen (1988); these are based on 92 couples in stable relationships who responded to an advertisement in New York in 1980. The mean age of the sample was in the early 30s and they were predominantly Caucasian and middle class. Comparative item data from other samples can be found in Libman, Fichten Creti, Amsel, and Brender (1986), LoPiccolo (1981), Nowinski and LoPiccolo (1979), and Weinstein et al. (1989).

Response Mode and Timing

Respondents are asked to circle the number which corresponds to the single most appropriate response for each question. The measure requires approximately 15 minutes to complete.

Scoring

The Global Sexual Functioning score is calculated using 12 of the original 28 items (items have been renumbered in the current 46 item version). Because certain items are relevant only for males, while others are relevant only for females, the items used to calculate the male and female Global Sexual Functioning score are somewhat different. The 12 items were selected as representative of various domains of sexual functioning: frequency of sexual activities, sexual desire, arousal, orgasmic and erectile abilities.

To arrive at the single summary score, SHF items are grouped into a 12 item scale; this reflects either male or female Global Sexual Functioning. The single summary score is derived by (1) converting the scores on each of the 12 items to a proportion of the maximum possible value [e.g., if on item #1, where response options are numbered 1 to 9, the respondent answers "(4) twice a week," this is converted to 4/9 = .44], (2) summing the 12 proportions, and (3) calculating the mean by dividing the total by the number of items which the respondent is deemed to have answered (usually 12). The resulting mean value, which is the Global Functioning Score, will be greater than 0 and less than 1. The calculation can be easily carried out using a calculator.

Table 1 specifies the items included in the calculation of the Global Sexual Functioning score. For items with an *, responses equalling 6 are considered "missing" since this response option is "have never tried"; in this case, the summed proportions are divided not by 12 but by the number of items which are deemed to have been answered (i.e., not "missing"). The scoring system is summarized in Table 1. Lower scores indicate better functioning.

Table 1

CALCULATING THE GLOBAL SEXUAL FUNCTIONING SCORE
Male		Female
Item #	Divide by	Item #	Divide by
1	9	1	9
2	9	2	9
6	9	6	9
7	9	7	9
10	6	16	5
16	5	23*	5
18	6	24*	5
19	6	25*	5
22	6	26*	5
23*	5	27*	5
24*	5	29	6
25*	5	37*	5

* Responses equalling 6 are considered "missing"
Scoring:
(1) convert scores to proportions
(2) sum proportions
(3) divide by number of items

Note: Although all items included in the Global Sexual Functioning score are present in the original 28 item version, items have been renumbered in the current 46 item version.

Reliability

The Global Sexual Functioning scores have excellent temporal stability. For example, in a sample of 27 older married women (mean age = 59), two week test-retest reliability was .92 (Creti et al., 1988). Temporal stability of the male Global Sexual Functioning score, based on a sample of older married men described by Libman et al. (1989) (n = 45, mean age = 65) was .98.

Evaluation of internal consistency also shows acceptable psychometric properties for the Global Sexual Functioning scores. For example, Cronbach's alpha for the male Global Sexual Functioning was .65. Good internal consistency is reported for the female Global Sexual Functioning score; item-total correlation coefficients presented by Creti et al. (1988) show r values ranging from .18 to .85, with the majority of values between .50 and .70.

Validity

Male Global Sexual Functioning. Data indicate that (1) the Global Sexual Functioning score can differentiate sexually well functioning from poorly functioning men and it is responsive to changes with therapy: Creti et al. (1987) reported that men with diagnosed sexual dysfunction had significantly (p.05) worse scores (M= .66, SD = .14) than well functioning men (M = .37, SD = .08), and Kalogeropoulos (1991) found scores to significantly improve in a sample of 53 males who had undergone vasoactive intracavernous pharmacotherapy for erectile dysfunction, (2) the Global Sexual Functioning score is significantly related to other sexual functioning measures: Creti et al. (1987) found that men with higher sexual self-efficacy scored significantly better (M = .48, SD = .07) than men with lower sexual self-efficacy (M = .59, SD = .10), and Global Sexual Functioning scores were found to be logically and significantly related to scores on measures of sexual satisfaction, sexual repertoire, sexual self-efficacy and sexual drive (Creti et al. 1987; Creti and Libman, 1989) , and (3) the Global Sexual Functioning score is sensitive to age differences in sexual functioning: Libman et al. (1989, 1991) showed that older married men (age 65+) had significantly worse scores (M = .50) than middle aged married men (age = 50 - 64) (M = .46), and Creti et al. (1987, 1989) found the score to be logically and significantly correlated with age. In addition, Libman et al. (1989, 1991) showed that there is a small but significant deterioration in middle aged and older men who have undergone surgery for benign prostatic enlargement (change from pre-surgery M = .43, SD = .08, to post-surgery M = .48, SD = .11).

Female Global Sexual Functioning. Data reported by Creti et al. (1988) indicate that: (1) women with diagnosed sexual dysfunction had worse scores (M = .68, SD = .17) than women who were functioning well (M = .49, SD = .14), (2) that female Global Sexual Functioning scores were logically and significantly correlated with sexual harmony, sexual satisfaction, diversity of sexual repertoire, and sexual drive, and (3) that younger women (age 21-46) had better scores (M = .46, SD = .03) than older women (age greater than 64) (M = .62, SD = .16). Global Sexual Functioning scores were also found to be related to the females' sexual efficacy expectations for her male partner (Creti & Libman, 1989).

Other Information

The 28 item version of the Sexual History Form is also available in French (Formulaire d'Histoire Sexuelle).

Conclusions

Psychometric properties for the male and female Global Sexual Functioning scores suggest that these provide a good index of the underlying construct. The single summary score, which reflects the multidimensional nature of the sexual response, is convenient to use both in assessment and in the evaluation of therapy outcome.

Norms have yet to be established for the Global Sexual Functioning scores. However, the score is useful in research and practice, even in the absence of norms. The single summary score allows investigators to classify respondents in terms of level of overall sexual functioning by using a mean or median split, for example. In addition, the score permits evaluation of changes in sexual functioning with varying situational parameters (eg., illness, surgery, therapy) in a convenient and clinically relevant manner. Last, but not least, the single score permits samples and findings from different investigators to be more readily compared.

REFERENCES

Creti, L., Fichten, C.S., Libman, E., Amsel, R., & Brender, W. (1988, June). Female Sexual Functioning: A global score for Nowinski and LoPiccolo's Sexual History Form. Presentation at the Canadian Psychological Association annual convention, Montreal. Abstracted in Canadian Psychology, 29(2a), Abstract #164.

Creti, L., Fichten, C. S., Libman, E., Kalogeropoulos, D., & Brender, W. (1987, November). A global score for the "Sexual History Form" and its effectiveness. Presentation at the 21st annual convention of the Association for Advancement of Behavior Therapy, Boston, Mass.

Creti, L. & Libman, E. (1989). Cognitions and sexual expression in the aging. Journal of Sex & Marital Therapy, 15(2), 83-101.

Fichten, C. S., Libman, E., Takefman, J., & Brender, W. (1988). Self-monitoring and self-focus in erectile dysfunction. Journal of Sex and Marital Therapy, 14, 120-128.

Kalogeropoulos, D. (1991). Vasoactive intracavernous pharmacotherapy for erectile dysfunction: Its effects on sexual, interpersonal, and psychological functioning. Unpublished doctoral dissertation, Concordia University, Montreal, Quebec, Canada.

Libman, E., Fichten, C.S., Creti, L., Weinstein, N., Amsel, R., & Brender, W. (1989). Transurethral prostatectomy: Differential effects of age category and presurgery sexual functioning on postprostatectomy sexual adjustment. Journal of Behavioral Medicine, 12(5), 469-485.

Libman, E., Fichten, C. S., Creti, L., Amsel, R., & Brender, W. (1986, June). Aspects of sexual functioning in an aging population. Presentation at the Canadian Psychological Association, Toronto. Abstracted in Canadian Psychology, 27, (Abstract #354).

Libman, E., Fichten, C.S., Rothenberg, P., Creti, L., Weinstein, N., Amsel, R., Liederman, G., & Brender, W. (1991). Prostatectomy and inguinal hernia repair: A comparison of the sexual consequences. Journal of Sex and Marital Therapy, 17(1), 27-34.

Libman, E., Rothenberg, I., Fichten, C. S., & Amsel, R. (1985). The SSES-E: A measure of sexual self-efficacy in erectile functioning. Journal of Sex and Marital Therapy, 11, 233-244.

LoPiccolo, J. (1981). Norms for Sex History Form (Male and Female). Unpublished manuscript, Texas A & M University.

Nowinski, J. K., & LoPiccolo, J. (1979). Assessing sexual behaviors in couples. Journal of Sex and Marital Therapy, 5, 225-243.

Schover, L. R., Fife, M., & Gershenson, D. M. (1989). Sexual dysfunction and treatment for early stage cervical cancer. Cancer, 63, 204-212.

Schover, L. R., Friedman, J. M., Weiler, J., Heiman, J. R., & LoPiccolo, J. (1982). Multiaxial problem-oriented system for sexual dysfunctions: An alternative to DSM-III. Arch Gen Psychiatry, 39, 614-619.

Schover, L. R., & Jensen, S. B. (1988). Sexuality and chronic illness: A comprehensive approach. (pp. 126-136). New York: Guilford Press.

Schover, L. R., & LoPiccolo, J. (1982). Treatment effectiveness for dysfunctions of sexual desire. Journal of Sex and Marital Therapy, 8, 179-197.

Schover, L. R., Novick, A. C., Steinmuller, D. R., & Goormastic, M. (1990). Sexuality, fertility, and renal transplantation: A study of survivors. Journal of Sex and Marital Therapy, 16, 3-14.

Schover, L. R., Yetman, R. J. Tuason L. J., Meisler, E., Esselstyn, C. B., Hermann, R. E., Grundfest-Broniatowski, S., & Dowden, R. V. (1995). Comparison of partial mastectomy with breast reconstruction on psychosocial adjustment, body image, and sexuality. Cancer, 75, 54-64.

Trudel, G., Ravart, G., & Matte, B. (1993). The use of the multiaxial diagnostic system for sexual dysfunctions in the assessment of hypoactive sexual desire. Journal of Sex and Marital Therapy, 19, 123-130.

Weinstein, N., Pencer I., Libman, E., Fichten, C. S., Creti, L., Rothenberg, P., Liederman, G., Amsel, R., & Brender, W. (1989, October). Does aging affect sexual expression? Presentation at the Société Québécoise pour la Recherche en Psychologie annual convention, Montreal. Abstracted in XIIième congrès annuel: Programme et résumés des communication, 177. SQRP: Montréal.

SEXUAL HISTORY FORM

(Items in bold are used to compute the Global Sexual Functioning Score.)

Please circle the most appropriate response to each question.

1. How frequently do you and your mate have sexual intercourse or activity?

1) more than once a day
2) once a day
3) 3 or 4 times a week
4) twice a week
5) once a week
6) once every two weeks
7) once a month
8) less than once a month
9) not at all

2. How frequently would you like to have sexual intercourse or activity?

1) more than once a day
2) once a day
3) 3 or 4 times a week
4) twice a week
5) once a week
6) once every two weeks
7) once a month
8) less than once a month
9) not at all

3. Who usually initiates sexual intercourse or activity?

1) I always do
2) I usually do
3) my mate and I initiate about equally often
4) my mate usually does
5) my mate always does

4. Who would you ideally like to initiate sexual intercourse or activity?

1) myself, always
2) myself, usually
3) my mate and I equally often
4) my mate, usually
5) my mate always

5. When your mate makes sexual advances, how do you usually respond?

1) I usually accept with pleasure
2) accept reluctantly
3) often refuse
4) usually refuse

6. How often do you experience sexual desire (this may include wanting to have sex, planning to have sex, feeling frustrated due to lack of sex, etc.)?

1) more than once a day
2) once a day
3) 3 or 4 times a week
4) twice a week
5) once a week
6) once every two weeks
7) once a month
8) less than once a month
9) not at all

7. How often do you masturbate (bring yourself to orgasm in private)?

1) more than once a day
2) once a day
3) 3 or 4 times a week
4) twice a week
5) once a week
6) once every two weeks
7) once a month
8) less than once a month
9) not at all

8. For how long do you and your mate usually engage in sexual foreplay (kissing, petting, etc.) before having intercourse?

1) less than 1 minute
2) 1 to 3 minutes
3) 4 to 6 minutes
4) 7 to 10 minutes
5) 11 to 15 minutes
6) 16 to 30 minutes
7) 30 minutes to one hour

9. How long does intercourse usually last, from entry of the penis to the male's orgasm/climax?

1) less than 1 minute
2) 1 to 2 minutes
3) 2 to 4 minutes
4) 4 to 7 minutes
5) 7 to 10 minutes
6) 11 to 15 minutes
7) 15 to 20 minutes
8) 20 to 30 minutes
9) more than 30 minutes

10. Does the male ever reach orgasm while he is trying to enter the vagina with his penis?
1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time)
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

11. Do you feel that premature ejaculation (rapid climax) is a problem in your sexual relationship?

1) yes
2) no

12. How satisfied are you with the variety of sexual activities in your current sex life? (This includes the different types of kissing and caressing with a partner, different positions for intercourse, etc..)

1) extremely satisfied
2) moderately satisfied
3) slightly satisfied
4) slightly unsatisfied
5) moderately unsatisfied
6) extremely unsatisfied

13. Would you like your lovemaking to include more:

Breast caressing 1) yes 2) no
Hand caressing of your genital area 1) yes 2) no
Oral caressing (kissing) of your genital area 1) yes 2) no
Different positions for intercourse 1) yes 2) no

14. If you would like a certain kind of sexual caress or activity, which way do you typically let your partner know?

1) I wait to see if my partner will do what I like without my asking
2) I show my partner what I would like my moving their hand or changing my own position
3) I tell my partner exactly what I would like

15. How have you typically learned about your partner's sexual likes and dislikes?

1) From my partner telling me exactly what they want
2) From my partner moving my hand or changing their position to signal what they would like me to do
3) From watching my partner's reactions during sex
4) From intuition

16. When you have sex with your mate do you feel sexually aroused (e.g., feeling "turned on", pleasure, excitement)?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never

17. When you have sex with your mate, do you have negative emotional reactions (e.g.,fear, disgust, shame or guilt)?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

18. Does the male have any trouble getting an erection before intercourse begins?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

19. Does the male have any trouble keeping an erection once intercourse has begun?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

20. If the male loses an erection, when does that usually happen?

1) before penetrating to start intercourse
2) While trying to penetrate
3) after penetration, during the thrusting of intercourse
4) not applicable, losing erections is not a problem

21. What is the male's typical degree of erection during sexual activity?

1) 0 to 20% of a full erection
2) 20% to 40% of a full erection
3) 40% to 60% of a full erection
4) 60% to 80% of a full erection
5) 80% to 100% of a full erection

22. Does the male ejaculate (climax) without having a full, hard erection?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

23. If you try, is it possible to reach orgasm (sensation of climax) through masturbation?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

24. If you try, is it possible for you to reach orgasm (sensation of climax) through having your genitals caressed by your mate?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

25. If you try, is it possible for you to reach orgasm (sensation of climax) through sexual intercourse?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

26. Can you reach orgasm (sensation of climax) through stimulation of your genitals by an electric vibrator or any other means (i.e., running water, rubbing with some object, etc.)?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

27. (WOMEN ONLY) Can you reach orgasm during sexual intercourse if, at the same time, your genitals are being caressed (by yourself or your mate with a vibrator, etc.)?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

28. Have you noticed a change in the intensity and pleasure of your orgasm?

1) much more intense and pleasurable than in the past
2) somewhat more intense and pleasurable than in the past
3) the same as in the past
4) somewhat less intense and pleasurable than in the past
5) much less intense and pleasurable than in the past

29. Is the female's vagina so "dry" or "tight" that intercourse cannot occur?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

30. Do you feel pain in your genitals (sexual parts) during intercourse?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

31. How often does pain (genital or nongenital) interfere with your ability to feel sexual pleasure?

1) never
2) rarely (less than 10% of the time)
3) seldom (less than 25% of the time
4) sometimes (50% of the time)
5) usually (75% of the time)
6) nearly always (over 90% of the time)

32. Have you noticed a change in the sensitivity to touch of your genitals?

1) much more sensitive than in the past
2) somewhat more sensitive than in the past
3) about as sensitive as in the past
4) somewhat less sensitive than in the past
5) much less sensitive than in the past

33. Overall, how satisfactory to you is your sexual relationship with your mate?

1) extremely unsatisfactory
2) moderately unsatisfactory
3) slightly unsatisfactory
4) slightly satisfactory
5) moderately satisfactory
6) extremely satisfactory

34. Overall, how satisfactory do you think your sexual relationship is to your mate?

1) extremely unsatisfactory
2) moderately unsatisfactory
3) slightly unsatisfactory
4) slightly satisfactory
5) moderately satisfactory
6) extremely satisfactory

35. Do you feel that your partner plays a part in causing a problem in your sex life?

1) yes
2) no

36. If your lovemaking does not go well, how does your partner usually react?

1) accepting and understanding
2) frustrated or annoyed
3) anxious and blaming self
4) neutral or uncaring

37. (WOMEN ONLY, MEN GO ON TO QUESTION 38) When you have sex with your mate (including foreplay and intercourse) do you notice some of these things happening: your breathing and pulse speed up, wetness in your vagina, pleasurable sensations in your breasts and genitals?

1) nearly always (over 90% of the time)
2) usually (about 75% of the time)
3) sometimes (about 50% of the time)
4) seldom (about 25% of the time)
5) never
6) have never tried to

38. (MEN ONLY) How often do you wake from sleep with a firm erection (including times when you wake up needing to urinate)?

1) daily
2) 3-4 times a week
3) 1-2 times a week
4) once every 2 weeks
5) once a month
6) less than once a month
7) never

39. (MEN ONLY) How often do you wake from sleep with a partial (semisoft) erection?

1) daily
2) 3-4 times a week
3) 1-2 times a week
4) once every 2 weeks
5) once a month
6) less than once a month
7) never

40. (MEN ONLY) How often are you able to get and keep a firm erection in your own masturbation (self-touch in private)?

1) nearly always, over 90% of the time
2) usually, 75% of the time
3) sometimes, 50% of the time
4) seldom, less than 25% of the time
5) rarely, less than 10% of the time
6) never
7) have not tried masturbation in the past 6 months

41. (MEN ONLY) What is your typical degree of erection during masturbation (self-touch in private?

1) 0% to 20% of a full erection
2) 20% to 40% of a full erection
3) 40% to 60% of a full erection
4) 60% to 80% of a full erection
5) 80% to 100% of a full erection

42. (MEN ONLY) Do you feel your erect penis has an abnormal curve to it, or have you noticed a lump or "knot" on your penis?

1) yes
2) no

43. (MEN ONLY) Do you believe your penis is abnormally small?

1) yes
2) no

44. (MEN ONLY) how does the amount of ejaculate (liquid or semen) now compare to the amount you ejaculated in the past?

1) much greater than in the past
2) somewhat greater than in the past
3) about the same as in the past
4) somewhat less than in the past
5) much less than in the past
6) I do not know

45. (MEN ONLY) Do you ever have the sensation of orgasm (climax) without any ejaculation of fluid?

1) never
2) rarely, less than 10% of the time
3) seldom, less than 25% of the time
4) sometimes, about 50% of the time
5) usually, about 75% of the time
6) nearly always, over 90% of the time

46. (MEN ONLY) Do you ever have pain and/or burning during or after ejaculation?

1) never
2) rarely, less than 10% of the time
3) seldom, less than 25% of the time
4) sometimes, about 50% of the time
5) usually, about 75% of the time
6) nearly always, over 90% of the time
7) I do not ejaculate

Author Notes

This measure was developed with research funding from the Conseil Québécois de la Recherche Sociale. We would like to thank Jackie Cohen, Gloria Liederman and Nettie Weinstein for assistance with various stages of this investigation. Requests for reprints should be sent to Laura Creti, Behavior and Sex Therapy Services - ICFP, SMBD Jewish General Hospital, 4333 Cote St. Catherine Rd., Montreal, Quebec, Canada H3T 1E4.