Automatic Associations between Sexual Function Problems and Pursuing Help in Pelvic Physical Therapy Practice: The Psychometric Investigation of an Implicit Association Test

Abstract

Not all women experiencing pelvic floor complaints and sexual function problems seek help in pelvic physical therapy practice. Decisions to seek help can result from explicit and implicit cognitive processes. Having found some explicit predictive factors for receiving help in this setting, this study examines possible complementary implicit associations between sexual function problems and pursuing help that might also be predictive. The Pursuing Help for Sexual Problems Implicit Association Test (PHSP-IAT) was specially developed for this purpose. The instrument’s reliability and validity were evaluated. High reliability was found (Spearman’s Rho = .95). Convergent and divergent validity analyses resulted in low and non-significant correlations between the PHSP-IAT and the chosen self-report measures. The PHSP-IAT was predictive for receiving help in pelvic physical therapy practice. Further research is necessary to determine the PHSP-IAT’s validity and its predictive value in other healthcare settings.

Introduction

Pelvic floor complaints (PFC), including urinary and fecal incontinence, micturition and defecation problems, pelvic organ prolapses, and pelvic pain, often have an adverse impact on women’s sexual function (Berghmans, 2018; Berghmans et al., 2016; Li-Yun-Fong et al., 2017). However, women experiencing these problems are not necessarily motivated to seek help. Multiple obstacles can withhold them from seeking help, including limited accessibility and high costs of care, the reluctance of partners to participate in therapy, psychosocial factors like shame, embarrassment, and stigma, as well as low self-confidence, and the assumption that their problems are not significant enough (Sever & Vowels, 2023; Zoorob et al., 2017).

Another obstacle for women suffering from these problems is the difficulty of discussing sexual function problems with a healthcare provider. As a result, sexual function problems can be overlooked and left undertreated in clinical practice (Voorham-van der Zalm et al., 2008). This raises the question of whether an unexpressed desire to address sexual function problems might encourage women to seek help, even if they are reluctant to discuss such issues openly. This discrepancy raises the question of whether women who receive help may unconsciously desire to address unresolved sexual function problems without bringing up the topic themselves.

PFC severity, including urinary and fecal incontinence, micturition and defecation problems, pelvic organ prolapses, pelvic pain, and painful intercourse, was found to be a predictor for receiving help in PPT practice (Brand, Waterink, & van Lankveld, 2023). Self-reported psychological burden linked with PFCs also predicted receiving help (Brand, Waterink, & van Lankveld, 2023). Surprisingly, sexual functioning levels, including sexual desire, arousal, lubrication, and orgasm, did not predict receiving help (Brand, Waterink, & van Lankveld, 2023). The finding that self-reported psychological burdens were predictive, and sexual function problems were not, inspired us to conduct further research into determinants of help-seeking behavior. In addition to conscious psychological factors, unconscious or automatic psychological factors might influence women’s decisions to seek help when experiencing sexual function problems (Seewald et al., 2023). Previous research has shown that implicit cognitions can complement and augment explicit cognitions to predict behavior (Bolos et al., 2019; Roefs et al., 2011).

At an automatic and unconscious level, associations between sexual function problems and pursuing help could affect women’s implicit beliefs about the desirability to seek help despite the aforementioned obstacles (Seewald et al., 2023). Implicit Association Tests (IAT) can be employed to examine automatic, unconscious associations between specific stimuli as an indication of implicit beliefs (Greenwald et al., 1998; 2003; Karpinski & Hilton, 2001; Karpinski & Steinman, 2006; Seewald et al., 2023). More positive associations are representative of stronger implicit beliefs about the desirability to seek help. The Pursuing Help for Sexual Problems Implicit Association Test (PHSP-IAT) was specially designed for this research to measure the strength of women’s implicit associations between the concepts of sexual function problems, referred to in the IAT as ‘sexual dysfunction’ (as opposed to ‘sexual health’) and seeking help, referred to in the IAT as ‘pursuing help’ (as opposed to ‘not pursuing help’). The predictive value of this test can be evaluated against women’s receiving help in PPT practice (Azar et al., 2013). Before confidently utilizing this new IAT in future research, investigating its reliability and validity is crucial to ensure accurate and meaningful results (Seewald et al., 2023).

Therefore, in this study, the reliability and some validity aspects of the PHSP-IAT were examined. The research questions were as follows: Is the PHSP-IAT a reliable and valid tool for assessing women’s implicit associations between sexual function problems and pursuing help stimuli? Are women with more positive implicit associations between sexual function problems and pursuing help more likely to receive help in PPT practice for sexual function problems compared to women with more negative implicit associations?

Materials and methods

Ethical considerations

The study protocol received approval from the Ethical Review Board of the Open University of the Netherlands (Date: May 29th, 2019/No. U2019/03973/HVM). Before participation, participants provided informed written consent. They were guaranteed anonymity during the data analysis and publication.

Design

In a cross-sectional exploratory design, an online survey was conducted among young adult women in the Netherlands. A link to a secure research platform was provided to potential participants to access both the survey questions and the PHSP-IAT following the online signing of the informed consent form.

Participants

Women were eligible to participate if they met any of the following inclusion criteria: ages between 18-45 years, pregnant with their first child, having a child below two years old, or being childless. Participants with and without PFC were recruited. Women with PFC were either receiving or not receiving PPT. Recruitment was done through the use of social media and with the assistance of general and pelvic physical therapists, general practitioners, midwives, and medical specialists. Additionally, women were personally invited during PPT treatments. Also, the snowball approach was utilized within the social networks of volunteers, participants, and recruiters for recruitment purposes. Furthermore, recruitment was facilitated by Hersenonderzoek.nl (www.hersenonderzoek.nl), a paid recruitment service for scientific research. The data collection period spanned from November 2021 to March 2023. Four hundred and fifteen participants completed the survey and the PHSP-IAT.

Instruments

The implicit association test

To measure implicit associations, an IAT was conducted using the target categories of “sexual health” and “sexual dysfunction”, and attribute categories of “pursuing help” and “not pursuing help”. The stimuli representing the non-problematic and problematic sexual function categories of the IAT were selected by 31 female adult participants in a pilot study. The PHSP-IAT used the top five most frequently chosen word stimuli for each category.

Sexual health was represented by the following word stimuli: satisfying sex, sexual desire, sexual pleasure, openness about sex, and respectful sex; in Dutch: “bevredigende seks”, “zin in seks”, “seksueel plezier”, “open over seks”, and “respectvolle seks”. Sexual dysfunction was represented by the following word stimuli: decreased sexual desire, not looking forward to sex, painful sex, sexual embarrassment, and vaginal dryness; in Dutch: “verminderd seksueel verlangen”, “geen zin in seks”, “pijnlijke seks”, “seksuele schaamte”, and “vaginale droogheid”. Pursuing help was represented by the following word stimuli: e.g., wishing for help, longing for help, desiring help, approaching help, and wanting help; in Dutch: “hulp wensen”, “verlangen naar hulp”, “streven naar hulp”, “hulp vragen”, and “hulp willen”. Not pursuing help was represented by the following word stimuli: warding off help, avoiding help, stopping help, preventing help, and averting help; in Dutch: “hulp afweren”, “hulp vermijden”, “hulp tegenhouden”, “hulp voorkomen”, and “hulp afslaan”. Word stimuli representing “pursuing” and “not pursuing” have been used in previous IAT research on liking and wanting sex (Dewitte, 2015; Van Lankveld et al., 2018).

Participants were instructed how to map the word stimuli, which were presented in random order at the center of their computer screen using the “A” and “L” keys on their QWERTY keyboard. The target and attribute words were positioned in the top left and right corners of the screen. The same key on the keyboard was assigned for either pursuing help or not throughout the entire IAT. The target categories of sexual health and sexual function problems were reversed in blocks 5 and 6, and these blocks differed from blocks 3 and 4 in terms of keyboard mapping. The blocks were presented in a fixed sequence, while the 20 stimuli within each block were randomly displayed. Test blocks 4 and 6 contained 40 stimuli per block, as each stimulus set consisting of 20 stimuli was shown twice. Error feedback was not provided during the test.

Participants began with two practice blocks of 10 trials each for, respectively, the target and attribute stimuli. During these brief blocks, the stimuli related to “sexual health” and “pursuing help” were assigned to key “A”, while the ones related to “sexual dysfunction” and “not pursuing help” were assigned to key “L”. The following two blocks consisted of a practice round of 20 trials and a test round of 40 trials in which the same target and attribute stimuli from the first two blocks were assigned to the same keys. Subsequently, the target stimuli “sexual health” and “sexual dysfunction” were assigned to the opposite keys, and participants were instructed to categorize word stimuli accordingly in another practice block of 20 trials and the final test block of 40 trials. In these blocks, “sexual dysfunction” and “pursuing help” stimuli were assigned to key “A”, and the “sexual health” and “not pursuing help” stimuli to key “L” (Greenwald et al., 1998). Participants were requested to work as fast and as accurately as possible.

Self-report questionnaires

Table 1 presents the psychometric information of the self-report questionnaires employed in this study. The online survey began by inquiring about demographics and eligibility, including age, pregnancy, and parity. Participants were asked if they received help in PPT practice during the time of participation.

Table 1. Overview of self-report instruments, variables, items, and scoring ranges in this study.

Variable	Scale	Items	Scoring range	Maximum score	Cronbach’s Alfa (N = 398)
Sexual Functioning	FSFI	16 out of 19 items	0–30	30	.96
Sexual Desire	FSFI	1, 2	1–5	6
Sexual Arousal	FSFI	3, 4, 5, 6	0–5	6
Lubrication	FSFI	7, 8, 9, 10	0–5	6
Orgasm	FSFI	11, 12, 13	0–5	6
Pain	FSFI	17, 18, 19	0–5	6
Psychological Burden	PFC-PBI	All 10 items	0–6	60	.95
Sexual Distress	FSDS	All 12 items	0–4	48	.95
Physical Restrictions	QBPDS	All 20 items	0–5	100	.95

Note. Cronbach’s Alfa is calculated based on the data in this study sample.

To assess the level of sexual functioning, the Female Sexual Functioning Index (FSFI) was used (Rosen et al., 2000; Ter Kuile et al., 2006). The scale comprised 16 items measuring sexual desire, arousal, lubrication, orgasm, and pain (Rosen et al., 2000; Ter Kuile et al., 2006). The items were rated on 5 or 6-point Likert scales indicating frequency, severity, and effort. Higher scores indicated higher levels of sexual functioning.

The Female Sexual Distress Scale (FSDS) was used to measure the participant’s level of sexual distress (Derogatis et al., 2002; Ter Kuile et al., 2006). The FSDS comprised twelve items, scored on a 5-point Likert scale with frequency response options ranging from never to always. Higher sum scores indicated greater levels of sexual distress.

To measure the psychological burden of the participants, the Pelvic Floor Complaint-related Psychological Burden Inventory (PFC-PBI) was used (Brand, Waterink, Rosas, et al., 2023). The inventory comprised ten items rated on a 7-point Likert scale of applicability with scores ranging from never applicable to always applicable. Higher cumulative scores indicated a greater psychological burden (Brand, Waterink, Rosas, et al., 2023).

To determine the participant’s level of physical restrictions in daily life due to pelvic, lower back, or coccyx pain, the Quebec Back Pain and Disability Scale (QBPDS) (Smeets et al., 2011) was used. Twenty activities were assessed on a 6-point Likert scale, measuring the level of effort required to perform each activity with scores ranging from “no trouble at all’ to “unable to do”. A higher total score reflected a greater degree of physical restrictions.

Data analysis

To ensure reliable outcomes, a minimum sample size of 300 participants is generally deemed necessary (Boateng et al., 2018). To determine the minimum sample size required for reliable predictive validity investigation employing binary logistic regression analysis, the formula n = 100 + 50*i can be used, where “i” denotes the number of independent variables (Bujang et al., 2018). By utilizing the four emergent mean scores from both the practice and test blocks of the PHSP-IAT, this method also indicates a minimum sample size of 300, as calculated by the formula 100 + 50*4.

Data from participants who completed the entire online survey and the PHSP-IAT were analyzed. Latencies in milliseconds were recorded for each stimulus in blocks 3 through 6, from stimulus presentation on the screen to pressing the “A” or “L” key. The D600 algorithm was used (Greenwald et al., 2022), following these steps: 1). Data with over 10% of trials having latencies below 300ms were deleted; 2). Latencies exceeding 10000ms were removed without imputation; 3). The mean latency of all correct responses in each block with incorrect responses was calculated, and the latencies of incorrect responses were replaced with the mean score of the correct responses in the block adding a 600ms penalty; 4). Two quotients were calculated separately for the practice blocks and the test blocks, by subtracting block 5 mean latency scores from block 3 mean latency scores, and block 6 mean latency scores from those in block 4, and dividing the difference mean latency scores by their associated pooled standard deviation. This method allowed for higher scores to indicate a more positive value for the degree of association; 5). The PHSP-IAT index was obtained by averaging both the practice and the test blocks’ quotients, collapsing the data from both target-attribute combinations.

IBM SPSS statistics (version 28) was utilized for statistical analysis (IBM Corp., 2021). The even and odd trials in all blocks across participants were used to calculate the split-half reliability of the PHSP-IAT scores (Eisinga et al., 2012). The Spearman-Brown coefficient for equal-length halves was used as a measure of reliability (Eisinga et al., 2012).

The construct validity of the PHSP-IAT was assessed against both neighboring sexual function-related and non-neighboring day-to-day function-related constructs using the FSFI (Rosen et al., 2000; Ter Kuile et al., 2006), FSDS (Derogatis et al., 2002; Ter Kuile et al., 2006), PFC-PBI (Brand, Waterink, Rosas, et al., 2023), and QBPDS (Smeets et al., 2011) scales. Convergent validity is generally indicated by significant correlations higher than .40, and divergent validity is shown by significantly lower correlations (de Vet et al., 2020). Conducting parallel analyses, the Multi-Trait Multi-Method (MTMM) approach was used by merging the correlation analyses with principal component analysis, utilizing Promax rotation (Kappa = 4) to examine the construct validity of the PHSP-IAT. Additionally, a binary logistic regression analysis was performed to determine the PHSP-IAT’s predictive value regarding seeking help in PPT practice for sexual function problems.

Results

Data from 17 women were removed after applying the D600 algorithm during the IAT index calculations (Greenwald et al., 2022). The remaining data from 398 participants with a mean age of 31.26 years were included in the analyses. Table 2 shows the demographics and mean scores on key variables of the total sample, as well as pregnant, parous, and nulliparous women who did and did not receive PPT in this study. Two hundred and ninety-five participants were in a committed relationship with a male partner, nine with a female partner, and thirteen were dating. Four participants reported having multiple partners, while 77 participants did not have a partner. Of the total sample, 66 participants (16.58%) reported a history of sexual trauma. At the time of participation, 88 participants were receiving PPT. The PHSP-IAT index in the overall sample ranged from −1.682 ms to 1.081 ms.

Table 2. Demographics and mean scores of key variables in the total sample, and of (pregnant, parous, and nulliparous) participants receiving and not receiving pelvic physical therapy.

Sample	N	Age in years	Gestation Age of Pregnancy in weeks	Number of Children	Percentage of women receiving Pelvic Physical Therapy	Sexual Functioning	Psychological Burden	Sexual Distress	Pelvic Pain-related Daily Restrictions	PHSP-IAT Index
Ranges						0-30	0-60	0-48	0-100
Total Sample	398	31.26			22	20.14	14.64	12.21	13.74	−.530
Pregnant	46	31.04	25.93		54	20.28	14.85	12.12	25.54	−.441
Parous	117	32.43		1.56	37	19.79	17.34	14.45	15.23	−.527
Nulliparous	235	30.73			9	20.29	13.25	11.11	10.69	−.550
No Pelvic Physical Therapy	310	31.45				20.55	12.50	11.26	10.70	−.554
Pregnant	21	32.86	24.24			20.05	11.71	9.24	19.43	−.516
Parous	74	32.78		1.46		21.38	13.91	13.84	10.93	−.573
Nulliparous	215	30.85				20.31	12.10	10.58	9.76	−.551
Pelvic Physical Therapy	88	30.61				18.70	22.16	15.55	24.45	−.447
Pregnant	25	29.52	27.36			20.46	17.48	14.56	30.68	−.379
Parous	43	31.81		1.72		17.06	23.26	15.51	22.63	−.448
Nulliparous	20	29.40				20.04	25.65	16.85	20.60	−.530

Note. PHSP-IAT: Pursuing Help for Sexual Problems Implicit Association Test.

The mean latencies in blocks 3 of 1494 ms (mean SD = 854 ms) and 4 of 1305 ms (mean SD = 724 ms) were found to be lower than those in blocks 5 of 1961 ms (mean SD = 965 ms) and 6 of 1726 ms (mean SD = 914 ms). A learning effect in sorting the stimuli into the correct category can be observed within the two tasks based on the faster responses and the resulting lower mean latencies in test block 4 compared to test block 3 and those in test block 6 compared to practice block 5. The proportion of incorrect responses in block 3 was 7.17%, in block 4 it was 26.12%, in block 5 it was 7.39%, and in block 6 20.21%.

IAT reliability and validity

The Spearman-Brown coefficient yielded a split-half reliability estimate of .95 for the full-length PHSP-IAT. Further investigation of the IAT’s validity was conducted using the PHSD-IAT index. Consistent with IAT validation studies, Table 3 shows low and non-significant correlations between the PHSP-IAT and the self-report questionnaires (Gawronski & Hahn, 2019).

Table 3. Correlations between the Pursuing Help for Sexual Problems Implicit Association Test and the scores of neighboring and non-neighboring constructs.

	Measure	PHSP-IAT	FSFI	PFC-PBI	FSDS
Sexual Functioning	FSFI	−.026
Psychological Burden	PBI	.012	−.333***
Sexual Distress	FSDS	.002	−.297***	.501***
Physical Restrictions	QBPDS	−.088	−.229***	.606***	.261***

The MTMM analyses confirmed this finding. The KMO measure, which represented the sampling adequacy, was .629, and Bartlett’s test of sphericity was significant, χ² = 360, df = 10, p < .001. The PHSP-IAT emerged as a distinct component. The other component that emerged consisted of all self-report questionnaires. This outcome supports the divergent validity of the PHSP-IAT against the non-neighboring construct of physical restrictions, as measured by the QBPDS. However, Table 4 indicates that the PHSD-IAT did not demonstrate convergent validity with the neighboring constructs of sexual functioning, sexual distress, and the psychological burden of pelvic floor complaints.

Table 4. Pattern matrix of principal component analysis of the implicit association test indices and the selected validation measures.

	Measure	Component 1	Component 2
Implicit Associations	PHSP-IAT		.960
Sexual Functioning	FSFI	−.602
Psychological Burden	PFC-PBI	.869
Sexual Distress	FSDS	.712
Physical Restrictions	QBPDS	.719
	Eigenvalue	2.143	1.027
	% of Variance	42.868	20.544
	Cumulative %	42.868	62.412

There were no significant age differences between the groups of women who received PPT and those who did not, and thus age was not included as a predictor. The model resulting from the binary logistic regression analysis that was conducted to examine the predictive validity of the PHSD-IAT index for help-seeking was significant (χ² = 4.01, df = 1, p = .045). This outcome, along with the non-significant results of the Hosmer and Lemeshow tests (χ² = 7.83, df = 8, p = .450) indicated a good fit of the model with the data. Implicit PHSP associations were predictive of seeking help in PPT practice, B = .545, SE = .273, β = 1.73, p = .045 (95% CI = 1.01 to 2.94). Pursuing help was 73% more likely with one standard deviation (SD) increase in association strength.

Discussion

The present research examined the reliability and some validity aspects of the PHSP-IAT, specifically its ability to predict receiving help. The internal consistency of the IAT in this study was deemed excellent. However, the results from the validity assessment presented a mixed picture. Correlations between the PHSP-IAT and self-report measures were consistently low, a finding which is in accord with prior investigations (Gawronski & Hahn, 2019). The non-significant and low correlations demonstrated support for the PHSP-IAT’s divergent validity with the chosen construct of physical restrictions. However, the correlations did not support the hypothesized convergent validity with the sexual function-related questionnaires. Possible explanations for these findings are discussed below.

Theoretically, low and non-significant correlations between an IAT and self-report questionnaires could be attributed to an IAT’s low internal consistency (Gawronski & Hahn, 2019). However, this explanation for the validation outcomes is contradicted by the excellent internal consistency of the PHSP-IAT. Despite the anticipated overlap between the PHSP-IAT target categories of sexual health and sexual function problems and the contents of the FSFI, FSDS, and PFC-PBI, which all focus on the presence and severity of sexual function problems and associated distress, the correspondence was not as expected. This lack of correlation may be attributed to the PHSP-IAT’s attribute category of pursuing help, which does not overlap with the content of any of the chosen neighboring constructs. In addition, women were unable to self-report motivation to seek help in the chosen self-report questionnaires. Consequently, this may have increased the distance between the measured constructs, resulting in low and non-significant correlations. This rendered the chosen questionnaires less related than originally assumed based on their sexual function-related content (Gawronski & Hahn, 2019). Thus, the PHSP-IAT might not capture the same construct at an implicit cognitive level as the explicit self-reported questionnaires (Gawronski & Hahn, 2019). More research is needed to refine and modify the PHSD-IAT and to further assess its usefulness in scientific research and clinical practice. Furthermore, its validity against other self-report questionnaires needs further examination to better understand the construct it measures, as well as the significance of more positive or negative indices.

Furthermore, it has been argued that IATs mainly reflect the cognitive activation of automatic associations between a target stimulus and an attribute stimulus, such as sexual function problems and the inclination to pursue help for participants in the current study, rather than the tangible expression of these associations as physical help-seeking behavior for sexual function problems (Gawronski & Hahn, 2019). Such automatic associations can trigger action readiness to emotionally respond to perceived stimuli (Frijda, 2010; Henckens et al., 2020). This perception initiates analytic cognitive processes whereby the stimulus is coded to previous causes and consequences. In this context, sexual function stimuli are regarded as emotional stimuli and sexual behavior may manifest in thoughts, fantasies, and an array of physical actions (Frijda, 2013). Based on this theory, in this study, the stimuli for sexual function problems are evaluated based on the sensitivity and needs of participants. Comparing these stimuli to personal experiences can potentially evoke the belief that it is beneficial to act upon the presented information. Subsequent appraisal of the urgency, difficulty, and severity of the evaluation will determine the need for action, resulting in the generation of an action plan (Azar et al., 2013; Frijda, 2005). The PHSP-IAT offers an action recommendation by presenting attribution stimuli for pursuing help. Faster responses could be interpreted as a stronger implicit belief that help is beneficial or action readiness to act upon the presented stimuli.

It has been suggested that conscious processing of information during an IAT can impact validation outcomes (Gawronski & Hahn, 2019). This suggests that explicit judgments can overrule automatic associations. In such cases, the correlations between an IAT with inconsistent information and self-report questionnaires are likely to increase instead of decrease due to the higher probability of deliberate processing, which allows associations to be explicit rather than implicit (Gawronski & Hahn, 2019). However, the absence of significant correlations in this study suggests that the PHSP-IAT may not contain inconsistent information. This suggests that the PHSP-IAT may be more valuable for collecting information that cannot be acquired via self-report questionnaires, despite possible underestimation of its validity due to the absence of significant correlations (Gawronski & Hahn, 2019). Alternatively, it is conceivable that the associations as evaluated in this specific IAT align with women’s self-reported psychological burden, which predicts receiving help in PPT practice. This suggests that psychological factors that contribute to pursuing help should not be disregarded.

Another counterintuitive finding was that the responses to combined sexual health and pursuing help stimuli were faster compared to those between sexual dysfunction and pursuing help stimuli. This was unexpected with the latter combination being more logical and intuitive than the former. Note must be taken that an increase in latencies might have been due to increasing cognitive fatigue during the test resulting in longer increased latencies toward the end of the test (Wolfs, et al., 2023). This finding also resulted in predominantly negative values of the IAT indices that represent the degree of association between the target and attribute stimuli. These negative PHSP-IAT indices would suggest a weaker association between sexual dysfunction and not pursuing help, assuming a zero-neutral reference point on the IAT index. Accordingly, positive IAT indices would indicate stronger, and negative indices weaker association between sexual dysfunction and pursuing help. However, with the use of this new IAT, the absence of normative data for interpreting the IAT indices needs to be considered. The PHSP-IAT indices are relative measures because the metric of implicit measures is arbitrary, and the neutral reference point in the PHSP-IAT is unknown (Gawronski & Hahn, 2019). Thus, it can be argued that more positive indices represent a stronger association between sexual dysfunction and pursuing help, and reflect a stronger implicit belief that it is beneficial to pursue help for sexual function problems, despite a negative IAT index value.

Another factor to consider regarding the lack of correlation between the PHSP-IAT and the selected self-report sexual function and distress questionnaires pertains to the participants’ characteristics. The study sample comprised women with and without PFC and varying levels of sexual functioning. Women with PFC also tend to report sexual function problems (Brand, Waterink, & van Lankveld, 2023). Discussing sexual functioning in clinical practice is challenging, due to the prevailing conspiracy of silence surrounding this taboo, private, and intimate subject (Leusink et al., 2023). Consequently, combining sexual dysfunction and pursuing help stimuli may have accounted for longer reaction times because pursuing help for sexual function problems requires discussing the topic in clinical practice. The negative PHSP-IAT indices due to the longer reaction times in blocks 5 and 6, where the stimuli from these particular categories were combined on the same key, could potentially reflect the result of deliberating options. Distress related to sexual function problems, including shame, embarrassment, and confrontation, and any potential reluctance to openly discuss the subject may have caused an additional delay in reactions due to a lengthier cognitive appraisal and interpretation of the presented stimuli.

Stronger implicit associations between sexual function problems and the inclination to pursue help, indicated by more positive PHSP-IAT indices, significantly predicted receiving help in PPT practice. Weaker implicit associations between the two categories decreased the likelihood of women receiving help. This finding contributes to our insight into why women receive help for sexual problems that are often overlooked and undertreated. Findings may also help to make sexual function problems more openly discussable despite all the obstacles involved. The discovery that women who receive help in PPT practice have a stronger implicit belief that pursuing help for sexual function problems is desirable, raises follow-up research questions about the role and relative influence of implicit processes and explicit opinions and decisions related to seeking help.

Strengths and limitations

The first strength of this cross-sectional study is its large sample size which has resulted in increased statistical power. Based on the present cross-sectional data, the predictive value of the PHSP-IAT suggests the involvement of implicit cognitions concerning sexual function problems and pursuing help in PPT practice. The stronger implicit associations between these two constructs in women who receive help may reflect a stronger implicit belief that help is beneficial compared to women who do not receive help. The cross-sectional study design, and retrospective analyses of the predictive value of the PHSP-IAT for receiving help could be seen as a limitation because of the lack of information about the onset or increase in severity of sexual function problems, and consequential changes in beliefs and behavior. Therefore, the PHSP-IAT’s prospective predictive validity should be examined in future research using a longitudinal study design. This could yield information about the influence of intrinsic motivation during women’s decision-making processes. This could, for example, be studied among women with sexual function problems who did not (yet) receive help, monitoring their help-seeking behavior over a prolonged period, using repeated measures.

Another limitation concerns the generalizability of the present findings, because the sample of participants may not be representative of the general population regarding the level of sexual functioning and help-seeking behavior in PPT practice. Furthermore, the data was collected in the Netherlands, which does not render the outcomes representative of women in other countries and cultures.

Finally, not counterbalancing blocks three and four with five and six among participants may be seen as another limitation because counterbalancing blocks are deemed desirable. Not counterbalancing the blocks might have influenced the value of the IAT indices. In this IAT, we chose not to counterbalance the blocks because, for this newly developed practical IAT, we had no idea how many respondents we would get, we were uncertain of the location of the zero-point of our IAT, and we did not know whether this IAT would be correlated at all to the self-report measures we chose to validate the IAT, based on sexual content only. Based on the evidence that hypotheses including new (practical) IATs can be tested satisfactorily without counterbalancing blocks when the zero-point is not critical, and because the order effect of the blocks was expected to have little effect on the correlations with other measures, we decided against counterbalancing the blocks at this stage of our scale development (Greenwald, et al., 2020). Counterbalancing the blocks in a new study with this PHSD-IAT could answer the question if this choice was warranted. In addition, we mapped both positive stimuli on the left key in blocks 3 and 4, rather than the right key, to avoid potentially faster responses as a result (Greenwald, et al., 2022). Within each practice and test block, stimuli were presented in random order to increase the effect of procedural variation.

Conclusion

The PHSP-IAT appears to be a reliable instrument to measure implicit associations between sexual function problems and pursuing help. However, the evidence concerning its convergent and divergent validity is unclear. Utilizing this IAT, implicit associations were found to predict women’s help-seeking behavior.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data is available under DOI: https://doi.org/10.17605/OSF.IO/268CP

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.