Are Digital Interventions the Next Frontier in Sex Therapy? A Mixed Methods Study Examining Attitudes toward Digital Sex Therapy

Abstract Digital health interventions can address governments’ aims of providing better care, better outcomes, and lower costs. No previous research has examined attitudes toward digital sex therapy to understand what might facilitate, or hinder, the uptake of these interventions. This sequential mixed-methods study with qualitative structured interviews (n = 27) followed by a quantitative survey (n = 334) aimed to understand participants’ expectations and attitudes toward digital sex therapy interventions. Participants reported a mixture of positive and negative attitudes to digital sex therapy. More positive attitudes, higher education level, and previous engagement in therapy predicted greater openness to using these interventions.


Previous research on attitudes to digital therapies
The Unified Theory of Acceptance and Use of Technology (UTAUT) model (Venkatesh, Morris, Davis, & Davis, 2003) was developed as a framework to evaluate the potential acceptance of new technologies in the future.The model accurately predicts 70% of the variability in the variance in acceptance, adoption, and usage of technologies (for reviews see, Dwivedi et al., 2021;Venkatesh, Thong, Xu, Hong Kong University of Science & Technology, & The Hong Kong Polytechnic University, 2016) and has been used to understand attitudes toward online psychotherapies (Apolinário-Hagen et al., 2018).The model suggests that there are four main factors that determine the use of technology: performance expectancy, effort expectancy, social influence, and facilitating conditions (Békés, Doorn, & Bőthe, 2022;Venkatesh et al., 2003).Performance expectancy refers to how much an individual believes a technology will help them and effort expectancy refers to how easy the application is to use.Social influence, on the other hand, refers to an individual's belief of whether others think they should use the technology.Finally, facilitating conditions refer to available support to use the technology.Attitudes toward the technology were suggested to influence these four factors and have been subsequently shown to be an important predictor of behavioral intentions and subsequent usage (Dwivedi et al., 2021).
In the present study, we use the model to guide the research.
A meta-analysis examining 92 online digital psychotherapies across a variety of outcomes found an effect size comparable to face-to-face therapies (Barak et al., 2008).Thus, the results suggest that digital therapies have the potential of being equally effective compared to in-person treatments and can provide a low-cost alternative which is more easily accessible.Despite the effectiveness of digital therapies, research has shown poor adoption of digital health services worldwide indicating low levels of acceptability and intention to use, potentially constituting a barrier to reaching the full potential of these services (Apolinário-Hagen et al., 2018;Klein & Cook, 2010;Mohr, Riper, & Schueller, 2018;Musiat, Goldstone, & Tarrier, 2014;Wahbeh, Svalina, & Oken, 2014;Wallin, Mattsson, & Olsson, 2016).The reasons for the poor adoption of digital interventions are not well understood but some research has suggested that positive attitudes and preferences toward digital health services can improve adoption of digital therapy (Apolinário-Hagen, Kemper, & Stürmer, 2017;Casey, Joy, & Clough, 2013;Klein & Cook, 2010;March et al., 2018).Recently, Békés et al. (2022) found that expectation of therapy quality, convenience and ease of use, and pressure from others were significantly positively associated with the intention to use digital services for psychotherapy in the future supporting the UTAUT model.Research has also found that while patients often prefer face-to-face therapies (Apolinário-Hagen et al., 2018;Klein & Cook, 2010;Musiat et al., 2014;Wallin et al., 2016) over online treatments, they are open to trying online treatment options (Békés et al., 2022).Other studies have also found that users prefer guided over non-guided digital treatments (Apolinário-Hagen et al., 2018;Casey et al., 2013;Klein & Cook, 2010;Musiat et al., 2014).
Digital interventions addressing sexual issues have similarly increased alongside other online treatments.These interventions often target a specific diagnosis of sexual dysfunction such as erectile dysfunction or rapid ejaculation in men (Van Diest, Van Lankveld, Leusink, Slob, & Gijs, 2007), low sexual desire in women (Brotto, Stephenson, & Zippan, 2022;Hucker & McCabe, 2015;Jones & McCabe, 2011;Stephenson, Zippan, & Brotto, 2021;Zippan, Stephenson, & Brotto, 2020), or sexual desire discrepancy in couples (Vowels, 2022a).To our knowledge, very few studies exist that have attempted to understand potential reasons for adopting or using sexual health interventions.Zippan et al. (2020) and Vowels (2022b) examined feasibility and usability of digital sex therapy interventions among participants who have chosen to participate in these interventions but do not explicitly address people's attitudes to digital sex therapy interventions.There are prior studies that have explored attitudes toward sex therapy in general, which may also be applicable to digital sex therapy.Overall, research has found that the general public has little knowledge about what exactly sex therapy is and their attitudes are often shaped by pop culture messaging (Gott & Hinchliff, 2003;Sever & Vowels, in press).A recent study found that many participants had negative attitudes and beliefs about sex therapy, poor understanding of what it would involve, and viewed sex therapy as a last resort (Sever & Vowels, in press).It is likely that the poor knowledge of sex therapy treatments and reluctance to seek help for sexual difficulties may contribute to poor uptake of digital sex therapy interventions.

The present study
Previous studies have shown that while sexual difficulties are incredibly common in the general population, only around 20% of people seek help for the difficulties (Hobbs et al., 2019).It may of course be that the sexual difficulties are not associated with distress or that, at least for some people, the difficulties improve over time without the need for treatment.However, it's probable that many individuals who would opt for treatment for sexual difficulties continue to face challenges without seeking help, likely due to numerous obstacles hindering their access to care.Hobbs et al. also found that despite online treatments being effective for a range of sexual dysfunctions, only between 22-25% of people who sought help for their sexual difficulties did so online.It is well-established that attitudes toward therapy have implications for the usage of these services.Therefore, to better understand how to help people to access these online treatments, it is important to better understand the general public's attitudes toward the intervention (Andersen & Newman, 2005;Fung & Wong, 2007).In the present sequential mixed-methods study, our aim was to provide a thorough understanding of people's attitudes toward digital sex therapy services.By gaining insight into how the general public perceives digital sex therapy services, we hope to dispel myths and improve interventions that can address reasons that might deter individuals from accessing these services.First, we conducted structured interviews with 27 participants to gain an in-depth understanding of participants' attitudes to digital sex therapy.We then conducted a larger online survey (n = 334) to understand how prevalent these attitudes were in the general population and whether there were any demographic characteristics that affected attitudes toward digital sex therapy.Across the two studies, we aimed to answer the following questions: 1. What are the expectations about what digital sex therapy involves (Study 1, expectation of time in Study 2)? 2. What are the attitudes toward digital sex therapy (Studies 1 and 2)? 3. Are there specific factors (gender, age, education level, prior experience with sexual issues, and prior attendance in therapy) that predict more positive (vs.more negative) attitudes or openness to using digital sex therapy (Study 2)?Based on the previous literature, we expected that women, younger people, more educated people and people with prior experience of sexual difficulties or therapy would hold more positive attitudes to digital sex therapy and be more open to trying them.4. Do more positive attitudes toward digital sex therapy predict openness to using digital sex therapy in the future (Study 2)?

Study design and participants
A total of 30 participants were recruited for the study.We used quota sampling to ensure heterogeneity with respect to age and gender.Informed consent was gained from all participants and the study was approved by the ethical committee of the first author's institution.One participant was excluded due to technical difficulties impacting interview sound quality and two participants were excluded due to difficulties with English.'Brien et al., 2014).

Procedure and interview questions
Recruitment took place between May and June 2021 through UserTesting.com,an online qualitative data collection platform for new applications and products.Participants were eligible to participate if they were currently engaged in a romantic partnership and if the participant or their partner had a current or previous history of sexual problems, defined as, "issues with your sex life in the past", with no specific timeline stated for the required duration of the sexual problem/s.Participants who did not speak English well enough to understand the transcripts were excluded.Unmoderated structured interviews (i.e., an interview in which there is no interviewer) were anonymously conducted online via the UserTesting platform to explore attitudes seeking sex therapy in response to the questions 1) Could you imagine doing sex therapy in an app format?, 2) If so, what do you imagine that app will be like?, 3) How quickly would you expect to notice the benefits from a sex therapy app? and 4) Do you think using a non-human app would be easier or more difficult than going to a sex therapist?In what ways?Other questions relating to barriers and attitudes to traditional sex therapy (in-person) was deemed outside of the scope of this study and not included in the analysis.The full interview protocol along with all participants' responses can be found on the Open Science Framework: https://osf.io/y6ksx.Completed interviews were transcribed using artificial intelligence software, and this was later moderated by a research assistant for errors.Participants received $10 directly via UserTesting after completion of the interview.

Data analysis
Qualitative interviews were analyzed using reflexive thematic analysis (Braun & Clarke, 2006, 2019) and an inductive approach to coding.Codes were created throughout the coding process by coding each meaning unit which varied in length and frequency.These codes were then refined iteratively until they converged onto the final themes.'[…]' was used in the quotes if unnecessary detail has been removed.Repeated filler words such as 'like' and 'yeah' were excluded to aid the readability of the quotes.All identifying information was removed.

Results
The results are structured around five main themes: expectations about therapist involvement, expectations about the format of digital sex therapy, positive attitudes toward digital sex therapy, negative attitudes toward digital sex therapy, and openness to using digital sex therapy.Each theme included several subthemes discussed in the following sections under the theme subheadings.

Expectations about therapist involvement
The participants had varying perceptions of what a digital sex therapy app would entail.Some participants expected it to include connecting with a real therapist either via a video call or a chat.They imagined that this would either take the form of using facetime, zoom, skype or phone call to get instantly connected with a therapist: "I feel like it would be an app that connects you to an actual therapist".The participants wanted to be able to communicate with a therapist in real-time and get personalized advice.One participant stated, "I feel like some of the hardest stuff about some self-help apps and stuff with counselling and whatnot can feel really detached to make it feel like your problem isn't anything, so I would definitely say real-time conversation." A few participants expressed a preference for non-face-to-face communication and suggested a chat room or messaging feature to interact with a therapist or expert, with the ability to opt-out as an option.
…wouldn't really require face to face, I wouldn't like video chat or anything.But if there was just a messaging section and we connect you with your therapist, and you would just be texting back and forth.I would be comfortable with that.
Several participants had prior experiences with other therapy apps like Talkspace, which provide video calls and chat services.These experiences influenced their expectations, which included a quick response time for messages.Some participants also wanted to be able to have an option of multiple therapists and to have the ability to change therapists if needed: I would want to be able to choose the therapists or maybe pay a monthly fee and then maybe I could jump around to different therapists.Something like that.I think that' d be really nice, but not being tied down to one individual.
While most participants expected digital sex therapy to involve talking to a therapist, there were also some participants who imagined digital sex therapy to include non-real time content, often taking a form of unguided psychoeducation or physical exercises.Imagined examples of psychoeducation included "question and answer" -type responses to problems; diagrams, pictures, or instructional videos; a blog section with articles or posts to give insight into different issues; and/or providing links to websites and books for further information: Pages with different information on them, links to websites, to books to somebody that you can talk to if you want to talk to somebody face to face or over video chat, and testimonials experiences about people who had problems, and though they're living their best lives, that kind of thing.
Additionally, some participants expected user testimonials to show that they were not alone, and other people were experiencing similar difficulties: "…testimonials and stuff like that so you would read something, and you would go, okay, other people have been in this scenario, I'm not alone".They additionally wanted the unguided content to help increase their comfort with sex and alleviate negative feelings: "Valuable things I'd like to get in would be feeling more comfortable to have sex with my husband with feelings of guilt and shame from my past."

Expectations about the Format of Digital Sex Therapy
In addition to the expectations of whether the app would involve live interactions with a therapist, participants talked about many other aspects that they expected such as personalization, look, cost, and time.Participants expected digital sex therapy to be personalized, or to have control over how to use and engage with the service.They mentioned that an app would use a questionnaire or a quiz to determine each partner's issues, which would then be analyzed and would inform the subsequent approach and advice received.They wanted to go "through the program at [their] own pace" and to have an option of having their partner to join if the issue was dyadic.One participant talked about how they imagined the app to anticipate their needs and be there when they needed the support: I would definitely say having it also be maybe on a, you can plan days where you're expected to kind of come in and at least go back and forth.But I think it would be a lot easier to have it be based around the client's needs.So, like two days before being like, "Hey, have you feeling really down about this recently, can we get a session" and something like that might be really nice for them to instead of feeling like you have to book something, two months ahead of time, and then, you know, you're waiting around.
One participant, who identified as a member of the LGBTQIA + community, expressed a desire for the digital sex therapy content to be relevant to their experiences and needs: I just think that it needs to be catered to every individual.So, it shouldn't be based on heteronormative relationships.And because I'm part of the LGBT community, and I'm in an LGBT relationship, so I would really appreciate if there was something like this to happen or to evolve that is inclusive for everyone.
In addition, some participants expressed their preferences for the visual appearance of the app.They emphasized the significance of a professional and polished look to increase credibility and their trust in the app: "I think if it's the type of app that looks like it's unprofessionally made I it would make me doubt the services.So, I think it would have to look professional, be very modern and feel progressive." They also wanted the app to be easy and simple to use.For example, one participant stated that "It would be really easy to use, and lots of kind of visuals and happy can have motivational things." And another one said "Big buttons, simple screen, you know what to do, nothing complicated.No ads.No drop-down simple stuff." Participants also discussed their expectations regarding the cost of digital sex therapy services.They strongly indicated that they did not want to feel as though they were wasting their time or money.They wanted the service to be low risk, something they could try out without an initial big financial commitment.Many participants suggested a monthly or per session type of fee system.Participants were also not inclined to pay money for the service initially and would prefer a free trial: "I don't think it's going to be something that people will easily just want to start using, especially if it does cost money up front." Another participant stated: "definitely maybe like a free week trial, I would definitely try it out.And then if I feel like it's helping, I would not be opposed to continue using it or paying for it." Other participants also talked about the high cost of sex therapists in general and said a digital sex therapy service would need to have a reasonable price that ideally would be covered by health insurance: "Reasonable price, because what can deter people from seeing a sex therapist is the high price." Participants had varied expectations regarding time.Some of the participants expected improvements to take longer if there was no contact with a therapist: "I would expect it [to take a] little longer than regular therapy, just because it takes away from that emotional, interconnected, human standpoint."However, other participants believed that they would see improvements faster because they could engage with it more frequently than seeing a therapist physically: "if I'm using an app, I can be using it more frequently than a physical therapist, I would believe so, I would really hope that it'd be faster than if I was going in person." Overall, participants' expectations of how long it would take to improve varied from a week to several months, but they expressed a need to notice some positive improvements quickly or they would lose motivation to continue: "I guess I'd like to see some kind of benefits fairly quickly to make it worthwhile doing or continuing."

Positive attitudes toward digital sex therapy
There were several positive attitudes toward digital sex therapy: increased privacy, reduced stigma/embarrassment, accessibility, and simpler to commence.Privacy was an important element in accessing sex therapy services and talking about such a sensitive issue for many participants.They talked about how they would feel more comfortable accessing sex therapy services through an application where they could stay anonymous and would not have to reveal identifying information about themselves.For example, one participant mentioned: If you could just have a username, not your real name that would be so much more helpful because if I know that the person on the other side of the of the app doesn't really know who I am, I mean, he or she doesn't know my name, my face, where I live, where I work, and so on and so forth.It would be so much more comfortable with me because I'm 100% sure it's gonna be confidential.
Another important element of digital sex therapy was reduced stigma and feeling like it would be less embarrassing.Participants felt that talking about sex was something secretive, something that people would not want the world to know they had issues with: "I am going to say that that is probably easy for some people once again, they want to do it alone.It's very secretive thing.Not a lot of people are out there telling what to tell the world that they have sexual issues." Some participants felt that engaging with an app could be especially helpful if someone was self-conscious or did not feel comfortable sharing openly with a therapist: I can totally understand how people would like to do it in an app format, the ability to not have to look someone in the eye and tell them what you think is wrong about yourself or situations you've been in that might have led up to why you feel this way about yourself and your sex life.
Participants also felt that digital sex therapy would be more accessible than a sex therapist.Doing sex therapy in an app format could be engaged with from the comfort of one's home where one feels safe, and it would be immediately accessible instead of having to find or wait for a therapist to be available: And easier again, in terms of you wouldn't have to travel there, you wouldn't have to say it was a secret.And where you're going to tell your friends and family where you're going.Whereas if you've got an app, I guess you could just go to your bedroom and use the app.So, for confidential reasons, that would be good." They felt that it would increase access to sex therapy services for everyone, even in places where sex therapy would potentially otherwise not be available "I think perhaps in Muslim countries, I mean, a sex therapist, I think that just would be like, way off the wall.Like, never gonna happen, but an app that might give people a chance to find some help".Accessibility of the service also overlapped with privacy: participants felt that being able to engage with an app from home would feel more confidential and more private than going to a sex therapist.
Finally, some participants also felt that digital sex therapy would be simpler to start and lower stakes or lower risk compared to face-to-face sex therapy.This overlapped with the stigma associated with sex therapy and embarrassment that people might feel engaging with a sex therapist.Interacting with an app felt easier: I can see the benefit, where it's, super low awkwardness, when you're really just kind of dealing with a screen, you're not looking at anybody, they're not looking at you, you can just kind of type and talk.That seems like it lowers the barriers, and some of the apprehension that would come with getting some type of sex therapy treatment.
The idea of an application being simpler to start with also overlapped with the accessibility: it was perceived to be something immediately available leaving little opportunity for avoidance: Because a lot of the times we may think, hey, I want to start a diet and you just postpone it.And by the time you have to start it, you no longer feel like it.And I think it goes the same way with this.I think if you're in the mindset and the moment of just wanting to get started, then I think that's the best moment you'll ever get.And I think in a way, it would be a bit easier than having to arrange a phone call or video call or you know, going in person.
Some participants also felt that digital sex therapy could also serve as an intermediary source of help that could aid them in deciding whether they would need to connect with a sex therapist: "And maybe it may also help you decide whether you actually need a therapist."

Negative attitudes toward digital sex therapy
In addition to positive attitudes toward digital sex therapy, there were also several negative attitudes toward the digital format.These included feeling that digital sex therapy would be less effective due to lack of human connection, lack of accountability, and being too generic.Other participants also distrusted technology.One participant said they were open to trying an app but would not expect it to be as effective without human interaction: "I probably would do it, but I also wouldn't expect to receive the same level of help, let's say as with a direct human to human interaction." Some participants had a clear preference for engaging with a real person.They felt that engaging with an app would lack human connection.For example, one participant stated: "I feel like in person is more of a personal connection kind of thing that needs to happen if you go to therapy".There was an overall expectation that an app would not reach the same level of depth as a therapist and thus it would not be as helpful.Another reason cited by individuals as to why a digital sex therapy application may not be as effective is due to the lack of accountability: "There's no one you're coming back and reporting to week after week" and "…we just forget about it.You know, okay, I'll do this for four days, and then I'll stop because I don't feel like it today." Some participants also expected that the advice would be too generic and thus it would not address their circumstances: "I just feel like with an app, it's gonna be so general, and not personal to what's going on in your life.I still think face to face therapy is going to be the best" and another participant said "Sex therapy is valuable and helpful.And I would never use an app for that.It's way too personal." Finally, some participants felt they distrusted technology and would not trust a bot or AI to give them advice about their sex life: "Who wants a robot telling them how their sex life should be better?No one".And while most participants felt that engaging with digital sex therapy would be more private, some were also concerned about typing intimate details into a computer or an app: "I would be a little bit concerned about typing those intimate details into my computer or my app."Privacy and security were clearly paramount for many participants.

Openness to using digital sex therapy
Overall, negative attitudes toward using digital sex therapy services often depended on what the participants' expectations were about what the app would involve.When participants perceived the digital sex therapy app as a means of communicating with a human therapist, they exhibited more favorable attitudes.Conversely, if they perceived it as being delivered by a robot or AI, they were less inclined to participate.Thus, people were more likely to be interested in using the app for sex therapy if they viewed it as a mode of therapy that involved talking to a real therapist in an online or app-based setting.However, most participants were open to trying or engaging with digital sex therapy, despite any reservations they may have because of the perceived low risk/stakes involved: "I would consider going through sex therapy just out of sheer curiosity.The barriers are so low, the stakes are low.You know, a lot, all the things I've talked about before are really low, so I don't see much negative and trying it." and "I would try it just because I'm curious.I wouldn't expect a lot out of it." Some participants said they would try the app if there was a free trial and then if they experienced the app helping they would be open to paying for it in the future: "Definitely maybe like a free week trial, I would definitely try it out.And then if I feel like it's helping, I would not be opposed to continue using it or paying for it." Study 2: survey data

Procedure and materials
Participants were recruited through an online data collection service, Prolific.Participants were invited to participate in a study asking about their attitudes toward digital sex therapy services.They were eligible to participate if they were aged 18 or over and spoke fluent English.Ethical approval for the study was obtained from the first author's institution.All participants were provided with an informed consent in which they were explained what the study involved.If participants agreed to participate, they were directed to complete a 5-min survey through the survey platform Qualtrics.Participants were asked information about demographic variables, whether they had previously struggled with sexual difficulties, and whether they had had previous experiences with therapy or sex therapy applications.
They were then asked about their attitudes toward digital sex therapy using the Attitudes toward Digital Sex Therapy scale.To ask participants about their attitudes to digital sex therapy, we modified the Attitudes Toward Guided Internet Interventions Survey (Apolinário-Hagen et al., 2018) which was modified from the original e-therapy attitudes measure (ETAM; .The original survey consists of 17 items and can be divided into two subscales: perceived usefulness and helpfulness scale (seven items) and relative advantage and comparability scale (ten items).The original scale reliability for the full scale was α = .92.We also had 17 items for the modified scale and the main changes included changing the prompt "internet-based therapies" to "digital sex therapy".Sex therapy and digital sex therapy were defined as "sex therapy applications [that] usually provide a mixture of listening sessions to learn about sex and practical sessions where users can either talk with their partner or do touch exercises alone or together with a partner."Example items include "Digital sex therapy will replace conventional face-toface sex therapy in the future."and "Digital sex therapy will reach more individuals with sexual problems".The items were rated on a Likert scale ranging from 1 "strongly disagree" to 5 "strongly agree".We used the predefined cutoffs from the original scale: mean scores of <2.5 (median values of 1 or 2) were defined as negative, values between 2.5-3.49(median score of 3) as neutral, and values ≥3.5 (median values of 4 or 5) as positive attitudes toward digital sex therapy.

Participants
Our aim was to collect a total of 300 participants with an equal number of men and women.We expected the sample size to be sufficient to provide basic information about attitudes toward sex therapy services and to perform simple analyses comparing different groups on whether their attitudes differed based on certain characteristics previously shown to be important predictors of attitudes toward services.We also conducted a sensitivity power analysis which showed that we had a power of 0.8 to detect an effect size of f 2 = 0.019 which is a small effect size (equivalent to β = .10-.19).
A total of 340 people entered the survey but six people did not begin survey completion.Therefore, final sample consisted of a total of 334 individuals (163 women, 169 men), all of whom completed the full survey.On average, participants were 38.68 years old (SD = 13.09,range 18-77).Around half the participants were cohabiting or married (47.3%) with 27.5% of the participants being single.The participants were mostly white and had at least an undergraduate degree.A minority of the participants reported having a previous sexual problem in the past 12 months (11.4%) and 19.8% had ever attended therapy (6.0% for sexual problems).Only 1.2% had tried a sex therapy app before.For the full list of demographic variables, please see Table 1.Note.Some of the percentages do not add up to 100% due to missing data.

Data analysis
All analyses were conducted in R and the code for the analyses can be found on the OSF project page: https://osf.io/y6ksx.First, we performed an EFA to examine the factor structure of the 17 items of the scale.The results from the scree plot were inconclusive: the Eigenvalues (>1) suggested a four-factor solution, parallel analysis suggested a three-factor solution, and the elbow of the scree plot (acceleration factor) suggested a one-factor solution.None of the solutions suggested a two-factor solution consistent with the original scale.We examined the three different options using principal axis factoring: one-, three-, and four-factor solutions.When we examined the three-and four-factor solutions, there was high cross-loading on some of the variables and thus we opted for the one-factor solution.The one-factor solution showed good reliability; α = .83.The primary purpose of the study was not to develop a scale for assessing attitudes to digital sex therapy but rather to examine attitudes toward digital sex therapy more holistically.Therefore, we only used the full scale to examine whether there are differences in the overall attitudes based on several variables (gender, age, education level, sexual issues, or prior attendance in therapy) as it would not be meaningful to examine differences for each scale item.These demographic variables were selected based on prior research suggesting differences in attitudes based on these factors.Analyses examining differences in attitudes based on gender, age, education level, previous sexual issues, or prior attendance to therapy were conducted using multiple regression.We used logistic regression to analyze whether attitudes predicted greater intention to use digital sex therapy.

How quickly would participants expect change to occur (Expectations; RQ1)?
Most of the participants expected results in 2-3 wk (n = 73), within one month (n = 88), or within a couple of months (n = 88) but the answers ranged from within a week (n = 6) to never (n = 31).

What are the Overall Attitudes toward Digital Sex Therapy (RQ2)?
The means, medians, and standard deviations for each scale item can be found in Table 2. Out of the 17 items, participants rated 7 items as positive, 8 items as neutral, and 1 item as negative.The participants agreed that compared to traditional therapy, digital sex therapy was more in line with modern times, more compatible with work-life balance, would reach more individuals, makes it easier to speak about important issues, and allows users to receive help earlier.
Participants also agreed that digital sex therapy would be suitable for most people and provides an appropriate alternative.
Participants were neutral about whether digital sex therapy would replace face-to-face therapy in the future, whether there is a difference in efficacy between the two, whether health insurance companies should pay for it (note: most participants were from the UK where health care is free and not insurance based), whether they would prefer or engage with digital sex therapy themselves, and whether there would be misunderstandings equally often in digital sex therapy compared to face-to-face therapy.
Only one item was rated as having negative attitudes related to worries about data security, which showed that the participants were worried about data security of digital sex therapy.

Do more positive attitudes predict openness to using digital sex therapy in the future? (RQ4)
Overall, 201 (60.7%) participants said they would consider using a digital sex therapy intervention if they had a sexual difficulty compared to 130 (39.3%) who said they would not.The results of the logistic regression analysis indicated that the more negative attitudes participants had about digital sex therapy, the less likely they were to consider using a digital sex therapy app in the future (β = −3.07,p < .001).Additionally, we also examined whether different people were more open to using a digital sex therapy intervention.We found that participants who were more educated were significantly more likely to be open to using a sex therapy intervention compared to participants who were less educated (β = −0.23,p = .007).This shows that, for example, participants with only an undergraduate degree scored −0.23 points lower than a participant with a postgraduate degree in openness to using digital sex therapy interventions.Participants who had previous experiences in therapy were also significantly more open to trying a digital sex therapy intervention compared to participants who had no previous therapy experiences (β = 0.83, p = .008).The results were not significant for age (β = 0.00, p = .629),gender (β = −0.18,p = .432),or having had a previous sexual issue (β = 0.61, p = .116).

General discussion
Digital health interventions have become an important avenue for organizations and governments to attempt to meet their targets for providing better care, better outcomes, and lower cost of health care (Berwick, Nolan, & Whittington, 2008).However, while previous research has shown benefits of digital interventions (e.g., Cuijpers, Donker, van Straten, Li, & Andersson, 2010;Domhardt et al., 2021;Goodarzi, Jafari, & Moradi Shaykhjan, 2022;Hobbs et al., 2019;Topooco et al., 2022;Zippan et al., 2020), these interventions often struggle to attract users in the first place and to keep their users engaged resulting in high dropout rates (Zarski et al., 2022).The Unified Theory of Acceptance and Use of Technology (UTAUT) model (Venkatesh et al., 2003)  Digital sex therapy will replace conventional face-to-face sex therapy in the future.3.15 (1.06) 3 3.
Digital sex therapy is more compatible with work and private life than conventional face-to-face sex therapy.
3.83 (0.86) 4 4. it makes no difference to me whether sex therapy is conducted through the internet or in a sex therapy practice in a clinic.
health insurance companies should cover the costs for digital sex therapy.
Digital sex therapy programs are as effective as conventional face-to-face sex therapy.
trust in a sex therapist can be just as easily built on the internet as in conventional face-to-face sex therapy.aims to provide a unified framework to evaluating acceptance of new technologies.In the present mixed-methods study, we used the framework to understand participants' attitudes toward digital sex therapy interventions.Due to the often taboo and stigmatized nature of sexual difficulties, interventions may be particularly useful in treating these issues (Cooper & Mcloughlin, 2001;Hobbs et al., 2019), but more work is needed to understand how to improve user uptake and engagement for these interventions (Andersen & Newman, 2005;Fung & Wong, 2007).
Our first aim was to understand the expectations people had regarding digital sex therapy interventions.Most of the participants in Study 1 expected the interventions to essentially provide therapy services with a real therapist either through a video call or a chat function.Some participants imagined an unguided application providing psychoeducation and exercises for their sexual difficulty.Participants' perception about the helpfulness of the interventions also depended on whether they expected to speak to a real therapist or to get "generic" information on the issue with the former expected to be more helpful.This aligned with previous research which suggests that people prefer face-to-face treatments to online interventions and guided interventions to unguided interventions (Apolinário-Hagen et al., 2018;Klein & Cook, 2010;Musiat et al., 2014;Wallin et al., 2016).However, only a minority of people struggling with sexual problems ever seek face-to-face help (Moreira et al., 2005;Ventegodt, 1998;Williamson et al., 2019) and due to issues with accessibility, stigma, and cost, many people feel reticent to engage in face-to-face intervention (Laumann et al., 2009;Moreira et al., 2005Moreira et al., , 2006;;Nicolosi et al., 2005).This leaves many people without care that they need.Unguided sex therapy interventions thus have the potential to reach a wider audience than traditional therapy.
Additional expectations included personalization of the intervention to their specific circumstances as opposed to something generic and a professional look to the application that created a sense of trust.They preferred to have a free trial to test out the intervention before investing into it financially.In both studies, the expectations of how long it would take to see improvements varied from immediately to never, but the quantitative results suggested that overall people expect to improve within a couple of weeks to a couple of months.However, given the reluctancy to pay for an intervention unless experiencing it as useful immediately, it is questionable whether many users would engage with an intervention long enough to experience these benefits.This is likely to raise challenges in developing digital sex therapy interventions and put a pressure on immediate improvements perhaps at the expense of long-term gains.
The second aim of the research was to understand participants' attitudes toward digital sex therapy interventions.There were many positive attitudes that participants expressed across the two samples: participants believed digital sex therapy interventions to be in line with modern times of online applications, be more private as one could stay anonymous, reduce stigma and embarrassment, improve accessibility of sex therapy services to a wider population, be more compatible with work-life balance, and have a lower bar of getting started immediately.Many said they would be willing to try it because of the low initial costs involved.These results indicate that digital sex therapy interventions have the possibility of addressing many of the established barriers to traditional sex therapy: stigma, accessibility, and cost (Laumann et al., 2009;Moreira et al., 2005Moreira et al., , 2006;;Nicolosi et al., 2005).However, both studies also highlighted several negative attitudes to digital sex therapy which can act as barriers and hinder people from accessing these interventions.These negative attitudes included perceiving online interventions as less effective, lacking human connection, lacking accountability, and being too generic.The most negative attitude based on the quantitative survey was a concern around data security, which was also reflected in the qualitative interviews around mistrust of technology.To ensure that digital sex therapy interventions effectively reduce barriers and improve access to treatment for individuals experiencing sexual difficulties, it is crucial to confront the obstacles that impede access to online sex therapy interventions.
While the present study was specific to digital sex therapy interventions, it is also likely that these barriers will be present for most, if not all, types of online mental health interventions.Indeed, Apolinário-Hagen et al. ( 2018) found similar barriers to guided internet-based therapies.
Failure to address these barriers may result in low utilization of digital sex therapy interventions.Additionally, these barriers may help elucidate why there is a suboptimal adoption of online interventions, despite their effectiveness.
Apart from attitudes and expectations, we also investigated whether some individuals were more inclined to use digital sex therapy interventions and held more favorable opinions toward them than others.Based on findings from previous studies on acceptance of health interventions, we examined age (Apolinário-Hagen et al., 2020;Hobbs et al., 2019), gender (Apolinário-Hagen et al., 2017, 2020;Batterham & Calear, 2017;Crisp & Griffiths, 2014), education (Topooco et al., 2017;Wangberg et al., 2007;Wells et al., 2007), prior experiences with therapy (Musiat et al., 2014), and past sexual difficulties as potential predictors of attitudes and intent to use.Interestingly, none of these variables predicted the general attitudes to digital sex therapy.However, the results showed that participants who were more highly educated and those who had previous therapy experiences (and thus were presumably more open to therapies in general) were more open to using a digital sex therapy intervention if they encountered sexual difficulties.Finally, participants who had more positive attitudes toward digital sex therapy also reported being more likely to use it, which is in line with previous research showing that attitudes predict intent to use (Dwivedi et al., 2021).Overall, 60% of the participants said they would consider using a digital intervention for sexual difficulties if the need arose.These results indicate that promoting awareness and education about digital sex therapy interventions, along with addressing the barriers associated with them, could increase the uptake of these interventions.

Theoretical implications
So, what are the implications of this research for the UTAUT model?The model suggests that performance expectancy, effort expectancy, facilitating conditions, and social influence predict user engagement in future technologies (Venkatesh et al., 2003(Venkatesh et al., , 2016)).Additionally, other recent studies have also shown that attitudes directly predict intent to use rather than only indirectly through these four key factors (Dwivedi et al., 2021).The results from the present study corroborate the findings on performance expectancy: many participants expected digital sex therapy interventions to be less effective compared to face-to-face interventions and thus expressed reluctance to using these interventions.Participants were also afraid that the online interventions would be overly generic and not generalized to their particular sexual concern which contributed to the perception that the intervention would not be as effective.Meta-analyses comparing digital and in-person therapies have found effect sizes that are comparable between the two modalities (Barak et al., 2008;Zarski et al., 2022).Nevertheless, there seems to be a prevailing notion that digital interventions are less effective.Therefore, it is crucial to focus on altering the public perception regarding the effectiveness of online interventions.
Effort expectancy, or ease of use, was also present in the qualitative interviews.When participants described what they expected a digital intervention to be like, they said it should be clear and easy to use as well as something that was fun and engaging.They also desired the flexibility to engage with it at their own pace.Furthermore, participants anticipated the opportunity to try the intervention before committing to paying for it, ascertaining its efficacy.However, a one-week trial may not provide adequate time for individuals to experience noticeable progress.This presents a potential concern for digital interventions, given that therapy is frequently challenging, and improvements often require time to manifest.The commitment to face-to-face therapies and the increased accountability to a "real person" may help patients to persevere with a therapist but may cause them to prematurely disengage from a digital intervention.As Vowels (2022b) noted, the digital sex therapy intervention was effective for those who completed the program, but the majority of participants did not.This raises a critical question regarding the overall effectiveness of the program if all participants had completed it.
In addition to expectations, the UTAUT model suggests that there are likely to be facilitating conditions that make the adoption of new technologies easier (Venkatesh et al., 2003(Venkatesh et al., , 2016)).The results from the present study, as well as from previous studies (Apolinário-Hagen et al., 2020), suggest that participants have more positive attitudes toward online therapies when a therapist is involved than when the interventions were unguided.Thus, a therapist involvement may help facilitate engagement.Other three potential factors may help facilitate uptake of digital sex therapy interventions: free trials, quick improvements, and relevance to the problem.Many participants were willing to try a digital sex therapy intervention despite low expectations because they are usually cheap and often include a free trial before committing to the intervention.If digital interventions can facilitate an immediate feeling of improvement or hopefulness, this may entice users to continue to engage with the intervention.Finally, many participants were reluctant to use digital interventions because they felt they would provide advice that was too generic rather than tailored to them.Thus, it is important for interventions to feel relevant and be personalized to the individual problem rather than provide one solution for everyone.
The final part of the model includes social influence and pressure to adopt a technology.In the case of digital sex therapy interventions, the social influence came from the perceived stigma and embarrassment associated with sexual difficulties rather than from others supporting the technology and promoting its use.This suggests that social influence can take many forms and sometimes people may seek out online interventions because of the privacy and anonymity that they can provide.For example, one participant said they would not want to engage with in-person sex therapy because they were worried this would show up on their medical records but would be willing to use and app if they could stay anonymous.
In addition to the four main components, the results also suggested that attitudes were an important predictor of intent to use.The results showed that participants who held more positive attitudes about digital sex therapies were more likely to be willing to try digital sex therapy in the future.However, we did not test the model's four main components as potential mediators and many of the attitudes reflected the four UTAUT model components.Therefore, we cannot report on whether attitudes would have had a direct impact on future use if we had modeled these mediators.Despite this, it is evident that attitudes play a crucial role and impact the four essential factors of the UTAUT model.Therefore, addressing the general public's perceptions and attitudes toward digital sex therapy interventions may facilitate more individuals being open to engaging with these interventions.

Strengths, limitations, and future directions
The current study offers both qualitative and quantitative evidence of attitudes toward digital sex therapy interventions, providing comprehensive insights into the potential barriers hindering people from accessing these interventions, as well as ways to address these barriers.The study also found that attitudes strongly predicted future intent to use.Notably, the survey participants were relatively representative of the broader UK adult population (97% of the participants came from the UK) concerning age, gender, ethnicity, and education.However, there are several limitations that should be considered when interpreting the results.While the unmoderated interviews presented certain advantages such as ensuring anonymity and reducing social desirability and stigma, it was not possible to ask follow-up questions in the interviews.While the inclusion criteria for the interviews mandated that participants must have experienced current or past sexual issues, no such requirement was imposed on the survey participants.Nonetheless, the findings from both approaches offered complementary insights into the attitudes toward digital sex therapy interventions, providing a comprehensive picture of the general public's views on these interventions.It is worth noting, however, that most of the survey participants may not be the target audience for such interventions, and therefore, their attitudes may be of less relevance to those developing these interventions.
Furthermore, the small sample size of survey participants with previous sexual difficulties may have contributed to the lack of significant differences in intent to use between those with and without such experiences.Therefore, future studies should aim to replicate these findings with a larger sample of individuals who have experienced sexual difficulties in the past.Another important consideration in interpreting our results is that all participants agreed to take part in a study about sex therapy, which may be a positive marker for help-seeking tendencies and openness to new sex therapy digital platforms.Despite the variances observed in interview participant dialogues and responses, the sample represented participants who had chosen to take part in an online platform testing new applications and products and represents relatively young individuals from western countries, potentially limiting this study's generalizability to other contexts.These results corroborated the findings from the more representative survey sample, but it still conducted online and thus the attitudes do not necessarily reflect the attitudes of the entire population but rather a subpopulation comfortable with internet use.Thus, some of the hard-to-reach populations that these interventions may aim to target may not engage with them perhaps because they are less familiar with using the internet.Therefore, while digital health interventions can address many of the accessibility issues raised by traditional therapies, they can only be delivered to populations with access to the internet.Alternative approaches are needed to individuals who may be living in rural areas without access to internet, or with poor internet connection, and who may live far away from in-person therapy centers.
Finally, both studies were cross-sectional which is sufficient to provide a snapshot of current attitudes toward digital sex therapy interventions and understand whether the attitudes are correlated with future openness to using online interventions.However, it was not possible to see whether these attitudes correlated with actual future use of digital sex therapy interventions.The study also provided some understanding of potential barriers to address in improving uptake of digital sex therapy intervention, but it may not be sufficient to understand how to improve adherence to digital interventions and lower the dropout rate of these interventions.Understanding ways to improve longer-term engagement with digital interventions will be an important next step to improving access to evidence-based and effective care to people struggling with sexual difficulties.

Conclusion
In conclusion, the study suggests that digital sex therapy interventions can help address many of the traditional barriers to seeking sex therapy services such as accessibility, cost, and stigma.However, digital interventions come with their own downsides such as lower perceived effectiveness, lack of human connection and accountability, being too generic, and distrust of technology.Companies and researchers developing these digital interventions should be mindful of the potential barriers and work to address them.

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

Funding
Study 1 was funded by Blueheart Technologies Ltd, London, UK.Study 2 was funded by University of Lausanne, Switzerland.The funders had no involvement in the collection, analysis, or interpretation of the data and were not involved in the writing or submission of this article.

Table 1 .
Demographic characteristics for study 2 participants.

Table 2 .
results for participants' attitudes in study 2.