The Role of Emotion Regulation Strategies for Sexual Function and Mental Health: A Cluster Analytical Approach

Abstract We investigated distinct profiles in emotion regulation strategies (reappraisal and suppression) and their associations with sexual function and mental health. The online survey sample consisted of 5436 adult participants. The gender stratified cluster analysis resulted in a four-cluster solution for both men and women. Better sexual function and mental health scores were found for participants with high cognitive reappraisal and low expressive suppression. High expressive suppression was associated with higher anxiety and depression and worse sexual function. Sexological care should take into account the assessment of emotion regulation abilities and emotion regulation training interventions to support reappraisal strategies.


Introduction
According to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders-5-TR (American Psychiatric Association, 2013), sexual disorders are characterized by difficulties in the ability to respond sexually or to obtain sexual pleasure.From a functional perspective, sexual health refers to the ability to experience the full sexual response cycle (Girardi et al., 2015).Mental health refers to the state of mental well-being which make individuals capable of managing their life stressors and accomplish their potential (World Health Organization, 2023) Epidemiological studies on sexual disorders in the general population report prevalence rates varying from 20-30% for adult men and 40-45% for adult women, fulfilling the criteria for at least one sexual dysfunction during their lifetime (Lewis et al., 2010).
The etiology of sexual disorders is multifactorial, encompassing physiological, affective, interpersonal, and psychological, context-dependent-factors (Willi & Burri, 2015), which predispose, precipitate, or maintain sexual dysfunction (Hawton & Catalan, 1986).Psychological factors include performance anxiety, attitudes toward sex, self-reported levels of stress and fatigue, and anxiety (McCabe, 2005), and they may either contribute to the development of sexual problems or be a consequence thereof (Leiblum & Rosen, 2000).
Emotional reactions and thoughts during sexual activity can also affect sexual functionality.With respect to emotions, studies have reported different patterns for individuals with and without sexual dysfunction.For instance, among healthy women and men, anxiety had no effect or even increased sexual arousal (Barlow, Sakheim, & Beck, 1983;Laan, Everaerd, Van Aanhold, & Rebel, 1993), whereas in women and men with sexual difficulties these factors rather decrease sexual responses (Beck, Barlow, Sakheim, & Abrahamson, 1987;Dèttore, Pucciarelli, & Santarnecchi, 2013).In a similar vein, sexually dysfunctional men reported significantly more sadness, disillusion, and fear, and less pleasure and satisfaction when compared to men without sexual problems.Similarly, women with sexual dysfunction showed less pleasure and satisfaction, and more sadness, disillusion, guilt, and anger (Nobre & Pinto-Gouveia, 2006).
These results suggest that emotion regulation (ER) may be important for sexual health and most likely also in the treatment of sexual problems.ER refers to the process of modulating an emotional response, which includes whether and how an emotion is experienced or expressed (Gross, 1998).Functionally, efficient ER involves: (1) awareness and understanding of emotions (clarity); (2) acceptance of emotions; (3) the ability to control impulsive behaviors and to behave in accordance with desired goals when experiencing both negative and positive emotions; and (4) the ability to use situationally appropriate ER strategies to achieve personal goals and meet situational demands (Gratz & Roemer, 2004).
Among the different ER strategies, the two most frequently studied are reappraisal and suppression (John & Gross, 2004).Reappraisal refers to the modulation of an emotional experience by changing how one perceives an emotionally provoking event or finding benign or positive attributions or interpretations of an event to prevent or reduce negative mood concerning the event (Gross, 1998;John & Gross, 2004).In contrast, suppression involves the inhibition of one's emotional reaction to an event (John & Gross, 2004).Depending on the context and on the situation, the use of different ER strategies can be considered adaptive or maladaptive (Rogier, Garofalo, & Velotti, 2019;Webb, Miles, & Sheeran, 2012).
Overall, greater use of reappraisal has been linked with better psychological well-being and more adaptive social functioning whereas greater suppression use has been associated with poorer social functioning and lower relationship quality (Chervonsky & Hunt, 2017).Also, the ability to communicate emotions (verbally or as overt behavior) is a crucial component of emotion regulation and of healthy coping (Bloch, Haase, & Levenson, 2014).
In this sense, the ability to flexibly regulate emotions can be seen as a therapeutic goal in sexual therapy since it facilitates emotional awareness and experience, problem-solving, acceptance and mindfulness, ultimately, diminishing the sensitivity and reactivity to negative stimuli (Rosen & Bergeron, 2019).
Sexual experiences occur in complex relational environments, with relationship processes being involved not only in the generation and experience of sexual emotions, but also in their regulation (Dewitte, 2014).In other words, the social-relational context and the dynamic interplay between cognitive, affective, and motivational responses may shape how sexual emotions are generated and regulated (Houck, Barker, Hadley, Menefee, & Brown, 2018).
Difficulties in regulating negative emotions may represent a key mechanism hampering the well-being of couples (Rosen & Bergeron, 2019).According to the interpersonal emotion regulation model of women's sexual dysfunction, a lack of emotional awareness, expression, and experience could lead to increased sensitivity and reactivity to negative stimuli (e.g., pain) and promote the use of less adaptive ER strategies (avoidance, suppression, catastrophizing, emotional outbursts), rather than adaptive ones (reappraisal, approach, problem-solving, appropriate disclosure, acceptance, mindfulness) (Rosen & Bergeron, 2019).Although not developed to include male sexual dysfunction, it is plausible that this model also is applicable for men.For example, a study investigating couples affected by Female Sexual Interest/Arousal Disorder found that respondents reporting difficulties regulating negative emotion and greater use of emotional suppression showed higher depression and anxiety, and lower relationship satisfaction (Dubé, Corsini-Munt, Muise, & Rosen, 2019) We recently conducted a scoping review aiming at identifying the state of the art of the relationship between ER and sexual health (Fischer, Andersson, Billieux, & Vögele, 2022).One of the main findings concerned the result that overall poor ER was associated with poor sexual health and diminished satisfaction.We concluded that ER interventions may be beneficial in the treatment of sexual difficulties.Notwithstanding these results, we also inferred from this review that little attention has been devoted in previous research to the investigation of the role of ER strategies and their relationships with sexual health.
The present study was designed to explore the role of ER strategies (cognitive reappraisal and expressive suppression) for sexual function and mental health using a data-driven cluster analytical approach to identify participants with different profiles of ER strategies in relation to their sexual function and mental health.Results from such studies may fill the current literature gap regarding ER strategies use and its relationship to sexual function as well as inform targeted interventions addressing the needs of patients according to their ER profiles.
We hypothesized that (1) higher use of cognitive reappraisal would be grouped with better sexual function and mental health scores both in men and women while (2) higher use of expressive suppression would be grouped with worse sexual function and mental health scores both in men and women.

Procedure
A cross-sectional online survey was conducted using the SoSci Survey platform addressing sexual function, mental health, and the use of ER strategies.The survey was available in English, French, German, Spanish, and Portuguese.All questionnaires used had previously been validated except for the PHQ-9 and GAD-7 French versions (Pfizer, https://www.phqscreeners.com/), which were translated but without published validation.Recruitment and advertisement took place mainly via social media platforms, such as Facebook and Instagram.Before taking part in the survey and electronically signing the consent form, participants were informed about the content and the purpose of the study, the guarantee of anonymity, their right to withdraw from the study at any moment without any explanation, and about the possibility to contact the research team for questions or concerns.No monetary incentive was offered to participants.
Participants were eligible to take part in the survey if they met the following inclusion criteria: a) 18 years of age or older, b) fluent in one of the languages in which the questionnaires were available (English, German, French, Spanish or Portuguese).
Data collection took place between January 2019 and October 2019, with a total response rate of 56% (44% gave consent and started completing the survey but did not finish it).The time taken to complete the survey was on average 10 min.Ethical approval was obtained from the University of Luxembourg Ethics Review Panel (ERP 18-075).

Sexual function
Sexual function assessment was conducted using the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF) and directed to the FSFI or the IIEF according to their self-reported biological sex.

Data analyses
The distributions of the questionnaire data were examined using the Kolmogorov-Smirnov test.Depending on the distribution, we computed internal consistency (Cronbach's alpha) and produced a correlation matrix using Spearman or Pearson correlations to examine the associations between the variables.
Cluster analyses were performed to generate profiles according to the preferred use of ER strategies.For these analyses we combined a hierarchical and nonhierarchical clustering approach, as recommended by Hair, Black, Babin, and Anderson (2010).By using this approach, the strengths of one method compensates for the disadvantage of the other (e.g., sensitivity to outliers).For the clusters' generation, we used the ER strategies from the ERQ (cognitive reappraisal and expressive suppression).After verifying the presence of collinearity between the clustering variables using the correlation matrix, we proceeded with the following steps: (1) we applied a z-transformation to cluster variables followed by (2) hierarchical clustering, using Ward's method with squared Euclidian distances.This approach is designed to identify the optimal number of clusters for the nonhierarchical clustering analyses.The best number of clusters was evaluated using the NbClust R package.This package is based on the majority rule and reports the best number of clusters proposed for all the available indices (e.g., Duda, silhouette, Dunn, Friedman, etc.); (3) we proceeded to a nonhierarchical K-means clustering (iter max = 1000, nstart = 50) to create the clusters using the optimal number of clusters identified with the hierarchical clustering; (4) we determined the characteristics of the clusters regarding their ER strategy use profiles; and (5) we compared the identified clusters on Anxiety (GAD-7), Depression (PHQ-9), and Sexual function (FSFI and IIEF).

Results
All scales used showed good Cronbach's alphas (see Table 2).Due to the non-normal distribution of the variables, we used Kruskal Wallis and Dunn's test with Bonferroni correction to analyze differences between clusters.Table 3 shows the Spearman correlation matrix.Correlations between the cluster variable (reappraisal and suppression) did not show multicollinearity (r s = .049).The hierarchical clustering analyses suggested 4 clusters.Among all the indices (n = 23), 7 proposed 4 as the best number of clusters.4. All clusters differed with respect to the reappraisal ER strategy (p<.001).Regarding the use of suppression as ER strategy, clusters also differed except for LR-LS and HR-LS who are identical (p = 0.0426), meaning that these 2 groups were similar regarding their suppression scores (Table 5).

Depression
Pairwise comparisons using Dunn's test indicated that all clusters differed with regards to depression scores (PHQ, p <.001), except for clusters HR-HS and LR-LS who were identical.It is important to note that their mean depression scores were close to the overall mean of the dataset.

Anxiety
The clusters differed in anxiety scores (GAD) except for the LR-HS and LR-LS clusters (p = 0.21).
It is interesting to note that the LR-LS groups showed significant differences on the HR-HS cluster, where the LR-LS scores were significantly higher on the anxiety scale (GAD).This was not the case for depression for which these two clusters showed no significant differences.Among all the clusters, individuals in the HR-LS cluster reported the lowest anxiety and the lowest depression scores, while the LR-HS cluster was characterized by a higher level of anxiety and depression.Clusters that were characterized by a high level of suppression tended to show higher anxiety and depression scores.
For both IIEF and FSFI scores, there were significant differences between LR-HS and HR-LS, and between HR-LS and HR-HS, where HR-LS showed a higher mean score suggesting better sexual function.In terms of sexual function, individuals in the HR-HS cluster did not differ from those in the LR-HS (IIEF: p = 1; FSFI: p =.0256) or LR-LS clusters (IIEF: p = 1; FSFI: p = 0.2955).
On the IIEF scale participants in the HR-LS cluster did not differ from those in the LR-LS cluster (p = 0.1149).In contrast, FSFI scores differed significantly between those in the HR-LS and the LR-LS cluster (p <.001), with the HR-LS indicating better sexual function.The same was true for the LR-HS and LR-LS clusters who were not significantly different on the IIEF scale (p = 0.5407) but differed on the FSFI (p <.001), with the LR-LS suggesting better sexual function.

Discussion
The present study investigated the role of ER strategies in relation to sexual function and mental health.The cluster analytical approach enabled us to examine self-reported sexual function and mental health in men and women in terms of their ER strategies, namely cognitive reappraisal, and expressive suppression.For both genders, four clusters were observed: low reappraisal and high suppression (LR-HS), high reappraisal and low suppression (HR-LS), high reappraisal and high suppression (HR-HS), low reappraisal and low suppression (LR-LS).
We hypothesized that in both men and women (1) higher use of cognitive reappraisal would be associated with better sexual function and mental health scores and (2) higher use of expressive suppression would be linked with worse sexual function and mental health scores.Both hypotheses were confirmed.Regarding mental health, our data showed to be in accordance with emotion regulation models and previous studies suggesting that poor emotion regulation interferes with adaptive coping, leading to adverse psychological consequences such as anxiety and depression (Aldao, Nolen-Hoeksema, & Schweizer, 2010;Ehring, Tuschen-Caffier, Schnülle, Fischer, & Gross, 2010;Gross, 2002;Vujanovic, Zvolensky, & Bernstein, 2008).
Higher scores on suppression were associated with higher anxiety and depression scores.In contrast, higher reappraisal and lower suppression were associated with better mental health (lowest scores in anxiety and depression in the current sample).In addition, participants using neither of these ER strategies had the highest anxiety scores.Difficulties with regulating (negative) emotions (e.g., poor awareness and clarity of the emotion) have been shown to be linked to poorer adjustment in several clinical conditions (e.g., posttraumatic stress disorder, pain disorders) (Doolan, Bryant, Liddell, & Nickerson, 2017;Lutz, Gross, & Vargovich, 2018).
Regarding sexual function, our hypotheses were also confirmed.Similar to the results on mental health, the cluster of participants with higher reappraisal use had better sexual function scores in both the male and the female questionnaire.Despite the overall positive association of reappraisal with sexual function for both men and women (and the association of suppression with sexual disorders symptomatology), there were some differences.For women, there was a significant difference between the groups with low suppression but with high and low reappraisal use.In other words, low use of both strategies differed from low suppression with high reappraisal.This is in line with previous studies on ER and gender differences, which found that for women the use of adaptive strategies (such as reappraisal) may have some compensatory effects among those with higher levels of maladaptive strategies (e.g., suppression).Such compensatory effects have not been shown for men (Nolen-Hoeksema, 2012).
Our study adds to the literature, by emphasizing the importance of ER strategies for sexual function.The ability to flexibly choose between ER strategies, and to be able to cognitively reappraise events and emotions generated, are associated with sexual function.In addition, it supports the interpersonal ER model of women's sexual dysfunction (Rosen & Bergeron, 2019) by supporting the negative effect of suppression and the positive effect of reappraisal for sexual function.This finding also reinforces the notion of ER ability as a transversal element in sexual function.Even though our study instruments did not focus on Genito-pelvic pain/penetration disorder (as did the model), we found the expected role of ER strategies for both men and women.
In the current study we used a cluster analytical approach as this methodology allows for the identification of profiles and, therefore, the characterization of ER groups and related patterns of ER with mental health and sexual function.The 4-group solution identified in the present study enabled a continuum perspective on the use of ER strategies and their effects on sexual function and mental health outcomes.

Limitations
First, due to the sexual function measures instruments used, no information about participants current sexual activity was collected.It is possible, therefore, that, for example, women's scores of sexual function are inflated (no activity can either indicate no motivation to engage in it or the lack of possibility).Second, the data were obtained via an online survey from non-representative samples, which does not allow for the extrapolation of the results to the general population and may not fully reflect what is found in clinical settings.Third, despite being fluent in one of the languages, many respondents did not answer in their maternal native language, which may have impacted the reliability of the results.Also, regarding language, due to the different countries of origin of our sample, respondents may have answered questionnaire validated in their language but not necessarily validated in their country.Fourth, due to the cross-sectional nature of the study, no conclusions can be drawn on the stability of the cluster identified.

Implications
Based on our findings we were able to identify profiles of men and women regarding sexual function, anxiety and depression based on their ER strategy profiles.Both for men and women, the higher use of cognitive reappraisal was associated with better sexual function and mental health.From a clinical point of view, the current findings underline the importance of the assessment of ER strategies and the inclusion of ER strategies when conducting treatments for sexual and mental health.From a research point of view, further investigations on the impact of ER strategies for sexual health should be conducted, encompassing other strategies than suppression and reappraisal.Also, future research should investigate the relationship between ER strategies and sexual motivation and activity.

Conclusions
We identified distinct clinical subgroups with respect to anxiety, depression and sexual disorders based on their preferred ER strategies.By revealing the impact of ER strategies on sexual function, anxiety, and depression these findings support the inclusion of ER training as therapeutic goal in sexological care.Our findings highlight the association between sexual and mental health and suggest that when dealing with sexological patients, ER abilities should be assessed and emotion regulation training interventions fostering reappraisal should be used.

Four
ER profiles were created using nonhierarchical K-means clustering (Fig 1).The identified profiles were characterized by: low reappraisal and high suppression (LR-HS), n = 1243; high reappraisal and low suppression (HR-LS), n = 1695; high reappraisal and high suppression (HR-HS), n = 1425; low reappraisal and low suppression (LR-LS), n = 1073.Details of the cluster profiles are shown in Table

Table 2 .
Cronbach's alpha for each scale (for each language).

Table 4 .
Descriptive statistics by cluster.

Table 5 .
Groups comparison (Kruskal Wallis rank sum test and Dunn's pairwise with Bonferroni correction).