Sexual Modes Questionnaire

Abstract

The Sexual Modes Questionnaire (SMQ) is a multidimensional psychometric instrument formulated by Pedro J. Nobre and José Pinto-Gouveia (2003) to operationalize and evaluate the cognitive-affective determinants of human sexual function and dysfunction. Grounded in cognitive theory and Aaron T. Beck’s concept of cognitive “modes,” alongside David Barlow’s cognitive-affective model of sexual response, the SMQ assesses the continuous dynamic interaction between automatic thoughts, emotional states, and subjective physiological sexual arousal occurring specifically during sexual activity. The SMQ is structured into two gender-specific instruments: the Male Version (comprising 30 items across three operational tiers) and the Female Version (comprising 33 items across three operational tiers). The core architecture consists of three interdependent subscales: the Automatic Thoughts (AT) subscale, the Emotional Response (ER) subscale, and the Sexual Response (SR) subscale.

Psychometrically, the SMQ displays robust construct and factorial validity. Exploratory factor analyses identify six distinct cognitive dimensions in women (accounting for 53.1% of the total variance: Sexual Abuse Thoughts, Failure and Disengagement Thoughts, Partner’s Lack of Affection, Sexual Passivity and Control, Lack of Erotic Thoughts, and Low Self Body-Image Thoughts) and five distinct dimensions in men (Failure Anticipation Thoughts, Erection Concern Thoughts, Age and Body-Related Thoughts, Negative Thoughts Toward Sex, and Lack of Erotic Thoughts). Reliability assessments reveal high internal consistency across both versions, with Cronbach’s alpha reaching α = .88 for the male total AT scale and α = .87 for the female total AT scale, with subscale alphas ranging from .69 to .83 in men and .71 to .80 in women. Test-retest reliability across a four-week interval demonstrated high temporal stability for women (r = .95, p < .01) and moderate-to-high stability for men (r = .65, p = .08; with subscales reaching up to r = .95). Convergent and discriminant validity are empirically supported by statistically significant associations with the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI), as well as significant score discrepancies between clinical populations with diagnosed sexual dysfunctions and sexually functional controls.

Keywords

Sexual Modes Questionnaire, SMQ, cognitive-affective assessment, automatic thoughts, sexual dysfunction, erectile dysfunction, female sexual arousal disorder, cognitive modes, sex therapy, subjective sexual arousal, psychometrics

Authors

The Sexual Modes Questionnaire was conceptualized, developed, and empirically validated by Portuguese clinical psychologists and sexologists:

• Pedro J. Nobre, Ph.D. — Faculty of Psychology and Educational Sciences, University of Porto (formerly at Universidade de Trás-os-Montes e Alto Douro), Portugal. Dr. Nobre is a distinguished researcher in sexology, Past President of the World Association for Sexual Health (WAS), and Director of the Laboratory of Human Sexuality (SexLab) at the University of Porto. Correspondence regarding permissions and administration of the instrument is directed to Pedro J. Nobre.
• José Pinto-Gouveia, M.D., Ph.D. — Center for Research in Neuropsychology and Cognitive and Behavioral Intervention (CINEICC), Faculty of Psychology and Educational Sciences, Universidade de Coimbra, Portugal. Dr. Pinto-Gouveia is a renowned clinical psychologist and psychopathology researcher who has contributed extensively to cognitive-behavioral therapies, schema therapy, and clinical assessment methodologies.

Purpose

The primary purpose of the Sexual Modes Questionnaire (SMQ) is to assess the complex, synchronous relationships between cognitive processing, affective reactions, and perceived sexual arousal during sexual activity. Throughout the history of modern sexology, early therapeutic and research models (such as those pioneered by Masters and Johnson, as well as Helen Singer Kaplan) highlighted the disruptive role of performance anxiety and cognitive distraction—often termed “spectatoring.” However, empirical methodologies capable of capturing the precise content of these distractions, the emotional states they induce, and their direct dampening impact on subjective sexual arousal remained underdeveloped.

The SMQ addresses this diagnostic and psychometric gap by operationalizing the construct of “sexual modes” within an ecologically relevant framework. Rather than evaluating general sexual attitudes or trait anxiety in abstract contexts, the questionnaire specifically directs respondents to isolate their mental and emotional reactions as they unfold during sexual encounters. The instrument serves several distinct clinical and academic purposes:

• Differential Diagnosis and Etiological Clarification: Clinicians utilize the SMQ to identify whether an individual’s or couple’s sexual dysfunction (such as erectile disorder, premature ejaculation, hypoactive sexual desire, female orgasmic disorder, or genito-pelvic pain/penetration disorder) is maintained primarily by performance failure expectations, bodily dissatisfaction, relationship mistrust, or suppressed erotic fantasy.
• Treatment Customization and Cognitive Restructuring: In cognitive-behavioral therapy (CBT) and cognitive sex therapy, the SMQ provides a baseline profile of maladaptive automatic thoughts and corresponding negative emotions (e.g., guilt, shame, disillusionment). Clinicians can track which cognitive schemas require targeted cognitive disputation, behavioral experiments, or sensate focus interventions.
• Empirical Research on the Mind-Body Link: In clinical sexology research, the SMQ allows investigators to quantify cognitive interference and test complex mediation models, determining how specific cognitions interrupt the feedback loop between autonomic physiological excitation and subjective sexual pleasure.

Psychological Construct

The SMQ assesses the multidimensional psychological construct of the Sexual Mode, defined as a synchronized, state-dependent activation of cognitive schemas, affective states, and subjective physiological perceptions during intimacy. Grounded in information-processing models, this construct posits that sexual difficulties are rarely isolated physiological events; instead, they represent cognitive-affective interference where internal negative self-talk competes for limited attentional capacity. The SMQ captures this network across three interconnected operational domains:

1. The Automatic Thought (AT) Dimension

Automatic thoughts represent immediate, reflexive, self-evaluative self-statements or mental images triggered during sexual stimulation. In sexually dysfunctional individuals, these thoughts skew toward catastrophe, performance failure, control demands, or perceived danger. The cognitive subscale differentiates between distinct gender-relevant sub-dimensions:

• Female Dimensions:
  • Sexual Abuse Thoughts: Intrusive memories, thoughts, or images of violation, coercion, or danger (e.g., “He is violating me,” “He is abusing me”), common in individuals with trauma histories or severe sexual aversion.
  • Failure and Disengagement Thoughts: Cognitions reflecting perceived inadequacy, inability to respond, or feelings of mental detachment (e.g., “I can’t feel anything,” “When will this be over?”).
  • Partner’s Lack of Affection: Attributions concerning a partner’s emotional detachment, ulterior motives, or emotional distance (e.g., “He only cares about me when he wants sex,” “Why doesn’t he kiss me?”).
  • Sexual Passivity and Control: Restrictive beliefs regarding agency, sexual assertiveness, and fear of negative social evaluation (e.g., “I should wait for him to make the first move,” “If I let myself go he is going to think I’m promiscuous”).
  • Lack of Erotic Thoughts: An absence of positive, sexually stimulating, and pleasurable cognitions (scored in reverse, measuring failure to engage in erotic fantasy).
  • Low Self Body-Image Thoughts: Self-deprecating mental evaluations centered on physical appearance, weight, and fear of physical unattractiveness (e.g., “I’m getting fat/ugly”).
• Male Dimensions:
  • Failure Anticipation Thoughts: Predictive fears of sexual disaster, self-worth degradation, and perceived inadequacy (e.g., “I’m condemned to failure,” “If I fail again I am a lost cause”).
  • Erection Concern Thoughts: Hyper-vigilant cognitive focus on penile turgidity, mechanical rigidity, and partner satisfaction (e.g., “My penis is not responding,” “I must achieve an erection”).
  • Age and Body-Related Thoughts: Maladaptive interpretations of physiological aging, declining stamina, and waning attractiveness (e.g., “I’m getting old,” “She doesn’t find my body attractive anymore”).
  • Negative Thoughts Toward Sex: Moralistic, conservative, or disgust-laden judgments toward sexual behavior (e.g., “This is disgusting,” “This way of having sex is immoral”).
  • Lack of Erotic Thoughts: Deficits in processing explicit sexual cues, sensations, and enthusiastic partner responsiveness.

2. The Emotional Response (ER) Dimension

The construct posits that automatic thoughts do not exist in isolation; they directly evoke specific emotional responses. The SMQ ER dimension evaluates the presence of ten specific primary and secondary emotions experienced when an automatic thought occurs. These include eight negative affects (worry, sadness, disillusion, fear, guilt, shame, anger, and hurt) and two positive affects (pleasure and satisfaction). By measuring the exact emotional tone elicited by negative thoughts, the instrument clarifies whether a patient’s sexual avoidance is driven primarily by performance anxiety (fear, worry), depressive resignation (sadness, disillusion), or interpersonal distress (anger, hurt).

3. The Subjective Sexual Response (SR) Dimension

The SR dimension measures the subjective intensity of physiological arousal (erection, lubrication, heart rate, pelvic warmth, and erotic engagement) experienced concurrently with each automatic thought. This construct reflects the degree to which particular cognitive-affective patterns suppress, extinguish, or (in the case of erotic thoughts) amplify physiological sensations.

Theoretical Framework

The SMQ is theoretically rooted in the integration of two major psychological frameworks: Aaron T. Beck’s Cognitive Therapy and Schema Theory (Beck, 1996) and David H. Barlow’s Cognitive-Affective Model of Sexual Dysfunction (Barlow, 1986).

Beck’s Mode Model and Cognitive Specificity

In Beck’s later formulations of cognitive theory, he introduced the concept of modes to explain synchronized, multi-component psychological reactions. A “mode” is an organized network of cognitive schemas, affective states, physiological responses, and behavioral programs that are activated simultaneously in response to specific environmental demands. When an individual encounters an intimate situation, latent cognitive schemas concerning intimacy, competence, and bodily safety are triggered. In functional individuals, an “Erotic Mode” dominates, marked by thoughts of pleasure, affective states of excitement, parasympathetic-sympathetic balance fostering genital blood flow, and approach behaviors. In sexually dysfunctional individuals, a “Threat or Failure Mode” is activated. Cognitive appraisals skew toward loss of control, vulnerability, or failure, triggering emotional distress and sympathetic autonomic hyperarousal, which directly counteracts sexual response.

Barlow’s Cognitive-Affective Feedback Loop

David Barlow (1986) articulated a functional-analytical model explaining the diverge paths of functional versus dysfunctional individuals during sexual opportunities. According to Barlow:

• Sexually Functional Individuals exposed to sexual stimuli direct their attentional focus toward erotic and romantic cues. This attentional focus leads to positive affect, enhanced subjective arousal, autonomic genital engorgement, and success, which creates a positive feedback loop reinforcing approach behaviors.
• Sexually Dysfunctional Individuals react to identical sexual demands with cognitive interference, such as performance demands or expectations of failure. These thoughts draw attention away from erotic cues toward internal self-monitoring (“spectatoring”) and threat detection. This attentional diversion induces autonomic anxiety (fear, panic), which disrupts genital vascular responses, leading to actual sexual impairment. This objective failure subsequently reinforces the initial core beliefs of sexual incompetence.

The SMQ operationalizes Barlow’s model by measuring the exact cognitions responsible for attentional diversion, the resultant emotional state, and the subjective sexual decrement within a single unified psychometric assessment.

Validity

The validity of the Sexual Modes Questionnaire has been established across clinical, nonclinical, and cross-cultural samples, confirming its construct, convergent, and discriminant validity.

Convergent Validity

Convergent validity was evaluated by correlating the SMQ dimensions with standard, validated clinical self-reports of sexual functioning: the International Index of Erectile Function (IIEF; Rosen et al., 1997) for men and the Female Sexual Function Index (FSFI; Rosen et al., 2000) for women (Nobre & Pinto-Gouveia, 2003, 2006):

• Female Sample: Total scores on the Female AT subscale demonstrated significant negative correlations with the FSFI total score and its constituent domains (arousal, desire, lubrication, orgasm, satisfaction). The strongest negative associations emerged between overall sexual functioning and Sexual Abuse Thoughts (Factor 1), Failure and Disengagement Thoughts (Factor 2), and Lack of Erotic Thoughts (Factor 5). Furthermore, the Emotional Response indices revealed that higher FSFI scores were positively correlated with the endorsement of pleasure and satisfaction, whereas lower FSFI scores were significantly correlated with higher indices of sadness, guilt, and anger during sexual activity.
• Male Sample: Total scores on the Male AT subscale were strongly negatively correlated with the IIEF erectile function, orgasmic function, sexual desire, and intercourse satisfaction domains. Particularly robust negative correlations were observed for Failure Anticipation Thoughts (Factor 1), Erection Concern Thoughts (Factor 2), and Lack of Erotic Thoughts (Factor 5). For the ER subscale, higher erectile function scores on the IIEF were associated with the emotions of pleasure and satisfaction, whereas lower scores were linked to disillusionment, sadness, and worry.

Discriminant Validity

Discriminant validity was assessed through contrast studies comparing clinical cohorts diagnosed with DSM-defined sexual dysfunctions (e.g., erectile dysfunction, premature ejaculation, female sexual arousal disorder, hypoactive sexual desire disorder) against sexually functional matched control participants (Nobre & Pinto-Gouveia, 2003, 2008):

• Women in the clinical group scored significantly higher than nonclinical controls on the total AT scale, as well as on Failure and Disengagement Thoughts and Lack of Erotic Thoughts. Clinically distressed women also exhibited significantly higher indices of negative affect (sadness, shame, guilt) and significantly lower subjective sexual arousal ratings.
• Men with sexual dysfunction displayed significantly higher mean scores than sexually functional controls on Failure Anticipation Thoughts, Erection Concern Thoughts, and Lack of Erotic Thoughts. Clinically dysfunctional men exhibited higher negative emotional indices (worry, disillusion) and markedly reduced subjective arousal ratings when engaging in these thoughts.

Reliability

The SMQ exhibits high internal consistency and longitudinal stability across empirical investigations:

Internal Consistency

In the original psychometric validation study conducted by Nobre and Pinto-Gouveia (2003), Cronbach’s alpha (α) was computed for both total subscales and individual factor dimensions:

• Male Version: The total Automatic Thoughts subscale demonstrated an internal consistency coefficient of α = .88. The individual factor subscales demonstrated acceptable-to-strong reliability ranging from α = .69 to α = .83: Failure Anticipation Thoughts (α = .83), Erection Concern Thoughts (α = .81), Age and Body-Related Thoughts (α = .73), Negative Thoughts Toward Sex (α = .69), and Lack of Erotic Thoughts (α = .72).
• Female Version: The total Automatic Thoughts subscale yielded a Cronbach’s alpha of α = .87. The individual factor dimensions exhibited coefficients ranging from α = .71 to α = .80: Sexual Abuse Thoughts (α = .80), Failure and Disengagement Thoughts (α = .78), Partner’s Lack of Affection (α = .76), Sexual Passivity and Control (α = .74), Lack of Erotic Thoughts (α = .71), and Low Self Body-Image Thoughts (α = .75).

Test-Retest Reliability

Temporal stability was evaluated by administering the SMQ on two distinct occasions separated by a 4-week interval among nonclinical respondents:

• Female AT Subscale: The Pearson product-moment correlation for the overall scale was r = .95 (p < .01), with individual factor dimensions exhibiting test-retest coefficients ranging from r = .52 (p < .05) to r = .90 (p < .01), demonstrating high stability over time.
• Male AT Subscale: The overall test-retest correlation was moderate to high at r = .65 (p = .08), with individual subscales demonstrating correlations ranging from r = .20 (p < .05) to r = .95 (p < .01), reflecting some natural situational fluctuation in male performance concerns alongside stable trait dimensions.

Factor Analysis

The internal structural validity of the SMQ was examined through exploratory factor analysis (Principal Component Analysis with Varimax orthogonal rotation) on the Automatic Thoughts items for both genders independently (Nobre & Pinto-Gouveia, 2003):

Female Factor Structure (SMQ-F)

For the female version, principal component analysis extracted a six-factor solution that accounted for 53.1% of the total cumulative variance. The identified factors and their psychometric structures are:

• Factor 1: Sexual Abuse Thoughts — Comprises 8 items (Items 1, 2, 3, 4, 6, 15, 32, 33). Score range: 8 to 40. Reflects thoughts of being degraded, forced, coerced, or violated during sexual activity.
• Factor 2: Failure and Disengagement Thoughts — Comprises 4 items (Items 19, 22, 26, 30). Score range: 4 to 20. Reflects cognitive feelings of numbness, detachment, and emotional abandonment.
• Factor 3: Partner’s Lack of Affection — Comprises 5 items (Items 7, 12, 24, 27, 28). Score range: 5 to 25. Focuses on perceptions that the partner lacks genuine romantic warmth or is using sex instrumentally.
• Factor 4: Sexual Passivity and Control — Comprises 6 items (Items 10, 14, 17, 21, 23, 29). Score range: 6 to 30. Captures self-inhibitory beliefs, fears of being judged as promiscuous, and passive behavioral scripts.
• Factor 5: Lack of Erotic Thoughts — Comprises 5 items (Items 5, 8, 11, 25, 31). Score range: 5 to 25. Represents reverse-scored items measuring positive erotic focus, enjoyment of technique, and sexual satisfaction.
• Factor 6: Low Self Body-Image Thoughts — Comprises 3 items (Items 9, 16, 20). Score range: 3 to 15. Assesses negative self-evaluations concerning physical attractiveness and weight.

Male Factor Structure (SMQ-M)

For the male version, factor analysis identified a five-factor structure accounting for a substantial proportion of variance across 27 retained items:

• Factor 1: Failure Anticipation Thoughts — Comprises 7 items (Items 1, 2, 3, 4, 6, 7, 16). Score range: 7 to 35. Captures impending dread of performance inadequacy and catastrophic loss of relationship standing.
• Factor 2: Erection Concern Thoughts — Comprises 7 items (Items 5, 8, 9, 10, 11, 12, 29). Score range: 7 to 35. Focuses specifically on mechanical erectile maintenance and penetration capacity.
• Factor 3: Age and Body-Related Thoughts — Comprises 4 items (Items 19, 21, 22, 28). Score range: 4 to 20. Captures aging-related decline, loss of physical stamina, and physical decay.
• Factor 4: Negative Thoughts Toward Sex — Comprises 5 items (Items 20, 23, 24, 25, 30). Score range: 5 to 25. Centers on moral discomfort, sexual guilt, disgust, and restrictive normative standards.
• Factor 5: Lack of Erotic Thoughts — Comprises 4 items (Items 14, 17, 18, 26). Score range: 4 to 20. Reverse-scored items assessing the endorsement of enthusiastic erotic arousal and enjoyment of partner pleasure.

Instrument / Measurement Tool

The Sexual Modes Questionnaire is a structured, multidimensional clinical self-report inventory. It can be administered via traditional paper-and-pencil or computerized digital formats.

• Assessment Type: Multi-tiered self-report inventory measuring state/trait cognitions, emotions, and perceived sexual arousal during sexual activity.
• Gender Versions: Two separate versions: Male (30 items total in the clinical inventory, 27 retained in factor scores) and Female (33 items).
• Subscale Architecture: Each test item involves three sequential rating steps:
  • Step 1: Automatic Thoughts (AT) Subscale: The respondent rates the frequency of occurrence of the thought during sexual activity using a 5-point Likert scale:
    • 1 = Never
    • 2 = Seldom
    • 3 = Sometimes
    • 4 = Often
    • 5 = Always
  • Step 2: Emotional Response (ER) Subscale: If an item is experienced (rated 2 or higher), the respondent checks which of 10 emotions are typically experienced when that thought occurs:
    • Negative emotions: Worry, Sadness, Disillusion, Fear, Guilt, Shame, Anger, Hurt
    • Positive emotions: Pleasure, Satisfaction
  • Step 3: Sexual Response (SR) Subscale: For endorsed thoughts, the respondent rates the typical intensity of subjective sexual arousal while experiencing that thought on a 5-point Likert scale:
    • 1 = Very Low
    • 2 = Low
    • 3 = Moderate
    • 4 = High
    • 5 = Very High
• Administration Time: Approximately 15 to 25 minutes depending on the number of thoughts endorsed.
• Scoring Protocols:
  • Automatic Thoughts Index: Calculated by summing all AT items. Positively valenced/erotic cue items are reverse scored (Items 14, 17, 18, and 26 in the Male version; Items 5, 8, 11, 25, and 31 in the Female version). Higher total scores reflect greater frequency of maladaptive, sexually disruptive automatic thoughts. Subscale totals are calculated by summing items within each factor.
  • Emotional Response Index: Calculated for each of the 10 emotions individually using the formula:
    
    Emotion Index = (Total number of times specific emotion is endorsed) / (Total number of all emotions endorsed)
    
    Indices range from 0.0 to 1.0, providing an affective distribution profile.
  • Sexual Response Index: Calculated using the formula:
    
    SR Index = (Sum of sexual response arousal ratings for all endorsed items) / (Total number of endorsed items)
    
    Scores range from 1.0 to 5.0, with lower scores indicating more severe subjective arousal impairment.

Permissions & Fee and Test Year

The Sexual Modes Questionnaire was formally published in 2003 by Pedro J. Nobre and José Pinto-Gouveia in the Journal of Sex Research. The instrument is protected under international copyright law held by the authors and the original publisher (Society for the Scientific Study of Sexuality / Taylor & Francis).

• Research & Non-Commercial Clinical Use: The questionnaire is typically made available free of charge for non-commercial academic research and clinical use upon formal request. Researchers and practitioners must obtain permission prior to reproduction or integration into digital assessment batteries.
• Contact for Permissions: Inquiries regarding test administration, authorized translations, manual guidelines, and research licensing should be directed to Dr. Pedro J. Nobre at the Faculty of Psychology and Educational Sciences, University of Porto, Portugal (or through his official institutional research laboratory, SexLab).

References

• Barlow, D. H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive interference. Journal of Consulting and Clinical Psychology, 54(2), 140–148. https://doi.org/10.1037/0022-006X.54.2.140
• Beck, A. T. (1996). Beyond belief: A theory of modes, personalities, and psychopathology. In P. M. Salkovskis (Ed.), Frontiers of cognitive therapy (pp. 1–25). The Guilford Press.
• Nobre, P. J., & Pinto-Gouveia, J. (2003). Sexual Modes Questionnaire: Measure to assess the interaction between cognitions, emotions and sexual response. The Journal of Sex Research, 40(4), 368–382. https://doi.org/10.1080/00224490309552206
• Nobre, P. J., & Pinto-Gouveia, J. (2006). Emotions during sexual activity: Differences between sexually functional and dysfunctional men and women. Archives of Sexual Behavior, 35(4), 491–499. https://doi.org/10.1007/s10508-006-9047-1
• Nobre, P. J., & Pinto-Gouveia, J. (2008). Differences in automatic thoughts presented during sexual activity between sexually functional and dysfunctional males and females. Cognitive Therapy and Research, 32(1), 37–49. https://doi.org/10.1007/s10608-007-9165-7
• Rosen, R. C., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D., & D’Agostino, R. (2000). The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy, 26(2), 191–208. https://doi.org/10.1080/009262300278598
• Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997). The International Index of Erectile Function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology, 49(6), 822–830. https://doi.org/10.1016/S0090-4295(97)00238-0

Items of the Scale