A Psychosexual Model of Sexual Functioning in Multiple Sclerosis: The Role of Body-Image Dissatisfaction, Avoidant Attachment, and Sexual Self-Efficacy

Background: Sexual difficulties (SDs) are prevalent multiple sclerosis (MS) yet remain underdiagnosed and undertreated, reflecting limited understanding of the psychological factors implicated. Although multidisciplinary models of care are increasingly advocated in MS, psychological interventions for SDs remain scarce. Sexual theory identifies avoidant attachment and internal representations of the body and sexuality as central determinants of sexual functioning. Aim: This study evaluated a novel psychosexual model in which body-image dissatisfaction was modelled as a predictor of domain-specific functions, mediated by lower sexual self-efficacy and higher avoidant attachment. Outcomes: Sexual interest, satisfaction, and orgasmic functioning domains were measured by PROMIS® Sexual Function and Satisfaction Brief Profile v2.0. Methods: A population-based cohort of 198 individuals with MS completed a cross-sectional survey, including 147 cisgender individuals reporting recent sexual activity (36 men; 111 women). Path analysis examined direct associations between body-image dissatisfaction and sexual interest, satisfaction, and orgasmic functioning, and indirect effects via avoidant attachment and sexual self-efficacy. Gender and gait-disability were included as covariates. A post-hoc sensitivity restricted to women evaluated the stability of structural pathways following the exclusion of men.Results: Body-image dissatisfaction predicted lower sexual self-efficacy (ß= -.20, p<.05, 95%CI: -.39, -.02) but not avoidant attachment or sexual function outcomes. Avoidant attachment predicted sexual interest (ß= -.22, p<.05, 95%CI: -.43, -.02), while sexual self-efficacy demonstrated medium-to-large associations across outcomes, with the largest for satisfaction (ß=.59, p<.0001, 95%CI: .37, .81). The model demonstrated excellent fit. Post-hoc sensitivity analyses suggested that findings are robust to the exclusion of men participants. Clinical Implications: Avoidant attachment and sexual self-efficacy are potentially important treatment targets. Higher avoidant attachment is relevant to diminished sexual interest, possibly reflecting a suppression of approach-oriented motivation that underpins spontaneous interest. Sexual self-efficacy is a more ubiquitous factor related to SDs. Strengths and Limitations: This is the first study to propose a psychological model of sexual functioning in MS, and examine the role of body-image dissatisfaction, avoidant attachment, and sexual self-efficacy in predicting sexual functioning outcomes in this population. The modest sample size precluded the use of multi-group path analysis to formally evaluate gender-related variation in pathways. Larger, gender-balanced samples are needed. Future research should further delineate the effects of body-image on sexual functioning. Conclusions: Avoidant attachment and sexual self-efficacy are potentially important targets for interventions targeting SDs in MS.