From Prevention to Promotion in Women’s Sexual Self-Perceptions of Efficacy: The Sexual Self-Efficacy Questionnaire

Self-efficacy, people’s beliefs regarding their ability to successfully perform an action to achieve desired consequences (Bandura, 1977), is a strong predictor of behaviors, including those leading to health-related outcomes (Leman et al., 2021). Sexual self-efficacy (SSE) refers to the confidence in one’s own ability to make decisions and actions regarding sexuality — particularly when faced with barriers and obstacles — including avoiding high-risk sexual behaviors (e.g., having sex after alcohol intake) and performing healthy protective and promotive behaviors to prevent undesired outcomes (e.g., using a condom) and to enhance positive aspects, such as sexual satisfaction (e.g., communicating personal desires), respectively. SSE plays a significant role in people’s control over their sexual life (Assarzadeh et al., 2019), as it is associated with behaviors and outcomes related to a healthy sexuality, e.g., sexual communication (Pariera, 2018), non-risky sexual behaviors (Van Campen & Romero, 2012), and sexual satisfaction (De Guzman, 2022). Notwithstanding the above, research regarding the relations between SSE and sexual health promotion or sexual satisfaction, in positive terms, is scarce, as it has focused on the relation between (lack of) SSE and risky sexual behaviors such as unprotected sex, having multiple sexual partners, alcohol/drug use or an early sexual debut (e.g., Guzmán & Dello Stritto, 2012; Penner et al., 2019; Viseskul et al., 2015), and their relationship with undesired outcomes such as unplanned/unwanted pregnancy and sexually transmitted diseases (STDs). Additionally, women’s sexuality has traditionally involved more negative expectations, social roles, associations, and outcomes than male sexuality, thus producing fewer opportunities to experience it positively (Conley & Klein, 2022). As such, research and intervention approaches have been mostly focused on dysfunctions and the medicalization of women’s sexuality, “a process of establishing universal norms and then declaring all variations disordered and in need of treatment” (Tiefer, 2003, p. 35); however, a critical position is increasingly being adopted; nonetheless, research on sexual health topics is usually based on general and stereotyped statements (Klein et al., 2022), not taking into account the cultural, social, and psychological distinctions between males’, females’, and non-binary persons’ sexuality.

Most of the tools used to date to assess SSE are ad hoc instruments (e.g., Carlson & Soller, 2019; Closson et al., 2018; Ferrer-Urbina et al., 2019) or measures that include SSE as a component of a broader construct (e.g., self-conceptions, Bond et al., 2020). Most of them have been created to measure self-efficacy regarding preventive sexual behaviors, such as the Self-efficacy Instrument for Protective Sexual Behaviors (SEA) (Kasen et al., 1992), the Self-Efficacy Instrument for Condom Negotiation and Condom Use (Pratte et al., 2010), the Self-Efficacy Subscale for Condom Use (CPS-AE) (Ballester et al., 2007, 2013), the Condom Use Self-Efficacy Scale (CUSES) (Brafford & Beck, 1991), the Contraceptive Self-Efficacy Scale (CSE) (Levinson & Beamer, 1998), and the Sexual Risk Behavior Beliefs and Self-Efficacy Scales (SRBBS) (Basen-Engquist et al., 1998). Appropriate psychometric properties have been reported for all these measures (Fisher et al., 1998; Milhausen et al., 2020).

There are many similarities between these tools. Most of them were created to measure male condom use during heterosexual dyadic relationships as a preventive sexual behavior: e.g., negotiation of its use, “Insist on using a condom even if your partner does not want to use it” (SEA). They also assess the ability to reject having sexual intercourse in condom-use-related situations: e.g., “If my boyfriend and I are getting “turned-on” sexually and I don’t really want to have sexual intercourse, I can easily stop things so that we don’t have intercourse” (CSE), or the sureness to be able to purchase condoms: e.g., “Be embarrassed to buy a condom” (Pratte et al., 2010). The CPS-AE includes the efficacy expectations to use other contraceptive methods (hormonal pills, diaphragm…), and the SRBBS also includes other types of beliefs, such as abstinence (e.g., “Most of my friends believe people of my age should wait until they are older before they have sex”).

All the above-mentioned measures include situations in which SSE is important to practice preventive behaviors in different sexual situations, but none of them include other behaviors besides the use of condoms or birth control for intercourse or rejection/management of sexual activities, nor do they include any sexual behavior specifically aimed at improving sexual satisfaction or a healthier sexuality (e.g., the confidence to perform pleasurable sexual behaviors or new techniques beyond intercourse, or one’s own ability to talk with the partner(s) about desired sexual behaviors, feelings, satisfactory experiences, etc.). Also, neither considers other sexual orientations except for heterosexual dyadic relations, and are always centered around intercourse.

Due to the limitations of the existing tools for assessing efficacy expectations surrounding a holistic, agentic, healthier, and positively viewed sexuality, this study aimed to validate a comprehensive measure of SSE, considering self-efficacy expectations to engage not only in preventive sexual behaviors but also in actions that promote sexual health and satisfaction (e.g., using fantasies, communication of desires, building personal strengths). In doing this, we carefully considered women’s and non-binary gender individuals’ perspective and inclusive language to extend the use of the measure to a broader population in terms of sexual identities and options, activities, and methods (e.g., protective aids), not limiting its boundaries to dyadic coital and heterosexual relationships. We thus developed an extensive self-report of SSE, the Sexual Self-Efficacy Questionnaire (SSEQ), and explored its reliability and validity in a wide sample of Spanish women.

As a first step, factorial validity was tested to verify the scale composition. Firstly, an EFA was conducted with MLE method for factor extraction and Oblimin rotation of the factor loading matrix. A Kaiser–Meyer–Olkin index of 0.91, Barlett’s sphericity chi-square = 16,835.784, p < 0.001, and Goodness of fit (chi-square = 6,806.734, p < 0.001) indicated the appropriateness of the EFA. The communalities found for most of the items were appropriate, ranging from 0.3 to 0.7. At this step, 11 items were definitively excluded from further analyses due to communality values < 0.2 and rotated weights < 0.4. Furthermore, the 5-factor eigenvalue-based initial solution was hardly meaningful; thus, we forced a two-factor solution, which was supported by (a) the conceptualization of the items to assess efficacy expectations for both preventive and health-promotive actions, (b) the leveling off of eigenvalues on the scree plot after the non-forced factor solution, and (c) the number of primary loadings in each factor and the difficulty of interpreting the original five-factor solution. Thus, the two-factor solution was preferred given its support for the bidimensional structure of the SSEQ and its easiness for interpreting. The two-factor solution (eigenvalues > 2.5) explained 34.5% of the variance. The factor loading matrix for this model is presented in Table 2, with item loadings > 0.4. The factors identified were the following: Factor 1, labeled SSE for health promotion actions, included 13 (of the initial 17) items assessing self-efficacy regarding the ability to perform behaviors aimed at achieving a potentially healthier and more pleasurable sexuality or talk about it with the partner(s), and Factor 2, labeled SSE for preventive actions, included 16 (of the initial 23) items assessing self-efficacy regarding the ability to perform certain preventive/protective behaviors or to talk with the partner(s) about prevention.

Secondly, a CFA was conducted with ML method. Initially, a bifactorial model (M1) following the EFA solution for the 29 final items was tested, showing a good model-data fit. Nonetheless, re-specified models were tested following the modification indices provided by AMOS, such as the exclusion of some items with factor loadings < 0.3 (M2), or the elimination of the poorest items in order to achieve an item-equilibrium in each factor composition (M3), both models showing better model-data fit. The final solution (M3) supported the bifactorial structure of the SSEQ. Table 3 shows goodness of fit of all models tested. Figure 1 shows the last model, selected as the one presenting the best model-data fit, according to both the goodness of fit indices and the theoretical approach. Furthermore, this final model had a “good” goodness of fit, according to the criteria adopted of reaching the cutoffs for three of the four goodness of fit indices.

Reliability for the 20-item SSEQ was high, with Cronbach’s alpha = 0.89 for the complete questionnaire. Internal consistency would not be improved if any of the items were excluded (alpha, if items were removed, ranged from 0.889 to 0.881). Reliability for each factor was also appropriate, alpha = 0.87 for Factor 1 SSE for health promotion actions and alpha = 0.82 for Factor 2 SSE for preventive actions.

Finally, Pearson’s correlation analyses were conducted to explore convergent validity of the SSEQ. Table 4 shows the findings, which indicated that all the variables were positively intercorrelated. Table 4 also shows the descriptive results obtained. All the scores on the four measures of SSE, including SSEQ subscales, were high and quite homogeneous.

This study presented the development and explored the psychometric properties of the SSEQ, aimed at assessing two complementary dimensions of SSE: the perceived confidence in performing both preventive sexual behaviors and, specially, those promoting a potentially healthier and more satisfying sexuality, counting on women’s perspective and other realities beyond intercourse and dyadic heterosexual relationships and hence overcoming the main limitations of the existing SSE self-reports.

An initial version with 40 items from a preliminary pool of elements was created. To refine the measure, factorial validity was explored. Then, the final 20-item version was further analyzed in terms of convergent validity and reliability. We thus followed a psychometrics-based sequential procedure to obtain the SSEQ.

The EFA and CFA conducted to explore the factorial structure of the SSEQ supported its bi-factoriality. Although in EFA it is common to determine the number of factors to retain following Kaiser’s criterion (Kaiser, 1960), it has been argued that it could result in an overestimation of the number of factors (Yong & Pearce, 2013). Consequently, we retained only the two factors above the point of inflexion shown in the scree test, a solution reliable in samples ≥ 200 participants (Yong & Pearce, 2013). This was coherent with the rationale underlying the construction of the measure and the contents of its items: one factor grouped items measuring self-efficacy expectations for conducting preventive-protective behaviors, whereas the other factor grouped items assessing self-efficacy for conducting overall well-being and sexual satisfaction promotion behaviors.

Based on the EFA results, a first model was tested with CFA that showed good but upgradeable model-data fit. Consequently, we re-specified the model and better model-fit indices were obtained. The final solution included 10 items for the factor SSE for promotive actions, such as the perceived confidence in freely and safely communicating on diverse aspects, innovating and being creative, practicing and enjoying oral sex, using fantasies; initiating sexual relations, and participating proactively in making sex more satisfying. All these contents relate to women’s sexual satisfaction and health (e.g., Mallory, 2022; Rausch & Rettenberger, 2021). The complementary factor, SSE for preventive actions, includes items about the perceived efficacy for discussing with the partner(s) and engaging in actions intended to prevent STDs or unwanted pregnancy, but also about the perseverance in these behaviors, inquiring about seeking information to effectively use contraceptive methods, condom negotiation with partner(s), or rejecting unprotected or unwanted sexual approaches (e.g., Casey et al., 2009).

Reliability for the SSEQ and its two dimensions was excellent. Although values ≥ 0.7 indicate an appropriate internal consistency, some authors have proposed that values too near to 1 could implicate the existence of redundant items that do not really add relevant information when assessing a construct (Rodríguez-Rodríguez & Reguant-Álvarez, 2020).

We also explored SSEQ convergent validity with some common measures used to assess SSE. All these measures were intercorrelated, as was expected given that all of them are validated instruments that assess SSE. Since these tools are mainly focused on dyadic, heterosexual relationships, and preventive behaviors, correlations between the SSEQ and them were modest, and more robust for the subdimension surrounding preventive actions. Moreover, the relation between both dimensions of the SSEQ is moderate, given that they are measuring complementary, yet different constructs. The comparison of the descriptive results obtained with the SSEQ and the remaining tools of SSE add value to the convergent validity of the SSEQ.

Regarding SSEQ, descriptive results showed that the participants were a homogeneous group with high SSE, with perceptions of self-efficacy for promotive actions as high as for preventive actions. The rest of SSE measures confirmed this high SSE and homogeneity. Hence, women in our study beneficiate in their sexual life from having high confidence in themselves for conducting behaviors intended to both maximize well-being and satisfaction and minimize risks and negative consequences, yet measures to date were not able to address efficacy expectations for the former ones.

Considered together, our findings support the use of the SSEQ as an alternative and psychometrically sound tool to gather information on two complementary SSE beliefs: those related to behaviors seeking to achieve an agentic, healthier, more pleasurable sexuality, and those related to behaviors aimed at preventing unwanted, potentially risky consequences derived from sexual activities.

Nonetheless, some limitations must be noted. Firstly, our findings were obtained with a sample of young and middle-aged females and replication with a more heterogeneous sample in terms of gender identity and sexual orientation is advisable. Indeed, it is possible that our findings are partly derived from the composition of the sample; for instance, it is possible that some items, such as practicing autoerotic activities like masturbation or correctly using a condom, would have obtained better results in a multi-gender identity sample (i.e., higher scores in a male sample; Carvalheira et al., 2015) and would have led to other decisions. For the same reasons, future lines of inquiry could focus on its application in other cultural backgrounds and age groups. Secondly, the reduction of the measure from the initial 40 items pool was based on the loadings obtained in the sample recruited. Some of the items excluded following EFA and CFA could be rewritten in order to improve their quality, such as efficacy expectations for using the emergency contraceptive pill (a safe and appropriate preventive behavior when risk of pregnancy is elevated due to unprotected or incorrectly protected intercourse, but current redaction of the item may have led participants to reject it as a “regular” protective behavior) or for rejecting a sexual relationship when suspicions regarding the risk of STDs are elevated (maybe by adding “and there is no possibility for safe protection” would have helped the respondents to consider its truly intended content). Some other items were unexpectedly discarded from the final measure (e.g., self-efficacy for communicating with the partner(s) about personal states or non-desired/non-wanted encounters, activities, or behaviors or for being able to acquire and carry protection methods or the emergency contraceptive pill) and future research might re-explore their contribution. In addition, some statements might be more determined by personal history and attitudinal background than efficacy expectations (e.g., communicating with the partner about prevention when having more than one sexual partner), and further research is warranted to establish the influence of personal experiences, values, and attitudes regarding sexuality. Finally, this is a cross-sectional study with validation purposes; further investigation incorporating the SSEQ in research and clinical contexts is warranted to confirm its generalizability and usefulness.

We validated a bidimensional measure of SSE including efficacy beliefs and expectations regarding actions with preventive and promotive goals from women’s perspective. This tool intends to solve the limitations of other measures, focused only on the first dimension. As long as females’ — and human — sexuality is much more than avoiding undesired aspects, and is mainly aimed at pleasure, joy, and fulfillment, a comprehensive measure of efficacy expectations was warranted. Furthermore, the SSEQ explores self-efficacy beliefs beyond the heterosexual, dyadic, and intercourse-focused frame. The psychometric soundness of the SSEQ in terms of reliability and factorial and convergent validity has been supported.