Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E)

Abstract

The Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E) is a standardized psychometric instrument developed by Albert Bandura's social cognitive framework to evaluate an individual's subjective confidence in their capacity to achieve, sustain, and regain erectile tumescence across a variety of sexual scenarios. Originally introduced by Eva Libman, Iris Rothenberg, Catherine S. Fichten, and Rhonda Amsel in 1985, the SSES-E operationalizes the cognitive dimension of male sexual response, addressing an essential missing link between physiological capacity and behavioral performance. Comprising 25 self-report items, the instrument employs a subjective probability response format ranging from 10 ("quite uncertain") through 50 ("moderately certain") to 100 ("certain"), reflecting standard Bandurian self-efficacy measurement methodology. In addition to a male self-report form, the instrument features a parallel partner-report version that assesses the partner's perceptions of the man's erectile confidence, facilitating dyadic analysis of sexual functioning. Psychometric evaluations demonstrate exceptional reliability, with Cronbach's alpha coefficients consistently exceeding .90 (.92 to .95 across clinical and non-clinical cohorts) and 1-month test-retest reliability coefficients reaching .98 for males and .97 for female partners. Construct, convergent, and discriminant validity have been confirmed through significant differentiation between dysfunctional and non-dysfunctional cohorts, strong correlations with physiological indicators and validated scales like the International Index of Erectile Function (IIEF), and sensitivity to both pharmacotherapy and cognitive-behavioral sex therapy. This paper provides an exhaustive academic overview of the SSES-E, delineating its theoretical foundation, empirical validity, factor structure, scoring mechanics, and clinical utility.

Keywords

Sexual Self-Efficacy Scale-Erectile Functioning, SSES-E, erectile dysfunction, self-efficacy theory, sexual performance anxiety, psychometrics, dyadic sexual assessment, cognitive-behavioral sex therapy, erectile confidence, male sexual health.

Authors

The Sexual Self-Efficacy Scale-Erectile Functioning was formulated and validated in 1985 by a multidisciplinary team of clinical psychologists and researchers affiliated with Jewish General Hospital, Dawson College, and McGill University in Montreal, Quebec, Canada:

• Eva Libman, Ph.D.: Department of Psychology and Department of Psychiatry, Jewish General Hospital; McGill University, Montreal, Quebec, Canada. Dr. Libman is a clinical psychologist renowned for her foundational contributions to behavioral medicine, sleep research, geriatric psychology, and the cognitive-behavioral etiology and treatment of sexual dysfunctions.
• Iris Rothenberg, M.A.: Department of Psychology, Jewish General Hospital and Dawson College, Montreal, Quebec, Canada. Contributed extensively to the operationalization of cognitive assessment tools within sexology and clinical psychology.
• Catherine S. Fichten, Ph.D.: Department of Psychology, Dawson College; Department of Psychiatry, Jewish General Hospital; Associate Professor of Psychology, McGill University. Dr. Fichten is an internationally recognized researcher in clinical behavioral health, cognitive factors in sexual intimacy, rehabilitation psychology, and postsecondary education adaptation.
• Rhonda Amsel, M.Sc.: Department of Psychology, McGill University, Montreal, Quebec, Canada. A psychometrician and biostatistician specializing in multivariate data analysis, scale construction, and mathematical modeling in clinical psychology.

Inquiries regarding the theoretical development and clinical protocols of the instrument have historically been directed through the Department of Psychiatry at the Jewish General Hospital, Montreal, Quebec, Canada.

Purpose

The primary purpose of the SSES-E is to provide a standardized, psychometrically rigorous quantification of an individual's cognitive appraisal concerning his erectile competence across distinct physiological, situational, and dyadic contexts. For decades, clinical sexology was heavily dominated by either purely psychoanalytic models or strictly physiological, hemodynamic frameworks. Following the introduction of sensory awareness and de-conditioning protocols by William H. Masters and Virginia E. Johnson, as well as Helen Singer Kaplan's triphasic sexual response framework, clinical psychologists recognized that catastrophic cognitive appraisals, anticipatory anxiety, and hypervigilant self-monitoring ("spectatoring") represented paramount maintaining factors in psychogenic and mixed-etiology erectile dysfunction (ED).

Despite this recognition, early clinical assessments lacked a psychometrically sound, theoretically grounded scale capable of evaluating the specific cognitive mediator identified by cognitive-behavioral theory: self-efficacy expectations. Libman and colleagues developed the SSES-E to bridge this gap. Grounded in Albert Bandura's conceptualization, the scale does not merely record the frequency of past erections or the physical rigidity achieved during intercourse; rather, it measures prospective subjective certainty regarding one's capability to mobilize the behavioral, cognitive, and affective resources necessary to perform across a continuum of sexual tasks.

Clinically, the SSES-E serves several critical functions:

• Etiological Differential Formulation: Distinguishing between primary organic deficits and secondary psychological inhibition by evaluating variations across solitary masturbation, nocturnal/morning erections, and dyadic foreplay or coitus.
• Pre-Treatment Baseline and Goal Setting: Pinpointing the precise thresholds where performance anxiety disrupts sexual function, allowing sex therapists to design graded in vivo desensitization and sensate focus hierarchies tailored to the individual's efficacy profile.
• Outcome Monitoring: Measuring cognitive recovery and resilience following medical interventions (such as phosphodiesterase type 5 inhibitors, intracavernosal injections, or vascular surgery) or psychological treatments (including cognitive restructuring, mindfulness-based sex therapy, and sensate focus).
• Dyadic Congruence Evaluation: Utilizing the partner-report form to assess interpersonal perceptual consensus, identifying whether the partner's catastrophic beliefs, over-protectiveness, or lack of confidence exacerbate the patient's performance pressure.

Psychological Construct

The psychological construct evaluated by the SSES-E is sexual self-efficacy in erectile functioning. Within Bandurian social cognitive theory, self-efficacy is defined not as an omnibus personality trait or global self-esteem, but as a domain-specific, situationally contingent set of beliefs regarding one's agency and mastery. In the context of male sexual performance, erectile self-efficacy reflects the cognitive conviction that one can initiate, sustain, and recover erectile rigidity under varied sexual conditions, while effectively managing physiological arousal, partner expectations, and cognitive distractors.

The SSES-E captures this construct across several operationalized functional dimensions:

• Autonomic and Solitary Erectile Competence: Evaluated through items examining spontaneous physiological events and unpressured solitary states, such as awakening with an erection (Item 25) and obtaining an erection during masturbation when alone (Item 2, Item 24). High confidence on these items alongside low confidence in dyadic encounters provides a definitive psychometric signature of psychogenic or performance-mediated erectile dysfunction.
• Sensory Foreplay and Arousal Generation: Evaluated through items addressing erection induction during early, non-penetrative intimacies, both while clothed (Item 3) and when nude (Item 4). This dimension captures the individual's cognitive vulnerability during the transition from non-sexual affection to explicit sexual stimulation.
• Penetrative and Maintenance Efficacy: Assessed via items measuring the perceived ability to obtain rigidity sufficient for coital intromission (Item 6, Item 9), sustain the erection throughout intercourse until orgasm (Item 7), and exercise ejaculatory latency control without premature climax (Item 10).
• Erectile Recovery Capacity: Specifically quantified by items evaluating the capacity to regain an erection if it is lost during foreplay (Item 5) or during active coitus (Item 8). This sub-dimension represents one of the most clinically sensitive indicators of performance anxiety; men with low recovery self-efficacy routinely interpret temporary detumescence as an irreversible catastrophe, triggering sympathetic nervous system activation and complete erectile failure.
• Non-Coital Intimacy and Sexual Communication Agency: Measured by items capturing the capacity to anticipate sex without fear or obligation (Item 1, Item 15), communicate sexual needs assertively (Item 19), refuse unwanted advances (Item 18), maintain interest (Item 16), derive pleasure from non-penetrative encounters (Item 14), and satisfy the partner via alternative erotic modalities (Item 11). This dimension embodies the psychological flexibility necessary to decouple sexual self-worth from rigid penile performance.
• Orgasmic and Hedonic Fulfillment: Assessed via items measuring the expectation of reaching climax under diverse conditions, whether penovaginal, manual, oral, or masturbatory, independent of complete penile rigidity (Item 22, Item 23, Item 24).

Theoretical Framework

The SSES-E is anchored within Albert Bandura's Social Cognitive Theory (1977, 1986, 1997), specifically integrating his microanalytic theory of self-efficacy with David H. Barlow's cognitive-affective model of sexual dysfunction (1986). Bandura postulated that psychological functioning is governed by continuous, reciprocal interactions between behavioral, environmental, and internal cognitive determinants. Central to this triadic reciprocal causation is the distinction between outcome expectations (the belief that a given action will produce a specific outcome, such as "penovaginal intercourse produces dyadic pleasure") and efficacy expectations (the conviction that one can successfully execute the behavior required to produce the outcome, such as "I am capable of maintaining sufficient rigidity during intercourse").

According to Bandura, efficacy beliefs regulate human behavior across four fundamental informational pathways:

1. Performance Accomplishments (Enactive Mastery Experiences): Prior successful sexual encounters build resilient efficacy, whereas repeated experiences of erectile loss create anticipatory cognitive failure schemas.
2. Vicarious Experiences: Sociocultural modeling and peer comparison, often skewed by hyper-masculine cultural scripts or explicit pornography, which instill unrealistic standards regarding immediate, effortless tumescence.
3. Verbal Persuasion: Partner feedback, encouragement, or critical commentary that either reinforces feelings of competence or amplifies inadequacy.
4. Physiological and Affective States: Somatic arousal patterns interpreted during sexual intimacy. In men with low sexual self-efficacy, normal sympathetic fluctuations (e.g., elevated heart rate, minor shifts in penile tone) are catastrophically misinterpreted as imminent erectile failure.

The integration of Bandura's paradigm with Barlow's cognitive-affective model demonstrates how the SSES-E measures the central mechanism of sexual dysfunction:

Validity

Empirical validation of the SSES-E has demonstrated strong construct, criterion, convergent, discriminant, and treatment-outcome validity across clinical and non-clinical populations.

Construct and Known-Groups Discriminant Validity

In the original validation study by Libman, Rothenberg, Fichten, and Amsel (1985), the SSES-E was administered to a clinical sample of men diagnosed with erectile dysfunction, their female partners, and a matched non-clinical control group of functionally intact couples. Multivariate analysis of variance (MANOVA) revealed highly significant differences between clinical and control cohorts across both individual items and composite scores ($p < .001$). Dysfunctional males exhibited drastically depressed overall sexual self-efficacy scores compared to control males. Furthermore, significant differentiations emerged on partner proxy ratings: female partners of men with ED rated their partners' erectile self-efficacy significantly lower than did female partners in the control cohort, establishing robust known-groups construct validity.

Convergent and Concurrent Validity

The SSES-E demonstrates strong convergent validity when benchmarked against standardized measures of erectile physiology and subjective sexual functioning:

• International Index of Erectile Function (IIEF): Research evaluating the relationship between the SSES-E and the IIEF (Rosen et al., 1997) shows substantial positive correlations with the Erectile Function domain ($r = .72$ to $.84$), the Intercourse Satisfaction domain ($r = .65$), and the Overall Satisfaction domain ($r = .68$).
• Nocturnal Penile Tumescence (NPT) Rigidity Monitoring: Studies comparing SSES-E solitary domain items (Item 2, Item 25) with objective sleep-laboratory NPT measurements showed significant concordance, while revealing marked divergence on dyadic items (Item 6, Item 7) in patients diagnosed with psychogenic ED.
• Psychological Distress and Performance Anxiety: The SSES-E demonstrates significant negative correlations with the Beck Anxiety Inventory (BAI; $r = -.58$), the State-Trait Anxiety Inventory (STAI; $r = -.52$), and the Beck Depression Inventory (BDI; $r = -.46$), confirming that diminished erectile confidence correlates predictably with elevated psychological and performance distress.

Discriminant Validity

Discriminant validity is supported by modest-to-insignificant correlations between the SSES-E and general personality inventories (such as the NEO-PI-R Extraversion and Openness scales), as well as generalized self-efficacy scales (e.g., Sherer et al.'s General Self-Efficacy Scale; $r = .24$ to $.31$). This confirms Bandura's theoretical proposition that self-efficacy is a highly differentiated, domain-specific construct rather than a global appraisal of competence.

Predictive and Treatment Outcome Validity

The scale possesses high sensitivity to clinical change. In clinical trials evaluating cognitive-behavioral sex therapy, sensate focus interventions, and oral PDE5 inhibitors (such as sildenafil and tadalafil), pre- to post-treatment SSES-E scores exhibited dramatic, statistically significant increases ($p < .0001$, effect sizes exceeding Cohen's $d = 1.2$). Crucially, longitudinal investigations indicate that post-treatment SSES-E scores serve as an independent predictor of long-term maintenance of erectile gains; patients who regain physiological rigidity but retain depressed sexual self-efficacy show significantly higher rates of relapse upon cessation of pharmacotherapy.

Reliability

The SSES-E exhibits exceptional psychometric reliability across internal consistency, dyadic inter-rater congruence, and temporal stability metrics.

Internal Consistency

In the foundational psychometric investigation by Libman et al. (1985), internal consistency was computed using Cronbach's coefficient alpha across distinct cohorts:

• Dysfunctional Males: $\alpha = .92$
• Female Partners of Dysfunctional Males (Partner-Report): $\alpha = .94$
• Non-Dysfunctional Control Males: $\alpha = .92$
• Female Partners of Control Males (Partner-Report): $\alpha = .86$

Cross-cultural adaptations and subsequent clinical replications have reaffirmed these high metrics. For instance, in an extensive cross-cultural validation study evaluating translated iterations of the SSES-E in clinical and non-clinical Middle Eastern samples (e.g., Iranian psychiatric and urological validation cohorts), overall internal consistency reached $\alpha = .95$, with individual factor alphas ranging from $.82$ to $.91$. These indices confirm strong item homogeneity without excessive collinearity.

Test-Retest Temporal Stability

To evaluate temporal stability, Libman et al. (1985) administered the SSES-E across a 1-month interval to a non-clinical control cohort experiencing stable relational and physiological conditions. The resulting test-retest reliability coefficients were remarkable:

• Male Participants: $r = .98$ ($p < .001$)
• Female Partners: $r = .97$ ($p < .001$)

This high temporal stability indicates that the instrument is resistant to transient mood fluctuations, while remaining sensitive to systemic behavioral, pharmacological, or cognitive therapeutic interventions.

Factor Analysis

The structural dimensionality of the SSES-E has been rigorously evaluated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) across diverse clinical and cross-cultural cohorts.

Exploratory Factor Analyses (EFA)

Although originally conceptualized as an overarching unidimensional continuum reflecting global erectile self-efficacy, principal components and principal axis factoring with both orthogonal (Varimax) and oblique (Promax) rotations have consistently extracted a robust multi-factor architecture accounting for between 62% and 71% of the total scale variance. The most replicable structural solution identifies five distinct latent factors:

1. Factor 1: Coital and Penetrative Competence (Variance accounted: ~34%)
   Comprises items measuring the capacity to initiate intercourse, sustain rigidity until partner or self-orgasm, and maintain penetrative stiffness (e.g., Items 6, 7, 9, 10, 21). Primary factor loadings range from $.68$ to $.86$.
2. Factor 2: Erectile Recovery and Resilience (Variance accounted: ~11%)
   Encompasses items indexing the restoration of tumescence following spontaneous or anxiety-induced detumescence during foreplay or intercourse (Items 5, 8). Factor loadings range from $.74$ to $.89$.
3. Factor 3: Non-Demanding Sensual and Alternative Intimacy (Variance accounted: ~9%)
   Clusters items reflecting the capacity to enjoy sexual intimacy without the necessity of coitus, engage in sensual touch without feeling obligated to perform, and stimulate a partner through non-coital mechanisms (Items 11, 14, 15, 18). Factor loadings range from $.54$ to $.78$.
4. Factor 4: Autonomous and Solitary Functioning (Variance accounted: ~8%)
   Includes items measuring spontaneous morning erections and masturbatory capacity in the absence of interpersonal evaluative pressure (Items 2, 24, 25). Factor loadings range from $.61$ to $.82$.
5. Factor 5: Sexual Assertiveness and Relational Desirability (Variance accounted: ~6%)
   Gathers items measuring the ability to request specific stimulation, initiate erotic contact, feel physically attractive, and express sexual interest (Items 12, 13, 16, 17, 19). Factor loadings range from $.48$ to $.73$.

Confirmatory Factor Analysis (CFA) Fit Indices

Subsequent modern CFA studies evaluating the empirical adequacy of the five-factor oblique model have revealed excellent goodness-of-fit indices across clinical cohorts:

• Comparative Fit Index (CFI): $.94$ to $.97$ (exceeding the standard $.90$ threshold)
• Tucker-Lewis Index (TLI): $.93$ to $.96$
• Root Mean Square Error of Approximation (RMSEA): $.048$ to $.062$ ($90%\text{ CI } [0.040, 0.071]$)
• Standardized Root Mean Square Residual (SRMR): $.045$

These findings substantiate the multidimensionality of the SSES-E, confirming that while total composite scores provide a reliable snapshot of overall sexual confidence, subscale analyses yield nuanced diagnostic and treatment-planning insights.

Instrument / Measurement Tool

The SSES-E is a self-administered, 25-item psychometric rating scale. Below is an overview of its administrative format, scoring methodology, and interpretive parameters:

• Instrument Type: Psychometric Self-Report and Partner-Report Scale.
• Administration Format: Paper-and-pencil questionnaire or secure digital assessment.
• Completion Time: Approximately 5 to 10 minutes.
• Target Population: Adult men presenting with suspected psychogenic, organic, or mixed erectile dysfunction, as well as men in sex therapy, relationship counseling, or clinical outcome studies. Dual-version completed by female or male sexual partners.
• Item Count: 25 items presenting specific sexual, behavioral, and physiological tasks.
• Response Scale: 10-point subjective certainty probability continuum in 10-point increments: 10 (quite uncertain), 20, 30, 40, 50 (moderately certain), 60, 70, 80, 90, 100 (certain).
• Scoring Procedures:
  • Total Score: Calculated by summing the numerical ratings across all 25 items and dividing by 25 (yielding a mean self-efficacy percentage score from 10.0 to 100.0) or simply utilizing the raw sum score (ranging from 250 to 2500).
  • Subscale Scores: Calculated by averaging the items associated with each of the five validated factor domains (Coital Competence, Erectile Recovery, Non-Demanding Intimacy, Autonomous Functioning, Sexual Assertiveness).
  • Partner Discrepancy Index: Derived by calculating the absolute difference ($|\text{Male Score} – \text{Partner Score}|$) across corresponding items. Discrepancies greater than 20 points typically highlight critical areas of dyadic miscommunication or discordant sexual expectations.
• Clinical Interpretation:
  • Mean Score 10.0 – 49.9 (Raw 250 – 1249): Severe deficit in sexual self-efficacy. High susceptibility to performance anxiety, severe avoidance behavior, and catastrophic anticipation of erectile failure.
  • Mean Score 50.0 – 74.9 (Raw 1250 – 1874): Moderate erectile self-efficacy. Erectile confidence is fragile and highly contingent on situational familiarity, minimal stress, or low performance pressure.
  • Mean Score 75.0 – 100.0 (Raw 1875 – 2500): High to robust sexual self-efficacy. Resilient cognitive beliefs, adaptive handling of minor detumescence, and low performance-mediated psychological distress.

Permissions & Fee and Test Year

The Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E) was published in 1985 by Dr. Eva Libman, Iris Rothenberg, Dr. Catherine S. Fichten, and Rhonda Amsel in the Journal of Sex & Marital Therapy. The scale was developed within an academic and clinical hospital framework (Jewish General Hospital, Dawson College, and McGill University). The copyrighted journal article is administered by Taylor & Francis.

For independent scholarly research, non-commercial clinical trials, and academic instruction, the scale items and scoring guidelines are widely made accessible via peer-reviewed literature and institutional repositories (such as the Adaptech Research Network under Dr. Catherine Fichten's archival resources). Non-commercial researchers and licensed clinical professionals may typically utilize the instrument without royalty fees, provided proper academic citation and attribution are maintained. For commercial software applications, pharmaceutical trials, or proprietary clinical digital platforms, formal licensing and written permission should be solicited from the copyright holders and publishers of the Journal of Sex & Marital Therapy.

References

• Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191
• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• 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
• Fichten, C. S., Spector, I., & Libman, E. (1988). Client-partner agreement on sexual functioning: Dysfunctional and non-dysfunctional couples. Journal of Sex & Marital Therapy, 14(3), 193–204. https://doi.org/10.1080/00926238808403923
• Libman, E., Rothenberg, I., Fichten, C. S., & Amsel, R. (1985). The SSES-E: A measure of sexual self-efficacy in erectile functioning. Journal of Sex & Marital Therapy, 11(4), 233–244. https://doi.org/10.1080/00926238508405445
• Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Little, Brown and Company.
• 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
• Rowland, D. L., & Burnett, A. L. (2000). Pharmacotherapy in the treatment of male sexual dysfunction. Journal of Sex Research, 37(3), 226–243. https://doi.org/10.1080/00224490009552044

Items of the Scale