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

Abstract

The Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E) is a standardized, multidimensional psychometric instrument developed by Bandura’s social cognitive framework to evaluate an individual’s cognitive appraisal of their capability to achieve, maintain, and recover erectile responses across diverse sexual contexts. Originally constructed by Eva Libman, Irv Rothenberg, Catherine S. Fichten, and Rhonda Amsel (1985), the SSES-E comprises 25 self-report items rated on a 10-point to 100-point subjective confidence continuum ranging from 10 (quite uncertain) to 50 (moderately certain) and 100 (certain). The instrument systematically captures both physiological aspects of erectile performance (e.g., attaining morning erections, sustaining rigidity during intercourse, regaining tumescence post-detumescence) and non-coital, interpersonal, and affective dimensions of sexual encounters (e.g., communication of sexual needs, refractory self-regulation, body image, and managing performance anxiety). Psychometric evaluations consistently demonstrate outstanding internal consistency, with Cronbach’s alpha coefficients of .92 for functionally impaired males, .92 for functional control males, and .86 to .94 for heterosexual partners completing parallel other-report assessments. Longitudinal test-retest reliability over a one-month interval reveals exceptional stability (r = .98 for males and .97 for females). Exploratory and confirmatory factor analyses delineate five robust latent dimensions: primary erectile attainment, maintenance/recovery, non-coital intimacy, sexual communication and assertiveness, and autonomic sexual responsivity. By decoupling psychological perceived competence from purely organic vascular parameters, the SSES-E serves as an indispensable clinical assessment tool and outcome metric in sex therapy, urology, and behavioral medicine.

Keywords

Sexual Self-Efficacy Scale-Erectile Functioning, SSES-E, erectile dysfunction, sexual self-efficacy, psychogenic impotence, social cognitive theory, performance anxiety, sexual medicine, sex therapy, psychometrics

Authors

The Sexual Self-Efficacy Scale-Erectile Functioning was conceived and standardized by an interdisciplinary team of clinical psychologists and quantitative methodologists in Montreal, Quebec, Canada:

• Eva Libman, Ph.D. — Department of Psychiatry, Jewish General Hospital, and Department of Psychology, McGill University, Montreal, Quebec, Canada.
• Irv Rothenberg, Ph.D. — Department of Psychology, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada.
• Catherine S. Fichten, Ph.D. — Department of Psychiatry, Jewish General Hospital; Department of Psychology, Dawson College; and Department of Psychology, McGill University, Montreal, Quebec, Canada.
• Rhonda Amsel, M.Sc. — Department of Psychology, McGill University, Montreal, Quebec, Canada.

Purpose

The primary purpose of the Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E) is to quantify an individual’s cognitive expectancies and perceived operational capability regarding his erectile capabilities and associated sexual behaviors. Historically, the clinical assessment of erectile dysfunction (ED) was dominated either by invasive physiological diagnostic measures (such as nocturnal penile tumescence monitoring, penile duplex Doppler ultrasound, and intracavernosal pharmacotesting) or by global behavioral indices of coital frequency. These paradigms frequently neglected the critical mediator between organic or psychological etiology and sexual performance: the patient’s subjective sense of mastery, self-confidence, and anticipatory cognitions.

Grounded in clinical observation and cognitive-behavioral principles, the SSES-E was designed to address three overarching objectives:

• Diagnostic Differentiation and Pre-Treatment Assessment: The scale enables clinicians to discern the cognitive profile of men suffering from sexual dysfunctions. Men with predominantly psychogenic erectile dysfunction often exhibit marked discrepancies between solitary sexual capacity (e.g., morning erections or masturbation) and dyadic sexual performance, accompanied by catastrophic beliefs regarding temporary loss of tumescence. The SSES-E provides granular diagnostic clarity across these varying conditions.
• Treatment Planning and Cognitive Restructuring: Within sex therapy and cognitive-behavioral therapy (CBT), the SSES-E systematically identifies individual cognitive bottlenecks. Clinicians can determine whether a patient suffers from deficient confidence in initiating sexual contact, fear of failing to regain an erection, inability to communicate sexual needs, or an all-or-nothing coital imperative that disregards non-penetrative pleasure.
• Monitoring Psychotherapy and Pharmacotherapy Outcomes: The instrument acts as an exquisitely sensitive outcome evaluation metric. While biomedical treatments (e.g., phosphodiesterase type 5 [PDE5] inhibitors) can mechanically induce vasodilation, they do not automatically resolve anticipatory anxiety or dysfunctional beliefs. The SSES-E monitors whether biological symptom improvement translates into robust psychological confidence and relational satisfaction.
• Dyadic and Partner Evaluation: A major strength of the SSES-E is its parallel applicability to sexual partners, allowing clinicians to evaluate partner congruency, discrepancies in expectations, and mutual cognitive biases that maintain sexual distress.

Psychological Construct

The core theoretical construct measured by the SSES-E is sexual self-efficacy within the specific behavioral domain of male erectile functioning. Conceptualized as an extension of perceived competence, sexual self-efficacy is defined as an individual’s subjective conviction that he can successfully execute the dynamic series of physiological, emotional, and behavioral responses required for mutually satisfying sexual experiences.

This construct is distinct from general self-esteem, generalized self-efficacy, or generalized sexual desire. It represents an affirmative appraisal of operational competence across specific, challenging situations. Within the SSES-E, sexual self-efficacy comprises five distinct behavioral-cognitive sub-domains:

• Erectile Attainment across Contexts: This dimension assesses the man’s confidence in obtaining sufficient penile tumescence under diverse ecological conditions. It measures autonomic response capacity in solitary settings (e.g., Item 2: masturbation alone; Item 25: morning erections) as well as varying degrees of dyadic intimacy (e.g., Item 3: foreplay while clothed; Item 4: foreplay while nude; Item 6: sufficient firmness to initiate penetration).
• Erectile Maintenance and Cognitive Recovery: One of the most pathogenic cognitions in erectile dysfunction is the catastrophic interpretation of normative, transient detumescence during foreplay or intercourse. Items 5, 7, 8, and 9 measure the psychological resiliency required to regain an erection if it is lost, maintain rigidity until orgasm, and achieve tumescence within a reasonable, pressure-free time frame. Low self-efficacy in this dimension is the primary cognitive engine of the performance anxiety vicious circle.
• Non-Coital Intimacy and De-emphasized Penetration: Psychological flexibility in sexuality involves valuing intimacy outside of pure penile-vaginal penetration. Items 11, 14, and 15 measure the capacity to stimulate a partner to orgasm by non-coital means, enjoy sexual encounters without intercourse, and anticipate sexual intimacy without feeling an unyielding obligation to perform intercourse. High efficacy here buffers against catastrophic performance anxiety.
• Sexual Assertiveness and Dyadic Communication: Sexual encounters require effective interpersonal signaling. Items 17, 18, and 19 measure the confidence to initiate desired sexual activities, the assertive capacity to refuse unwanted sexual advances, and the direct communication required to ask the partner for specific types and durations of tactile stimulation.
• Affective and Self-Evaluative Acceptance: This dimension encompasses the subjective emotional experience of the self as a sexual being. Items 1, 12, 13, and 16 evaluate the ability to anticipate sex without apprehension, perceive oneself as physically and sexually desirable to a partner, maintain comfort with personal sexuality, and sustain intrinsic sexual interest.

Theoretical Framework

The SSES-E is firmly anchored in Albert Bandura’s Social Cognitive Theory (1977, 1986, 1997), specifically his foundational construct of perceived self-efficacy. Bandura posited that psychological functioning is mediated by cognitive representations of personal capability rather than by objective physiological capacities alone. According to Bandura, self-efficacy beliefs determine what actions people choose to pursue, how much effort they invest, how long they persevere in the face of obstacles and failures, and whether they experience debilitating anxiety or motivational resilience when confronted with demanding environmental tasks.

In sexual psychopathology, Bandura’s theory was integrated with the classic cognitive formulations of sexual dysfunction pioneered by William Masters and Virginia Johnson (1970) and Helen Singer Kaplan (1974), as well as David H. Barlow’s (1986) cognitive-affective model of sexual dysfunction:

• The Cognitive-Affective Feedback Loop: In Barlow’s model, sexually functional individuals respond to erotic stimulation with positive affect, accurate appraisal of physiological arousal, outward focus on sensory cues, and enhanced erection. Conversely, individuals with low sexual self-efficacy anticipate failure, experience intrusive negative affect, direct their attention inward toward self-monitoring (the “spectatoring” phenomenon described by Masters & Johnson), and activate sympathetic nervous system arousal, which biochemically counteracts parasympathetic penile vasodilation.
• Sources of Efficacy Information: Bandura identified four principal sources of self-efficacy expectations: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological/affective states. The SSES-E evaluates the psychological output of these four sources. A single enactive failure (an unexpected episode of detumescence) in a man with low baseline sexual self-efficacy triggers autonomic hyperarousal, which is misattributed as definitive evidence of total biological impotence, reinforcing a downward spiral of avoidance.
• Outcome Expectancies vs. Efficacy Expectancies: Bandura drew a sharp distinction between outcome expectancies (the belief that a given behavior will produce a certain outcome, e.g., “If I have a firm erection, my partner will be pleased”) and efficacy expectancies (the personal conviction that one can successfully execute the behavior, e.g., “I am confident I can maintain this erection”). The SSES-E strictly measures efficacy expectancies across systematically graded micro-behaviors, reflecting true Bandurian methodology.

Validity

The psychometric validity of the SSES-E has been rigorously documented across clinical, community, and cross-cultural cohorts using rigorous construct, discriminant, convergent, and predictive validation protocols.

Construct and Discriminant Validity

In the seminal validation study by Libman, Rothenberg, Fichten, and Amsel (1985), the SSES-E demonstrated powerful discriminant validity by clearly differentiating between men with clinically diagnosed erectile dysfunction and asymptomatic control subjects across all scale dimensions (p < .001). Sexually functional men exhibited mean confidence ratings clustering between 85 and 98, whereas men with erectile dysfunction exhibited substantially depressed mean scores, typically ranging between 25 and 55 on dyadic penetration items.

Furthermore, the instrument successfully differentiated between situational (psychogenic) and generalized (organic) erectile impairments. Men with situational dysfunction scored high on masturbatory confidence (Item 2) and morning erections (Item 25) while scoring precipitously low on items requiring dyadic intercourse (Items 6, 7, and 8), confirming the construct validity of the individual sub-dimensions.

Convergent Validity

The SSES-E demonstrates strong convergent validity with established measures of sexual functioning and affective state:

• It correlates strongly and positively with the International Index of Erectile Function (IIEF), particularly the Erectile Function and Intercourse Satisfaction domains (r values typically ranging from .65 to .82).
• It correlates moderately to strongly with the Derogatis Sexual Functioning Inventory (DSFI) and measures of dyadic marital satisfaction (such as the Dyadic Adjustment Scale).
• It correlates negatively with measures of performance anxiety, trait anxiety (e.g., State-Trait Anxiety Inventory), and cognitive distraction during sexual activity.

Predictive and Evaluative Validity

Studies evaluating clinical interventions have shown that increases in SSES-E scores over the course of sex therapy significantly predict long-term maintenance of gains at 6-month and 12-month follow-ups. Men whose physiological erections improved via biomedical aids (e.g., vacuum erection devices or intracavernous injections) but whose SSES-E cognitive scores remained depressed demonstrated significantly higher rates of treatment discontinuation, underscoring the scale’s clinical predictive utility.

Reliability

The reliability of the SSES-E has been comprehensively evaluated across multiple independent empirical investigations, confirming exceptional internal consistency and temporal stability:

• Internal Consistency: In the original validation by Libman et al. (1985), the overall Cronbach’s alpha coefficient was .92 for functionally impaired males and .92 for functional control males. When administered to female partners assessing their male partners’ efficacy, the Cronbach’s alpha was .94 for partners of dysfunctional men and .86 for partners of control men. Cross-cultural adaptations, including Persian clinical validation studies, have replicated this high internal consistency, yielding global Cronbach’s alpha coefficients as high as α = .95, with underlying factor subscales ranging from .82 to .91.
• Test-Retest Stability: Temporal stability was evaluated by Libman et al. over a 1-month test-retest interval in asymptomatic control participants. The Pearson product-moment correlation coefficient was r = .98 for males and r = .97 for female partners, demonstrating that in the absence of clinical intervention, sexual self-efficacy beliefs represent a remarkably stable cognitive schema.
• Inter-Rater / Dyadic Concordance: Studies evaluating the agreement between male patients and their intimate partners on parallel versions of the SSES-E have demonstrated moderate-to-high concordance (intraclass correlation coefficients ranging from .70 to .88), indicating that the behavioral items are observable and reliably appraised within intimate relationships.

Factor Analysis

Both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) have confirmed that the SSES-E possesses a coherent latent dimensional architecture that maps directly onto clinical domains of sexual behavior.

In classical factor analytic investigations using principal components analysis with varimax and oblimin rotations, a 5-factor structure consistently emerges, accounting for over 65% to 72% of the total variance across clinical and non-clinical samples:

• Factor 1: Coital Rigidity and Persistence (Item Loadings: .68 – .86): Encompasses items directly measuring the attainment, maintenance, and duration of erection during penetrative intercourse (Items 6, 7, 8, 9, 10, 21). This factor accounts for the largest proportion of common variance in erectile dysfunction samples.
• Factor 2: Non-Coital and Communicative Intimacy (Item Loadings: .59 – .78): Encompasses behaviors that provide sexual pleasure and dyadic connection without requiring penile-vaginal intercourse (Items 11, 14, 15, 17, 18, 19).
• Factor 3: Solitary and Autonomic Responsiveness (Item Loadings: .62 – .81): Encompasses items measuring erectile functioning independent of partner performance pressure, including nocturnal/morning erections and solitary masturbatory capacity (Items 2, 24, 25).
• Factor 4: Non-Genital Foreplay and Partner Arousal (Item Loadings: .55 – .75): Captures early arousal stages during clothed and nude foreplay and partner stimulation (Items 3, 4, 20, 22).
• Factor 5: Affective Comfort and Sexual Desirability (Item Loadings: .52 – .74): Captures psychological comfort, freedom from anticipatory dread, and perception of personal sexual appeal (Items 1, 12, 13, 16, 23).

Structural equation modeling and confirmatory factor analyses validate this multi-factor paradigm over a unidimensional model, showing superior goodness-of-fit indices (Comparative Fit Index [CFI] > .92, Tucker-Lewis Index [TLI] > .90, and Root Mean Square Error of Approximation [RMSEA] ≤ .06).

Instrument / Measurement Tool

The SSES-E is a self-administered, 25-item psychometric rating scale. The specific technical parameters of the instrument are detailed below:

• Instrument Type: Standardized self-report rating scale (also adaptable for partner collateral report).
• Item Count: 25 distinct behavioral and cognitive statements.
• Administration Format: Paper-and-pencil or secure computer-based digital questionnaire.
• Completion Time: Approximately 8 to 12 minutes.
• Response Scale: A 10-point interval confidence scale ranging from 10 to 100 in increments of 10 points:
  • 10: Quite uncertain
  • 20 – 40: Low certainty
  • 50: Moderately certain
  • 60 – 90: High certainty
  • 100: Certain
• Scoring Procedure:
  • Total Score: Calculated by summing the numerical ratings across all 25 items and dividing by 25 to yield a mean global sexual self-efficacy index ranging from 10.0 to 100.0 (or, alternatively, expressing the raw sum between 250 and 2500).
  • Subscale Scores: Calculated by summing the items comprising each factor dimension and computing the mean score for that specific behavioral domain.
  • Interpretation: Higher scores reflect stronger subjective confidence in erectile functioning and sexual mastery. Mean scores below 50 indicate clinically significant self-efficacy impairment, commonly accompanied by severe performance anxiety and coital avoidance.

Permissions & Fee and Test Year

The Sexual Self-Efficacy Scale-Erectile Functioning was published in 1985 by Eva Libman, Irv Rothenberg, Catherine S. Fichten, and Rhonda Amsel in the Journal of Sex & Marital Therapy. The scale was established as an open-access empirical instrument for academic, non-commercial clinical, and research purposes.

Researchers and qualified mental health clinicians may utilize the instrument without payment of licensing fees, provided that appropriate scholarly attribution and bibliographic citation are maintained in all publications and clinical reports. For commercial applications, pharmaceutical trial integration, or proprietary digital health platforms, permission should be secured from the copyright holders or the corresponding original authors via the Department of Psychiatry at the Jewish General Hospital / McGill University, Montreal, Canada.

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. (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., Libman, E., & Rothenberg, I. (1988). The Sexual Self-Efficacy Scale-Erectile Functioning (SSES-E). In C. M. Davis, W. L. Yarber, R. Bauserman, G. Schreer, & S. L. Davis (Eds.), Handbook of Sexuality-Related Measures (pp. 559–560). Sage Publications.
• Kaplan, H. S. (1974). The New Sex Therapy: Active Treatment of Sexual Dysfunctions. Brunner/Mazel.
• 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/10.1080/00926238508406089
• 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

Items of the Scale