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