Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=hjsr20 The Journal of Sex Research ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hjsr20 Attitudes toward Help-Seeking for Sexual Problems among College Women Kenneth J. Parnell, Douglas A. Spiker, Tiana A.K. Johnson & Mackenzie B. May To cite this article: Kenneth J. Parnell, Douglas A. Spiker, Tiana A.K. Johnson & Mackenzie B. May (2023) Attitudes toward Help-Seeking for Sexual Problems among College Women, The Journal of Sex Research, 60:4, 535-544, DOI: 10.1080/00224499.2022.2029808 To link to this article: https://doi.org/10.1080/00224499.2022.2029808 Published online: 09 Feb 2022. Submit your article to this journal Article views: 227 View related articles View Crossmark data Attitudes toward Help-Seeking for Sexual Problems among College Women Kenneth J. Parnell a , Douglas A. Spiker b , Tiana A.K. Johnson a , and Mackenzie B. May a a Applied Psychology and Counselor Education, University of Northern Colorado; b Counseling and Psychological Services, Purdue University ABSTRACT Prior research has indicated that 65–70% of college age women have experienced at least one sexual problem. Sexual problems are associated with higher rates of depression, anxiety, and relationship distress; however, few college age women seek professional help for sexual difficulties. The present study used the Theory of Planned Behavior to explore how adherence to traditional feminine norms and self-stigma are associated with intention to seek professional psychological help for a sexual difficulty. Results of structural equation modeling analysis demonstrated approximate fit in a sample of 259 college women. The structural model indicated that self-stigma and stronger endorsement of specific feminine gender norms (i.e., romantic relationship, sexual fidelity, sweet and nice) were found to be associated with less intention to seek help for a sexual problem. We discuss future research directions and implications for clinical services. Findings from national surveys reveal that 24%-44% of women report experiences of sexual difficulties (Hendrickx et al., 2014; Laumann et al., 1999). In two surveys that focused on women in college, 65%-70% endorsed at least one sexual problem (Garneau-Fournier et al., 2017; Turchik & Hassija, 2014). This is a significant concern as sexual experiences in young adulthood lay the foundation for sexual health and wellbeing for the future. Additionally, sexual problems have been linked to higher rates of depression, anxiety, and relationship distress (Kendurkaur & Kaur, 2008; Laurent & Simons, 2009; Rosen et al., 2019). While the sexual problems college age women face has gar- nered needed attention in recent years, there is still a noticeable lack of empirical research on the subject (Garneau-Fournier et al., 2017; Tambling & Reckert, 2014). One area of concern is why so many women with sexual problems do not seek professional help. According to prior research, only 19% of women who had a sexual problem sought treatment and only about 9% reported being asked about sexual problems during routine medical checkups (Moreira et al., 2005; Shifren et al., 2008). Research has also demonstrated that the majority of psychologists have not received adequate training on sexual problems and often do not bring up sex unless specifically asked by the client (see, Cruz et al., 2017). The failure to address these problems in a timely manner leaves many to suffer longer and more intense symptoms, as well as psychological and relational distress (Donaldson & Meana, 2011). Previous research on sexual health in college women has focused primarily on prevalence rates and risk factors associated with sexual problems (Galinsky & Sonenstein, 2011; O’Sullivan et al., 2014; O’Sullivan & Majerovich, 2008). Fewer studies have explored the barriers women face in seeking psychological help for these issues, despite the low numbers of women seeking help for sexual problems and the high correlation between sexual problems and other key health indicators (Laumann et al., 1999; Lykins et al., 2006). Research has established that stigma is one important barrier for seeking mental health services for anxiety and depression, which may translate to barriers in help-seeking for sexual problems (Eisenberg et al., 2007; Vogel et al., 2017). Only preliminary studies have explored stigma in relation to seeking help for sexual problems among college age populations (Bergvall & Himelein, 2014; Normansell et al., 2015). Research has also found that greater endorsement of traditional feminine gen- der role attitudes is correlated with less sexual risk knowledge and less sexual assertiveness among women (Curtin et al., 2011). However, research has not directly measured if greater adherence to specific aspects of traditional feminine norms may influence college women’s beliefs regarding help-seeking for a sexual problem. The present study addressed the current gap in the help- seeking literature by utilizing the Theory of Planned Behavior (TPB; Ajzen, 2006) to examine how self-stigma and adherence to traditional feminine norms may be associated with college women’s attitudes, subjective norms, perceived behavioral con- trol, and intention to seek psychological help for sexual pro- blems. It is hoped that the findings of this study will shed light on what factors limit women’s help-seeking for sexual pro- blems. With this understanding, researchers can better develop models of help-seeking, and health centers can better plan interventions and psychoeducation to prevent problems or change attitudes and facilitate help-seeking for these women. Theory of Planned Behavior and Help-Seeking The Theory of Planned Behavior model has been used to understand and predict mental health help-seeking behaviors using three cognitive components, including attitude, CONTACT Kenneth J. Parnell kenneth.parnell@unco.edu Applied Psychology and Counselor Education, University of Northern Colorado, Campus Box 131, Greeley, CO 80639, USA THE JOURNAL OF SEX RESEARCH 2023, VOL. 60, NO. 4, 535–544 https://doi.org/10.1080/00224499.2022.2029808 © 2022 The Society for the Scientific Study of Sexuality subjective norms, and perceived behavioral control (PBC; Ajzen, 2006; Shea et al., 2019). Attitude refers to an individual’s evaluation (i.e., good-bad, helpful-unhelpful) of the help- seeking action, subjective norms refer to perceived social expectations surrounding the action, and perceived behavioral control refers to the perceived difficulty in completing the help- seeking action. Attitude, subjective norms, and PBC influence intentions. In the TPB, intentions are thought to be the stron- gest predictor of future behavior. Intentions “capture the moti- vational factors that influence a behavior, they are indications of how hard people are willing to try, of how much of an effort they are planning to exert, to perform the behavior” (Ajzen, 1991, p. 181). The TPB has been applied to investigate a wide variety of human behaviors to better understand help-seeking for various mental and physical health-related problems, including psychological (Hess & Tracey, 2013; Mo & Mak, 2009; Smith et al., 2008), sexual and relational (Lin et al., 2017; Parnell & Hammer, 2018; Spiker et al., 2019), and other medical concerns (Hunter et al., 2003; Wu et al., 2015). Therefore, the TPB appears to be an appropriate model to further explore what factors may contribute to college women’s reluctance to seek psychological help for sexual problems, specifically feminine gender norms. Feminine Gender Role Norms While women generally appear to have more favorable atti- tudes toward psychological help-seeking than men, research has found more nuance than is commonly understood. Evidence is mounting that gender differences in help-seeking either balance out or even reverse depending on presenting concerns, culture, treatment modality, and other contextual factors (see, Vogel & Heath, 2016). Regarding help-seeking for sexual problems specifically, it should be noted that people of all genders demonstrate low rates of help-seeking, and thus, this issue is not unique to women (Moreira et al., 2005). The present study examined whether adherence to traditional fem- inine roles may be an obstacle to help-seeking for sexual difficulties in order to more narrowly focus on variables that may be more relevant for women. Although research suggests women are slightly more likely to generally seek help for sexual problems, they are less likely to seek help from a mental health professional than men (Moreira et al., 2005). This is despite the fact that the most common sexual problem women report is a lack of interest in sex (Moreira et al., 2005). Therefore, it is critical that researchers not focus exclusively on gender dis- crepancies but come to a more nuanced understanding of how gender influences help-seeking. Exploring adherence to gender norms in the context of help-seeking for particular problems may help explain why few emerging adult women seek profes- sional help for sexual concerns despite high prevalence rates and associated distress (Curtin et al., 2011; Eisenberg et al., 2007; Garneau-Fournier et al., 2017). Gender role norms refer to sexual scripts, or rules and expectations, which society holds around socially appropriate behaviors for men and women. Conformity to these gender role norms describes an indivi- dual’s level of adherence or agreement with society’s expecta- tions for their gender (Parent & Moradi, 2010). Adherence to traditional gender norms has been found to limit socially legitimate masculine and feminine sexual goals and behaviors that impact sexual health and empowerment for all genders (Curtin et al., 2011; Grose et al., 2014; Impett et al., 2006; Shea et al., 2017). A growing body of research has established links between adherence to traditional feminine norms and sexual concerns. Specifically, women who endorse more traditional gender roles demonstrated less sexual health knowledge and lowered con- fidence in their ability to advocate for themselves sexually (Curtin et al., 2011). These same women also expressed less knowledge about reproductive health and disease and preg- nancy prevention. Therefore, it is possible that women who adhere more strongly to certain feminine norms may not interpret and encode internal and external cues in such a way to prioritize their own needs when they may be experiencing a sexual functioning concern that merits professional attention (Fitter et al., 2009; Vogel et al., 2006). Further, when women perceive a sexual concern, they may feel less comfortable seek- ing and advocating for support from a professional, given that they tend to feel less confident advocating for their sexual needs in general (Marriott & Thompson, 2008; Shallcross et al., 2018). Evidence also supports a connection between greater body self-consciousness, a core aspect of feminine norms, and lower levels of sexual pleasure, arousal, decreased self-confidence to refuse sex, and lower condom usage (Kiefer & Sanchez, 2007; Woertman & van Den Brink, 2012; Yamamiya et al., 2006). These studies support similar notions that feminine norm-adhering women may not be as comfor- table asserting their needs, which may be associated with lower levels of help-seeking for sexual problems (Braksmajer, 2018; Impett et al., 2006). A further exploration of feminine norms reveals that tradi- tionally, women have often been discouraged from engaging in sexual behaviors outside of specific circumstances. For exam- ple, the norm of sexual fidelity refers to limiting sexual experi- ences to being within committed relationships (Mahalik et al., 2005). According to traditional feminine scripts, sexual experi- ences outside of a committed relationship are considered inap- propriate. From this perspective, help-seeking for sexual concerns may be considered risky because acknowledging sex- ual activity and problems associated with it could imply that one is violating the norm of sexual fidelity and could open oneself to the judgment of others, including peers, family, and health care workers. If women have internalized these norms, they may also shame themselves, which could be another barrier to seeking help. The norm of thinness, or the pursuit and preoccupation with body image (Mahalik et al., 2005) may also be associated with attitudes toward help-seeking for sexual problems. Evidence suggests that greater body self-consciousness is asso- ciated with higher levels of sexual avoidance, ambivalence in sexual decision making, and sexual risk taking (Sanchez & Kiefer, 2007; Schooler et al., 2005; Yamamiya et al., 2006). Further, recent research discovered body dissatisfaction pre- dicts sexual dissatisfaction in both heterosexual and bisexual women (Moreno-Domínguez et al., 2019). Women receive constant societal messages that link their worth and person- hood with their bodies and physical appearance (Fredrickson & Roberts, 1997; Hill & Fischer, 2008). Further, a woman’s 536 K. J. PARNELL ET AL. body is often primarily valued for its use to or consumption by others, often within a sexual context (Impett et al., 2006; Szymanski, 2020). In other words, women may have learned to link their self-worth with their bodies and its performance, and acknowledgment of sexual functioning concerns could imply a ‘broken’ body and lead to decreased self-worth and shame over perceived inadequacies (Ayling & Ussher, 2008; Braksmajer, 2018; Shallcross et al., 2018). Conversely, a meta- analysis by Murnen and Smolack (2009) found that feminist identity was correlated with more positive body image and negatively associated with valuing thinness. Taken together, these findings suggest that women who have internalized tradi- tional gender norms regarding their bodies may feel less empowered to seek professional help for sexual problems. Investing oneself in a romantic relationship is another fem- inine norm (Mahalik et al., 2005; Parent & Moradi, 2010) that may serve to either motivate or inhibit help-seeking for sexual concerns in women. A qualitative study of women experien- cing vulvar pain during sex found that participants perceived sex as central in “proper” romantic relationships (Marriott & Thompson, 2008), despite their own discomfort and pain. This perspective may encourage women who more strongly adhere to the romantic relationship norm to seek help in order to be an accommodating sexual partner, which may be associated with a more positive attitude toward help-seeking. However, research suggests that dominant sexual narratives in hetero- sexual relationships often promote male partner’s sexual plea- sure over women’s, conveying the message that women must endure pain and prioritize their partner’s pleasure to regain their femininity and avoid rejection by partners and peers (Hogue et al., 2019; Impett et al., 2019; Marriott & Thompson, 2008; Shallcross et al., 2018). Women who have internalized this norm may experience themselves more as “observers than as actors,” minimizing their own pleasure or health even to the point of considering sexual problems as normal and not deserving of professional attention (Curtin et al., 2011, p. 51). These same women may also feel inhibited to seek help because of taboos surrounding women and sex and harmful responses from professionals and others when they do risk bringing up the subject, decreasing their perceived beha- vioral control over seeking help (Ayling & Ussher, 2008; Braksmajer, 2018; Kaler, 2006). Being perceived as sweet and nice and modest are addi- tional traditional feminine norms (Parent & Moradi, 2010), and may be added barriers to a woman’s perceived behavioral control in help-seeking for sexual concerns. Traditionally, women who more closely adhere to these norms may have internalized messages that they need to behave in passive ways and therefore may perceive assertively seeking help for sexual difficulties as challenging their sweet and passive demeanor. Additionally, studies support that when women do seek help for sexual concerns, their concerns are not perceived as legitimate (Braksmajer, 2018; Marriott & Thompson, 2008). Receiving minimizing or invalidating responses may make accessing help feel increasingly difficult for women who feel the need to behave in submissive ways because of internalized feminine norms. As a result, they may experience decreased perception of behavioral control to seek help for sexual problems. Self-Stigma Researchers have commonly examined two types of stigma: social stigma and self-stigma. Social stigma associated with seeking professional help refers to the perception that those who seek professional help are in some way socially undesir- able or flawed (Vogel et al., 2006). Self-stigma is the internali- zation of a society’s stigmatizing views toward those who seek help (Vogel et al., 2006), and has repeatedly been shown to be an important barrier to seeking professional help (e.g., Corrigan & Rao, 2012; Vogel et al., 2006). College students from countries across the world have indicated self-stigma is a limiting factor in help-seeking more broadly (Vogel et al., 2017). Self-stigma has been explored within the TPB frame- work as well as other models and has been found to be nega- tively associated with help-seeking beliefs among women and college students (Lin et al., 2017; Shea et al., 2017). Several studies have found evidence that stigma mediates the relation- ship between cultural values, such as adherence to gender norms, and attitudes towards help seeking (Choi & Miller, 2014; 2014; Shea et al., 2017; Spiker et al., 2019). Self-stigma has been explored in help-seeking among young adult women experiencing sexual problems, although the research is limited. Bergvall and Himelein (2014) compared how self-stigma affected help-seeking for sexual concerns in two small samples of college students in Sweden ( n = 81) and the United States ( n = 71). Researchers found that participants who reported a tendency to self-stigmatize were less willing to seek help from a range of professionals. While not a study on college women, Lin et al. (2017) used the TPB to explore the impact of self-stigma on help-seeking behaviors for sexual concerns in a sample of Iranian women. Self-stigma was found to be negatively associated with help-seeking attitudes and behavior. The present study built on previous findings by examining how specific feminine norms were associated with self-stigma and help-seeking beliefs for sexual problems in a sample of college women. Current Study The current study aimed to add to our understanding of vari- ables that limit college women’s intention to seek professional help for sexual problems within an established theory of help- seeking. Following TPB and prior research, we hypothesized a structural model with positive associations between attitudes, subjective norms, and perceived behavioral control with inten- tion to seek help (Hess & Tracey, 2013; Parnell & Hammer, 2018; Smith et al., 2008). To better understand how adherence to traditional feminine norms influenced perceptions of help seeking, we hypothesized inverse relationships between the feminine norms of sexual fidelity, romantic relationship, and thinness with attitudes. Additionally, we hypothesized inverse relationships between the gender norm of romantic relation- ship, sexual fidelity, and sweet and nice with subjective norms and an inverse association between romantic relationship, sex- ual fidelity, sweet and nice, and modesty with perceived beha- vioral control for the reasons described above. As prior research has demonstrated that self-stigma is a barrier to col- lege students and women’s help-seeking (Shea et al., 2017; THE JOURNAL OF SEX RESEARCH 537 Vogel et al., 2017, 2006) we hypothesized that self-stigma would be negatively associated with attitudes and perceived behavioral control as well. The present study examined parti- cipants' attitudes toward help-seeking if they had a sexual problem. According to TPB and prior research, intention is key to behavior (Ajzen, 2002; Armitage & Conner, 2001). As stated previously, little research exists on women’s help- seeking for sexual concerns; as such we followed the accepted pattern of literature on help-seeking to explore participants' beliefs about help-seeking without requiring that they be experiencing the problem currently (Bergvall & Himelein, 2014; Hess & Tracey, 2013; Parnell & Hammer, 2018; Rochlen & O’Brien, 2002; Vogel et al., 2017). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), sexual dysfunction is conceptua- lized primarily as a problem relating to desire, arousal, orgasm, and/or pain during sexual activity. In the present study, we were interested in assessing participants’ attitudes toward seek- ing help for a sexual problem even if they had not met with a professional or met criteria for a formal diagnosis. Consequently, the phrase “sexual problem” was used in place of sexual dysfunction. The present study included the DSM framework and assessed participants' willingness to seek help if they experienced a sexual problem relating to desire, arousal, orgasm, and/or pain during sexual activity. Method Participants and Procedure Participants were 259 cisgender women college students at a mid-sized university in the Rocky Mountain region of the U.S. Eligible participants included those who identified as women and were 18 years of age or older. Participants ranged in age from 18 to 28 ( M = 19.34, SD = 2.02). Approximately 65.5% of the sample identified as White/Caucasian, 20.1% as Latina/x, 5.7% as Black, African American, or African- Caribbean, 3.8% as Asian, 1.1% as American Indian or Alaska Native, 0.8% as Native Hawaiian or Pacific Islander, and 3% preferred not to answer. Regarding relationship sta- tus, 55.2% of the sample identified as single, 40.5% as in a relationship (never married), 3.9% married or in a domestic partnership and 0.4% as separated. After ethics approval, participants were recruited through a university research pool administered by the psychology department. Compensation was provided for participants in the form of extra credit and course credit for academic coursework in specific undergraduate college courses. Interested participants were directed to an online survey that began with an informed consent page, continued with the survey items, and ended with a debriefing page. Approximately 58.3% of the sample had sought help from a mental health professional in the past. Measures TPB-based instruments measuring intention, subjective norms, attitudes, and perceived behavioral control were cre- ated based on Ajzen’s (2002) scale development guidelines. Participants were not asked if they were currently experiencing sexual problems, and they were instructed that for the purposes of the study, sexual problems included issues such as lack of arousal, lack of orgasm, pain during sex, or lack of desire. Intention Intention was assessed with a 3-item help-seeking intention instrument (e.g., “I would plan to seek help from a mental health professional to address a sexual problem”) rated from [1] extremely unlikely to [7] extremely likely ). Higher scores indicated greater intention to seek therapy. The internal con- sistency of this instrument was found to be .96 from scores in the current sample. Help-seeking intention instruments that follow Ajzen’s guidelines have previously demonstrated evi- dence of reliability (α ≥ .97; Hammer & Vogel, 2013; Mo & Mak, 2009) and validity (e.g., significant positive associations between intention and both attitudes and subjective norms around seeking professional psychological help; Hammer & Vogel, 2013; Mo & Mak, 2009). Subjective Norms Subjective norms was assessed with a 3-item subjective norm instrument (e.g., “It is expected of me that I seek help from a mental health professional to address a sexual problem)” rated from [1] extremely unlikely to [7] extremely likely ). Higher scores indicated more positive subjective norms regarding help seeking for sexual concerns. The internal con- sistency of this instrument was found to be .80 from the scores in the current sample. Help-seeking subjective norms instru- ments that follow Ajzen’s guidelines have previously demon- strated evidence of reliability (α ≥ .85; Hammer & Vogel, 2013; Mo & Mak, 2009) and validity (e.g., significant positive asso- ciation between subjective norms and intention to seek help; e.g., Mo & Mak, 2009). Attitudes Attitudes was assessed with a 5-item bipolar help-seeking atti- tudes instrument with the stem “For me, seeking help from a mental health professional to address a sexual problem would be . . . “. Six adjective pairs (e.g., bad – good) were rated on a 7-point Likert type scale. Higher scores indicate more posi- tive attitudes toward seeking therapy. The internal consistency of this instrument was found to be .85 from scores in the current sample. Help-seeking attitudes instruments that follow Ajzen’s guidelines have previously demonstrated evidence of reliability ( α ’s ≥ .82; Hess & Tracey, 2013; Mo & Mak, 2009) and validity (e.g., significant positive association between atti- tudes and intention to seek help; e.g., Mo & Mak, 2009). Perceived Behavioral Control Perceived behavioral control was assessed with a 4-item perceived behavioral control instrument (e.g., “If I wanted to, I could seek help from a mental health professional to address a sexual problem)” rated from [1] definitely false to [7] definitely true . Higher scores indicated greater perceived behavioral control to seek help for sexual concerns. The internal consistency of this instrument was found to be .66 in the current sample. Help-seeking perceived behavioral control instruments that follow Ajzen’s guidelines have 538 K. J. PARNELL ET AL. previously demonstrated evidence of reliability (α ≥ .69; Hess & Tracey, 2013; Mo & Mak, 2009) and validity (e.g., significant positive association between perceived beha- vioral control and intention to seek help; e.g., Hess & Tracey, 2013; Mo & Mak, 2009). Conformity to Feminine Norms The Conformity to Feminine Norms Inventory (CFNI-45; Parent & Moradi, 2010) is a 45-item scale with nine subscales measuring endorsement of facets of feminine ideology. The current study used the following five subscales: Romantic Relationship (e.g., “Having a romantic relationship is essential in life”; α = .70), Sexual Fidelity (e.g., “I would feel guilty if I had a one-night stand”; α = .87), Thinness (e.g., “I would be happier if was thinner”; α = .90); Sweet and Nice (e.g., “Being nice to others is extremely important”; α = .68), and Modesty (e.g., “I always downplay my achievements”; α = .82). Questions are rated from 1 ( strongly disagree ) to 4 ( strongly agree ) with higher scores indicating greater endorsement of feminine norms. The other subscales were not used due to the lack of empirical or theoretical support for help-seeking for a sexual problem. The CFNI-45 has demonstrated internal consistency ( α = .65 – .93) and construct validity (e.g., body esteem) has been found in samples of college women (Parent & Moradi, 2010; Siegel & Calogero, 2019). Self-Stigma of Seeking Help The 10-item ( α = .74) Self-Stigma of Seeking Help Scale (SSOSH; Vogel et al., 2006) assesses perceived self-stigma for seeking psychological help (e.g., “I would feel inadequate if I went to a therapist for psychological help.”). Participants rated each item from 1 ( strongly disagree ) to 5 ( strongly agree ) with higher scores indicating greater self-stigma. The SSOSH has demonstrated strong relationships with theoretically- related constructs in a college adult sample of mostly White women (e.g., attitudes; Vogel et al., 2006). The SSOSH has demonstrated test-retest reliability over a period of 2 months ( α = .72) and internal consistency (α = .89; Vogel et al., 2006). Past Help-Seeking Behavior Past couple help-seeking behavior was assessed with the fol- lowing yes/no item: “Have you ever attended counseling with a mental health professional before?.” Results Data Preparation The initial dataset contained 300 individuals. Thirty-six cases with significant (> 95%) total missingness were deleted as this fell outside of the tolerance range recom- mended by prior researchers (Dodeen, 2003). The 36 deleted cases did not differ significantly on any demo- graphic (e.g., age) or study variables. Participants older than 28 years of age ( n = 5) were removed from the sample as the focus of the study was college women, which the literature typically conceptualizes within the emerging adulthood development stage (Jensen Arnett, 2015). In the retained sample ( N = 259), no variables exceeded cutoffs of 3 and 10 for high univariate skewness and kurtosis values, respectively (Kline, 2016; Weston & Gore, 2006). The exo- genous variables did not exhibit multicollinearity based on correlation coefficients below Kline’s 2016 recommendation (i.e., less than .9). Missing data ranged from a low of 0% for many items to a high of 2.7% on one perceived beha- vioral control item. Results of the missing completely ran- dom at test (MCAR) indicated that the data were missing at random, χ2 (259) 2099.04, p = .471. Due to the ordered- categorical nature of the item response data, we used a polychoric correlation matrix based on the mean and variance adjusted weighted least square (WLSMV) estima- tor in M plus version 6.11 (Muthén & Muthén, 1998–2012). WLSMV uses pairwise deletion to handle missing data, which was appropriate given the insubstantial amount of missing data (i.e., covariance coverage ranged from .958 to 1.00). See Table 1 for descriptive statistics and intercorrela- tions among study variables. The scaled chi-square statistic (scaled χ 2 ), Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), and Tucker-Lewis Index (TLI) were used to assess the goodness of fit for the model. The WLSMV estimator does not provide the Standardized Root Mean Square Residual (SRMR). The following fit criteria were used: RMSEA ≤ .07, CFI ≥ .90, and TLI ≥ .90 for approx- imate fit (Kline, 2016). To disattenuate measurement error, latent variables were created for each construct. We mod- eled all latent constructs using the corresponding (sub)scale items as manifest indicators. Past help-seeking was opera- tionalized as an observed variable. Table 1. Means, standard deviations, and intercorrelations among measures (N = 259). Dependent Variables Possible Range M SD 1 2 3 4 5 6 7 8 9 10 11 1. Intention 01-Jul 3.72 1.81 - 2. Attitudes 01-Jul 3.94 1.24 .63** - 3. Subjective Norms 01-Jul 3.21 1.62 .57** .44** - 4. Perceived Behavioral Control 01-Jul 5.38 1.06 0.38 .39** .18** - 5. Self-Stigma of Seeking Help 01-May 2.55 0.59 −0.1 −.24** −0.06 −.27** - 6. Fidelity 01-Apr 2.55 0.76 −0.02 −.18** −0.05 −0.03 0.04 - 7. Romantic Relationship 01-Apr 2.9 0.51 −.14* −0.12 0.01 −0.01 0.01 0.002 - 8. Thinness 01-Apr 2.81 0.77 −0.05 −.22** −0.05 −0.07 0.09 −0.01 0.05 - 9. Sweet and Nice 01-Apr 3.36 0.44 0.02 0.04 −0.04 0.09 −0.02 −0.01 .26** 0.11 - 10. Modesty 01-Apr 2.3 0.52 −0.11 −0.08 −0.07 −0.12 .16** 0.01 −.17** .13* 0.07 - 11. Past Help Seeking N/A N/A N/A 0.03 0.03 0.08 −0.02 0.12 .21** −0.01 −.14* −0.06 −0.03 - * p < .05, ** p < .01 THE JOURNAL OF SEX RESEARCH 539 Analyses We first used confirmatory factor analysis to ensure the data fit the measurement model (Weston & Gore, 2006). The measurement model demonstrated approximate fit, χ 2 (1082, N = 259) = 1797.38, p < .001; RMSEA = .050 [90% CI of .046, .054]; CFI = .952; TLI = .947. The manifest indicator loadings on the latent variables were all significant at p < .05. The hypothesized structural model (see Figure 1) exhibited approximate fit, χ2 (1145, N = 259) = 2183.77, p < .001; RMSEA = .059 [90% CI of .055, .062]; CFI = .932; TLI = .927. Many parameter estimates supported our hypotheses, with a few notable exceptions. Fidelity, thinness, and romantic relation- ship variables had non-significant associations with self-stigma. Thinness demonstrated a non-significant association with atti- tudes and the association between sweet and nice and subjective norms was non-significant. Finally, sweet and nice exhibited a positive association with perceived behavioral control rather than an inverse association. The structural model accounted for 65.1% of the variance in intention, 66.3% of the variance in attitudes, 35.2% of the variance in PBC, 32.7% of the variance in subjective norms, and 7.6% of the variance in self-stigma. Discussion The purpose of this study was to utilize an established theory of help-seeking to help fill a gap in the literature as to why so few college women seek help for sexual problems. Specifically, we examined how adherence to traditional feminine gender norms and self-stigma influence college women’s intent to seek pro- fessional psychological help. The results of structural equation modeling provided support for TPB as a useful framework for this form of help-seeking, indicating that attitudes, subjective norms, and PBC are each important for understanding college women’s intentions to seek mental health help for a sexual problem. Subjective norms had a particularly strong associa- tion with intention to seek help. Subjective norms refers to one’s belief about whether most people (especially peers and those important to them) would approve and support their behavior to seek help in this context. The association between subjective norms and intentions to seek help suggest that the desire to conform to important others’ beliefs around sexual problems was a strong influence in this population. This find- ing appears congruent with the literature on adolescence and emerging adulthood, which highlights the significant role peers and key influencers play in the socialization process (Jensen Arnett, 2015). This association also appears to support a finding by Kaler (2006), who reported that women experien- cing sexual problems frequently perceive negative impact not only on their romantic relationships but also on other peer relationships as they felt shame and exclusion. To our knowledge, the present study is the first to examine relationships between traditional feminine norms and the intention to seek professional help for a sexual problem. As predicted, specific feminine norms were associated with more negative attitudes, subjective norms and PBC. Specifically, stronger endorsement of the romantic relationship norm and sexual fidelity norm warrant close attention. The negative correlation between these two norms and attitudes was parti- cularly strong, suggesting that women who strongly value investing in a romantic relationship and only having sex with one committed partner may view acknowledging and seeking help for a sexual concern as threatening the stability of that relationship. This interpretation of the findings is supported by previous research that has identified a bias toward male plea- sure in heterosexual partnerships, indicating a belief that in order to maintain a relationship, women must prioritize their partner’s pleasure, even at the cost of physical pain during sex, Figure 1. The structural model. Parameter estimates represent standardized regression coefficients. Dashed lines indicate nonsignificant direct relations and full lines indicate significant direct relations at p < .05. Error terms, correlations, and indicator factor loadings are omitted for visual clarity. 540 K. J. PARNELL ET AL. or risk rejection (Impett et al., 2019; Shallcross et al., 2018). Therefore, women may be operating under the belief that their own sexual needs are secondary to those of their partner and addressing their own needs may be a threat to their relational values and identity (Hogue et al., 2019). This finding also aligns with prior research that found women reported a loss of fem- inine identity when experiencing a sexual difficulty (Ayling & Ussher, 2008; Marriott & Thompson, 2008). It may be that this painful loss of identity makes it more difficult for women to risk further loss of identity by disclosing it to a partner or professional helper. The association between these feminine norms and attitudes within TPB may also suggest that these women hold the belief that seeking professional help would not be an effective strategy either because of a lack of knowledge on how it could be useful or because of negative prior help-seeking experiences (Braksmajer, 2018). The significant correlation between the relationship and fidelity norms and subjective norms suggests that college women do not believe other women who have a sexual pro- blem would seek professional help or that the people in their life whose opinion they value most would approve of them seeking help. These beliefs might contribute to a sense that this issue is better left unexplored or minimized, thus decreasing intention to seek help (Kaler, 2006). It may be that women in the sample believed that others would not expect them to get help because lack of desire, arousal, orgasm, and/or pain is perceived to be “normal” and they have become resigned to this experience as a woman and there is not a reason to seek help for something that is “normal” (Elmerstig et al., 2008; Elmerstig et al., 2013). Research has shown that women often feel a pressure to overly focus on meeting their partner’s sexual needs to the exclusion of their own needs in order to feel valuable, leading to relationship and sexual distress, as well as symptoms of anxiety and depression (Hogue et al., 2019; Impett et al., 2019). Women with these experiences might be less likely to seek help for these sexual problems and then present for services to address anxiety or depression, never mentioning sexual problems without careful assessment (O’Sullivan & Pasterski, 2014). The norms of sexual fidelity and relationships were also associated with less perceived behavioral control, which implies that these women may evaluate help-seeking for a sexual concern as being difficult and at odds with maintaining their relationship. Though the association between these gen- der norms and PBC was relatively smaller than the association between attitudes and subjective norms, it seems to be of critical importance that these women appeared to have decreased confidence that they could seek services if they wanted to. A limitation of the current study was not examining if sexual orientation impacted help-seeking attitudes. For queer-identified women, internalized homonegativity or hav- ing experienced identity-based discrimination may increase the perceived difficulty in seeking professional help (Kuyper & Vanwesenbeeck, 2011). This aligns with prior research that found staggering rates of substandard care and discrimination in health care settings for queer-identified women, as 37% of sexual minority women reported experiences of being treated differently than others in health care settings (Lambda Legal, 2010). Contrary to our hypothesis, the sweet and nice norm was positively related to perceived behavioral control. Future research would need to explore this association further. Women who more strongly endorse the sweet and nice norm may have more confidence in their ability to secure assistance if and when they seek help, suggesting this may be a strength associated with this norm in the context of help-seeking. Also contrary to our hypothesis, thinness was not associated with attitudes or self-stigma, demonstrating that preoccupation with physical appearance was not associated with beliefs relat- ing to the benefits of seeking help. Prior research has estab- lished a connection with feminine gender norms relating to body consciousness and it may