DEVELOPMENT OF SEXUAL ASSERTIVENESS AND ITS FUNCTION FOR HUMAN SEXUALITY: A LITERATURE REVIEW

The aim of this paper was to present a literature review on sexual assertiveness (SA), on factors and life experiences that are associated with its development, and on its function in human sexuality. It was found that demographic variables (e.g., age, education, gender), sexual experiences (e.g., type of partnership, sexual victimization), psychosexual issues (e.g., sexual functioning, body self-esteem, emotion regulation, resourcefulness) and cultural factors (e.g., sexual scripts, gender stereotypes) might positively or negatively contribute to SA. Furthermore, the outcomes of SA for both individuals and intimate relationships are presented. Based on this review, it is concluded that although SA could be fostered by training programs, cultural factors still withhold many individuals from reaching a satisfactory level of SA. Finally, recommendations about how to further the study of SA are presented.


Introduction
Sexual assertiveness (SA) has been identified as an important construct in the context of human sexuality (Santos-Iglesias & Sierra, 2010) and is defined in various ways. These definitions comprise many elements including the ability to initiate or to refuse sexual activity with a partner, the capacity to negotiate the use of condoms or other contraceptive methods, the ability to discuss with a partner about each other´s sexual history, and the communication of sexual desires and satisfaction (Loshek & Terrell, 2014;Morokoff et al., 1997;Noar, Morokoff, & Harlow, 2002).
Previous research has shown that SA may have positive outcomes for both individuals and their relationships. It was shown that SA positively affects the level of satisfaction with oneself as well as with a partner (Greene & Faulkner, 2005), that it contributes to sexual functioning , and constitutes a possible prevention strategy for unwanted pregnancies, sexually transmitted infections (STI) and sexual victimization (Livingston, Testa, & VanZile-Tamsen, 2007;Noar, Carlyle, & Cole, 2006;Noar et al., 2002).
The recognition of the importance of SA in human sexuality has resulted in an increased research interest in the topic that started in the 1970s (Santos-Iglesias & Sierra, 2010). Initial research into SA viewed it as one of the overall categories of general assertiveness (Gambrill & Richey, 1975). However, it was found that an assertive person is not necessarily assertive in a sexual context (Onuoha & Munakata, 2005), which led to the assumption that SA is more difficult to develop than general assertiveness (Morokoff et al., 1997;Noar et al., 2002). Since the 1990s, more studies have focused on sexual assertiveness as a construct in its own right and have attempted to better understand it (Loshek & Terrell, 2014;Morokoff et al., 1997).
Moreover, based on the positive outcomes of SA, it is suggested that further study into SA will be helpful in unravelling the reasons behind unwanted and unsafe sexual activities. This might be especially important in social contexts in which, as a result of cultural norms, indicators of sexual and reproductive health are problematic, i.e., having to consent to unwanted sexual intercourse (Bay-Cheng & Eliseo-Arras, 2008) because one is not able to refuse (Santos-Iglesias, .
Previous studies have suggested that SA is developed throughout the life of a person and is seemingly due to a combination of facilitating and inhibiting factors (Zerubavel & Messman- 2020, Vol., 54, No. 2, e948 ARTICLE | 3

Revista Interamericana de Psicología/Interamerican Journal of Psychology
Moore, 2013). However, studies suggest that there are conceptual differences in SA across sociocultural contexts, highlighting the importance of taking contextual factors into account when studying SA (Yoshioka, 2000).
Historically, most studies have focused on understanding the importance of SA in human sexuality both theoretically (Santos-Iglesias & Sierra, 2010) and empirically (Greene & Faulkner, 2005;Morokoff et al., 1997;. While this approach has led to a good foundation in understanding SA, a broader, more global understanding of the development of SA in both sexes that takes into account the associated factors and cultural context is needed. The aim of this paper is to present a literature review on sexual assertiveness (SA), on factors and life experiences that are associated with its development, and on its function in human sexuality.

Article Retrieval
To find relevant sources pertaining to SA, a search for scientific articles was conducted using the search engines PubMed, Limo and Google Scholar. The following keywords were included: (Sexual) Assertiveness, Negotiation Strategies, Communication, Sexual Agency, and the Spanish term Asertividad Sexual. These keywords also brought up other key words related to the topic, and facilitated the retrieval of relevant literature.

Inclusion criteria
Scientific articles were included if they were: (1) published in an English or Spanish peerreviewed journal; (2) based on an empirical study on sexual assertiveness or any of its associated factors; and (3) published in the last 15 years. Studies that were published more than 15 years ago were only included when they were frequently mentioned in the literature and were presented as important to the field, i.e. authors that made important contributions and articles containing information on useful instruments that are relevant to empirically studying SA (Appendix 1).

Characteristics of the studies
In total, 46 scientific articles (see Table 1 (Loshek & Terrell, 2014;Morokoff et al., 1997). Finally, there were some intervention studies that aimed to evaluate the impact of training programs on levels of sexual assertiveness in certain populations.

Findings
The results of this review revealed that SA is influenced by a combination of several aspects. The importance of and extent to which each aspect influences SA is presented around the description of several topics, i.e., demographic characteristics, cultural context, sexual experiences, and psychosexual factors.

Demographic characteristics
As presented below, demographic characteristics, such as age, education and gender, have been shown to be associated with the development of SA.

Age
Although SA can develop throughout one's life, there are key periods in which this development is most likely to occur and thus, deserved research attention. During adolescence and emerging adulthood, romantic relationships and sexual activity are normative. This means that this is an important key period for both sexes to develop the necessary skills to attain a healthy sexual life (Shulman & Connolly, 2013;Manlove, Franzetta, Ryan, & Moore, 2006). Therefore, in these periods there is a need to understand the various types of relationships individuals have (Kan & Cares, 2006), but also how they transition from being single (individualistic processes) to becoming a couple (dyadic processes) (Shulman & Connolly, 2013). In this period, challenges to the development of SA are related to a lack of experience in negotiating sexual activity (Beres, 2010), a low awareness of their sexual and reproductive rights (Rickert, Sanghvi, & Wietmann, 2002), and an increased vulnerability to act under pressure (e.g., comply in unwanted sexual activities to keep their partner) (Bay-Cheng & Eliseo-Arras, 2008). Additionally, in an effort to have a 'successful' relationship, individuals at this age often put their partner's needs before their own, even if this may be detrimental to their own physical and mental health (Rickert et al., 2002).

Education
Level of education was considered in some studies as this element also typically increases with age. A study comparing graduate and undergraduate female students found an association between higher levels of education and greater SA (Rodriquez, Johnson, & Combs, 2001). In addition to the level of education, it is also important to take into account the exposure, or lack thereof, to sex education programs that stimulate the development of SA in individuals. Hirst (2008) highlighted the importance of sex education and training programs in improving factors that have an impact on the contexts, motivations and outcomes of sexual encounters and therefore have implications for SA. Importantly, there are dimensions of SA that are more easily fostered by training programs, such as a sense of empowerment and self-efficacy to resist pressure from a sexual partner to have sexual intercourse (Kelley, Orchowski, & Gidycz, 2016).

Gender
There are specific gender-based norms that influence sexual behavior in intimate relationships and these norms are discussed in some studies on SA. Men and women seem to assert their sexual thoughts in different ways . Research has shown that men and women are expected to derive their specific roles from social scripts and that they act in accordance with these gendered standards (Fetterolf & Sanchez, 2015). Social scripts for men often include seeking pleasure and fun, and so they should regularly initiate sexual intercourse (Manago, Ward, & Aldana, 2015;Vannier & O'Sullivan, 2011), whereas scripts for women regarding sex refer to love and affection, and, as 'gatekeepers of sex', women need to develop skills to refuse and prevent sexual intercourse (Bourdeau, Thomas, & Long, 2008;Manago, Ward & Aldana, 2015;. Given the importance of gender scripts in SA, it is necessary to consider the current differences, but also how they can be changed and adapted in the modern era. An important new challenge is to study how social media and an online 'messages' affect the development of SA in women and men (Manago, Ward, Lemm, Reed, & Seabrook, 2015).

Cultural context
The premise that cultural context shapes sexual behavior informs the idea that the development of SA in men and women is, in part, the result of gender dynamics in a society. It is important to take into account that cultural context varies widely and that many groups have their own perceptions of what SA means and how it is tied to different codes and values (Yoshioka, 2000;Rickert et al., 2002). Cross-cultural studies that have evaluated the levels of SA between cultures have concluded that women and men living in Western, i.e., European and North American, culturesalso known as individualistic societiesshow higher levels of SA compared to those living in Eastern, i.e., Asian, and Latin American culturesalso known as collectivisticsocieties (Rodriquez et al., 2001;Yoshioka, 2000).
In a broad conceptual sense, cultural context operates by giving ´standards of normality´ which in turn result in dominant specific gender ideologies (Fetterolf & Sanchez, 2015

Sexual scripts
Sexual behavior is the result of cognitive modelsalso known as sexual scriptsthat organize the understanding of certain situations and drive individuals' behavior (Simon & Gagnon, 2003). Sexual scripts refer to actions that are appropriate in certain situations and guide individuals' thoughts before taking action. These scripts lead to a permanent evaluation of one´s behavior based on the learned roles that differ for men and women (Greene & Faulkner, 2005).
It has been shown that less adherence to traditional sexual scripts leads to more discussions between partners about sexual activities, although this did not influence efficacy to request certain sexual behavior (Greene & Faulkner, 2005). Moreover, it has been suggested that 'traditional' scripts are still predominant for women and especially in Latin American cultures. In Latin American cultures women are expected to be passive, submissive and non-assertive, and to demonstrate desire for affection and love, rather than for sex. In contrast, men are expected to be aggressive, emotional, intensive, and uncontrollable when they are sexually aroused. It is expected that men are the ones who will initiate sex and that it will be focused on conquest and seeking pleasure for themselves (Castillo , Perez, Castillo, & Ghosheh, 2010;Goicolea et al., 2012). Given the societal pressure to conform to these scripts, gender stereotypes and a sexual double standard are reinforced, clearly highlighting a disparity for what is considered acceptable behavior for both sexes (Manago, Ward & Aldana, 2015).

Gender stereotypes
Gender stereotypes are a combination of personality traits, attitudes, values, and behaviors that characterize the social expectations of men and women . In general, most cultures differ in terms of the social expectations for men and women concerning behavior in sexual situations (Tolman et al., 2016). In Latin American cultures, these social expectations are quite conservative. For a Latin woman, it is difficult to openly speak about her sexual desire with her partner, and, in some cases, even acknowledging her sexual desire might be an issue (Impett, Schooler, & Tolman, 2006). In contrast, Latin men are expected to be open about their sexual desires and to initiate sexual activity (Manago, Ward & Aldana, 2015). When analyzing gender stereotypes in Latin American cultures, it is important to consider the moral codes, machismo and marianismo, and their reinforcement by the system of familismo, as they play a significant role in the sexual expectation of men and women (Castillo et al., 2010).
Machismo refers to a gender stereotyped role in which virility is mainly based on an exaggerated role of masculinity and power exerted by men, particularly to dominate women in the context of intimate relationships (Arciniega, Anderson, Tovar-Blanc, & Terrence, 2008). This concept is often related to a kind of male power that drives all masculine behaviors and reinforces the idea that a man is allowed to guide the relationship, especially with regard to sexual activities (Sastre et al., 2015).
Marianismo is the cultural counterpart of machismo and defines the stereotyped gender role of women within Latin society. This moral code emphasizes the spiritual superiority of women over men, as shown in qualities such as modesty, devotion, chastity, and virginity. Moreover, this concept leads to a cultural image of a woman as a familiar and spiritual pillar and the one who stays silent and submissive (Castillo et al., 2010).
Machismo and marianismo are reinforced by familismo which is a well-known belief system that characterizes Latin American families (Manago, Ward & Aldana, 2015). Familismo refers to the identification, or extension of oneself, that an individual might have within their family (Raffaelli & Ontai, 2004). It implies having respect for, and submitting to others, particularly to figures of authority such as older people, parents, men and husbands. This often dictates that women take on a subordinate position within the dynamic of a family (Castillo & Cano, in Castillo et al., 2010). It is assumed then that within this concept, a woman's behavior should be a reflection of the norms that were taught in the home.
Machismo, marianismo and familismo are considered important barriers for the development of SA within intimate relationships due to the opposite expectations that these stereotypes prescribe for both genders (Bourdeau et al., 2008). These expectations are particularly marked when considering the initiation of sex: men feel that they are expected to initiate sex (Vannier & O'Sullivan, 2011), whereas women report not having control over sexual encounters as they feel that they must wait to be 'seduced' by their male partner (Goicolea et al., 2012). This sentiment is also echoed when it comes to contraception. Sastre et al. (2015) suggest that the use of condoms for safe sex is typically under the control of the man, whereas when a woman insists on using condoms, it is often interpreted as mistrust or even an indication of promiscuity (Greene & Faulkner, 2005).

Sexual experiences
Another factor associated with the development of an individual's SA is one's sexual experiences either as a child, an adolescent, or an adult. Every element that constitutes sexual experience plays an important role, acting either as a barrier or a facilitator in the development of SA. Elements related to sexual experiences that are found to be associated with SA are presented below (Morokoff et al., 1997;Beres, 2010;Santos-Iglesias & Sierra, 2012;Kennett, Humphreys, & Schultz, 2012;Zerubavel & Messman-Moore, 2013).

Type of partnership
The impact of type of partnership has received increased attention since research has shown that the levels of SA might differ in an individual when they move from one partner to another (Morokoff et al., 1997). As intimate relationships differ depending on the type of partnership, the dynamic and quality of each relationship can have a varying influence on an individual's SA (Morokoff et al., 1997). Despite the varied types of partnerships, two elements were identified as strong determinants for SA in most sexual relationships.
First, the initial stages of a relationship are typically characterized by greater difficulties regarding communication, as the individuals have not been exposed to each other very long and do not know each other very well. This feeling abates over time as confidence grows when more time is spent with each other (Kitzinger & Frith, 1999 Second, the other strong determinant of SA is sexual experience and the number of previous partners. This is particularly relevant for women, although evidence from review is conflicting. On one hand, when it comes to initiating sexual activities, sexually experienced women have been found to be more assertive in comparison with less experienced women (Rickert et al., 2002), however, women with more previous sexual partners have been found to have more difficulties refusing sexual activity and implementing prevention strategies (Auslander, Perfect, Succop, & Rosenthal, 2007).

Sexual Victimization
Sexual victimization refers to any violent or coercive experience, including cuddling, fondling, kissing, and in several cases rape and incest, for which physical force, authority, or difference in age is used as a mechanism to dominate another person (Greene & Navarro, 1998, in Santos-Iglesias & Sierra, 2012. While this phenomenon occurs in both genders and across all ages, higher incidences are reported by women, children and adolescents . It is also important to note that sexual victimization also includes consenting to unwanted sexual activity with a partner (Kennett, Humphreys, & Schultz, 2012).
According to the literature, the relationship between sexual victimization and the development of SA is reciprocal (Livingston et al., 2007). Individuals affected by sexual victimization may have difficulties initiating and controlling sexual activities, and negotiating the use of condoms Santos-Iglesias & Sierra, 2012;Rickert, et al., 2002). This can lead to the possibility of further victimization, known as re-victimization. Subsequent experiences of sexual victimization are a well-known characteristic of early victimization (Kelley et al., 2016). Conversely, SA was found to be a particularly salient mediator for sexual victimization in women (Kelley et al., 2016;Livingston et al., 2007). It has been found that individuals that had previously experienced sexual victimization were better able to adapt to possible detrimental encounters, specifically when it comes to refusing to have sexual intercourse (Schry & White, 2013).

Psychosexual factors
Despite the challenges of determining a consistent model that predicts the development of when it comes to initiation and refusal . When considering the relationship between sexual function and SA, however, it is important to consider and include sexual dysfunction, as this can have a significant impact on SA (Leclerc et al., 2015;. A recent study of women with experienced vestibulodynia, a condition that causes pain at the vaginal opening, found that women with higher levels of SA were better able to communicate with their partners about sexual choices and preferences for sexual activities (McNicoll, Corsini-Munt, Rosen, McDuff, & Bergeron, 2016).

Body self-esteem
Body self-esteem refers to the evaluation individuals make about their own body (Auslander et al., 2012). This psychosexual factor has been found to be important for SA, specifically regarding the use of condoms and other contraceptive methods. The way body selfesteem operates on an individual level is related to increased body satisfaction, which lays the foundations for things such as the correct negotiation of the use of condoms (Auslander et al., 2012). Given the prevalence of social media in modern society and the veneration of body image and aesthetics that it cultivates, it is important to consider the effect it has on body positivity and self-esteem. A recent study found that Facebook involvement increases objectified body consciousness and can affect the SA of an individual positively, by increasing someone's selfesteem, or negatively, by fostering feelings of shame about their body .

Emotion regulation
Emotion regulation refers to an individual's ability to acknowledge and regulate emotions and feelings that may positively influence sexual responses (Zerubavel & Messman-Moore, 2013).
To regulate an appropriate response, individuals must be aware of, understand, and accept their own emotions. Individuals who are capable of satisfactory emotion regulation are more likely to communicate to their partner both verbally and non-verbally in a direct and assertive way (Gratz & Roemer, 2004;Zerubavel & Messman-Moore, 2013). Research has found that emotion regulation is particularly associated with SA when it comes to initiation and refusal of sexual intercourse due to the sense of empowerment and agency an individual may feel (Zerubavel & Messman-Moore, 2013).

Resourcefulness
In the context of SA, resourcefulness is the ability to resist pressure from a partner to participate in unwanted sexual activities: the ability of an individual to say 'no' or to leave a pressured situation . This is achieved through the use of positive self-instructions, problem-solving methods, and delay of gratification (Kennett et al., 2012;. To utilize such strategies, an individual must be able to rely on high levels of self-control, learn appropriate behaviors and responses applicable to specific situations, and be able to rely on coping strategies when problematic situations or negative emotions occur.
Resourcefulness is clearly an important facilitator for the development of SA when it comes to the use of negotiation strategies and resistance to external pressure (Kennett et al., 2012;.

Outcomes of Sexual Assertiveness
While the factors mentioned above have a clear impact on the development of SA, it is important to highlight three main outcomes for sexuality that were consistently described throughout the literature reviewed.

Impact on the level of satisfaction within the intimate relationship
Given the importance of communication in intimate relationships, several studies have suggested that asserting and controlling desired sexual activities has a positive influence on both satisfaction within relationships (Leclerc et al., 2015;McNicoll et al., 2016;Noar et al., 2002) and overall sexual satisfaction (Ménard & Offman, 2009). SA is considered key to achieve a good sexual life as it allows the needs of the individual and their partner to be met. Furthermore, McNicoll et al. (2016) found that SA is positively associated with perceived 'facilitative,' i.e., encouraging, affectional, and positive, responses.

Sexual assertiveness as a protective factor for unwanted pregnancies and STIs.
Despite the increasing quality and quantity of information available, and efforts to prevent unwanted pregnancies and STIs, there are still barriers for women to negotiate about the use of condoms for safe sex (Noar et al., 2006). Traditionally, men are considered to be responsible for carrying condoms and for expressing the necessity to use them (Noar et al., 2002;Sastre et al., 2015), whereas women may feel that it is easier to engage in unwanted pregnancies, rather than openly discuss their desires (Bay-Cheng & Eliseo-Arras, 2008). Negotiation about condom use by both men and women should include inquiring about a partner's sexual history, so as to be able to estimate the potential risks of a sexual encounter (Greene & Faulkner, 2005). SA is considered the best predictor for the use of contraceptive methods, particularly condoms, as low levels of SA are related to inconsistent use of contraceptive methods (Noar et al., 2006(Noar et al., , 2002.

Protective factor against victimization.
SA is seen as a central component in the prevention of sexual victimization (Kelley et al., 2016;Zerubavel & Messman-Moore, 2013). Any type of abuse, trauma or sexual victimization, particularly a history of child sexual abuse, negatively interferes with the development of SA and the likelihood of experiencing victimization or re-victimization is increased when an individual's SA is low (Livingston et al., 2007;Rickert et al., 2002). In contrast, a high level of SA might constitute one of the protective factors against future sexual victimization (Kelley et al., 2016).

Discussion
The aim of this paper was to present a literature review on sexual assertiveness (SA) and factors and life experiences that are associated with its development, and function in human sexuality. The results of this review revealed that SA is the result of a combination of several aspects. Sexual agency, which refers to an individual's inner notions about their own sexual needs and desires (Fetterolf & Sanchez, 2015) was found to influence SA. The development of SA is also the result of the balance between barriers and facilitating factors (Zerubavel & Messman-Moore, 2013). It is clear that demographic characteristics, cultural context, previous sexual experiences, and psychosexual factors may all influence SA. These associated factors influence SA by either facilitating positive practices or by acting as a barrier for the development of SA.
Yet, not all of the mentioned factors may equally influence the multiple dimensions of this construct (Auslander et al., 2012(Auslander et al., , 2007. This review also confirmed the relevance of SA already described in previous studies Undoubtedly, one of the most relevant findings of this review was the influence that cultural context has on the development of SA, through the presence of sexual scripts and gender stereotypes. When evaluating the SA of an individual, it is important to consider the cultural context that has influenced their life (Yoshioka, 2000;Rickert et al., 2002). As previously described, in Latin American cultures, higher levels of SA may be difficult, particularly for women. Despite differences across cultures, in general and globally women are more restricted by cultural norms and expectations than men (Bourdeau et al., 2008). Studies conducted in Latin America suggested that women are less sexually assertive than men, but this seems the result of cultural factors that shape and script their position and prescribe non-assertive behavior in relationships. In contrast, scripts for Latin American men allow for higher levels of sexual assertiveness and it is more culturally appropriate for them to express their sexual desire and to initiate sexual activity (Fetterolf & Sanchez, 2015;Manago, Ward, & Aldana, 2015). It can be concluded that, particularly in Latin American cultures, cultural context may result in a conflict between personal motivations and social expectations, but also between the importance of collectivism over individualism (Yoshioka, 2000). SA is considered to be a better fit in individualistic societies where cultural norms are predominantly focused on the needs, thoughts, and feelings of the individual and less on the family or the broader community (Castillo et al., 2010;Manago, Ward, & Aldana, 2015).
Apart from the impact of cultural context, this review also highlights the reciprocal relationship between previous sexual experiences and the development of SA. This implies that one´s sexual experiences influence the development of sexual assertiveness, but also that one's level of sexual assertiveness predicts future sexual experiences in either a positive or negative way (Livingston et al., 2007). This review further revealed that the study of SA is a developing field with several possible avenues for future research. First, given the association between SA and cultural patterns, conducting future research using qualitative methods might yield more information about the role SA plays in intimate relationships and allow us to gain a better understanding of the sexual double standard (Bourdeau et al., 2008;Fetterolf & Sanchez, 2015). This will be particularly pertinent for future studies in Latin American countries, where the gender stereotypes of machismo, marianismo and familismo clearly have a significant impact on an individual's sexual life (Bourdeau et al., 2008). However, caution should be used, as formulated by Loshek & Terrell (2014), who suggested that the traditional gender stereotypes may not apply equally to all dimensions of SA.
As most research is based on a variety of scales to measure SA, it is suggested that there is a need for a more comprehensive measurement of SA that includes all the theoretical elements discussed in this review. While the new scale proposed by Loshek and Terrell (2014) is promising, it needs to be further tested and validated in more studies before its value can be ascertained.
Future studies should focus on the importance of SA in intimate relationships, as it is evident that higher levels of SA translate into an increased likelihood of achieving personal goals during intimate interactions. When both partners are equally assertive there is greater chance that their own sexual goals will be adequately represented and/or achieved. As sexual relationships involve two people who may have their own levels of SA, studies should evaluate the SA of both partners and not just focus on women, as the majority of studies have done until now. The outcomes of this literature review should be interpreted taking into account some limitations. First, given the limited amount of information available, this review is rather descriptive, as the information did not allow for a more thorough integrated analysis. Second, the limited available information implies that the studies used in this review might be biased, as the retrieval of new articles was often informed by the suggestions for further reading from other studies. Lastly, as the literature review findings mostly show the complexity of the Latin American context for the development of SA in women, further studies that include a broader range of cultures would be advantageous, as this would improve our understanding of the impact that different cultures have on SA.
In conclusion, SA is clearly relevant in human sexuality on an individual level, by enabling individuals to express their preferences in a relational context, and on a societal level, given its role in protection against sexual coercion. SA seems to be the outcome of developmental processes and the result of a combination of facilitating and inhibiting demographic and psychosexual factors. Cultural determination of SA was a pivotal theme in this review, which not only highlighted findings on the development of SA, but also that there are still important gaps in our understanding of this interesting and important topic.

Main results of the revised studies about Sexual Assertiveness (SA)
Author Machismo was related to aggressive behavior, greater levels of alexithymia, and more wishful thinking as coping mechanism; it was also related to less education. Caballerismo was found to be a positive variable associated with affiliation, ethnic identity, and problem-solving coping

General Assertiveness
The Assertion inventory appears to be useful clinically and in the investigation of group differences. Men had higher scores than women, i.e., were more assertive.
Data set 1: 8 young woman; data set 2: 36 health care providers; data set 3: 24 young men; data set 4: 11 activist young men Data set 1: interviews; data set 2: interviews and focus groups; data set 3: interviews and focus groups; data set 4: interviews.
Age and gender with SA.

Emotion regulation/ dysregulation
The existence of six separate dimensions of emotion regulation: lack of awareness; lack of clarity; non-acceptance; limited access to strategies perceived as effective; difficulties controlling impulses when experiencing negative emotions; difficulties engaging in goal-directed behaviors when experiencing negative emotions. Greene, K., & Faulkner, S. L. (2005).  (Morokoff, et al., 1997); items for depression symptoms; Post traumatic stress disorder items.

SA and violence
There is a reciprocal relationship between history of victimization with SA and between SA and the possibility of subsequent victimization.
Loshek, E., & Terrell, H. K. Prevalence of four types of messages they heard from parents and friends: sex is only for marriage (family messages), sex is only appropriate in a loving relationship (family messages), sex is for pleasure (peer messages) and sexual double standard. There are strong gender differences in the mentioned sex messages. Sexual function, SA, sexual satisfaction.
Higher levels of SA mediated the associations between greater perceived facilitative partner responses to pain and higher levels of sexual function and satisfaction. Ménard, A. D., & Offman, A. (2009). 25 men and 46 women, mean age 27.65 years Index of Sexual Satisfaction (Hudson et al., 1981), Sexual Assertiveness Scale, The sexual self-esteem scale (Zeanah and Schwarz, 1996) Sexual self-esteem, SA and sexual satisfaction Sexual assertiveness has been shown to be a partial mediator of the relationship between sexual self-esteem and sexual satisfaction.  The Sexual Assertiveness Scale (SAS) was designed and tested; The Social desirability subscale of the Jackson Personality Research Form (Jackson, 1984); the Relationship Satisfaction Scale (Roach, Frazier and Bowden´s, 1981); More say in the relationship scale (Celebucki, 1990); Sexual Victimization Scale (Koss & Oros, 1982); Sexual Experience Scale. Items regarding anticipated negative partner response, self-efficacy STDpreventive behaviors, childhood sexual abuse. SA, relationship satisfaction, sexual victimization SA comprised three factors: Initiation, Refusal and Pregnancy STD-prevention. Greater woman´s sexual experiences is associated with greater self-reported ability to initiate sex. Sexual experience, anticipated partner response and self-efficacy predict SA. SA is associated with relationship satisfaction.