ORIGINAL RESEARCH—OUTCOMES ASSESSMENT: Development and Validation of the Female Genital Self-Image Scale

IntroductionWomen's sexual function may be influenced by various factors including medical conditions, trauma or abuse, medications, relationship dynamics, relaxation, mood, and body image. However, few studies have explored the influence of a woman's genital self-image on her sexual function or behaviors.AimsThe purpose of this study was to establish a reliable and valid measure of female genital self-image, the Female Genital Self-Image Scale (FGSIS), and to assess the relationship between scores on the FGSIS and women's sexual function.MethodsThe FGSIS was developed in two stages. Phase One involved an analysis of cross-sectional paper-based survey data and a review of the literature. Phase Two involved a cross-sectional internet-based administration of the scale items to a total of 1,937 women.Main Outcome MeasuresPsychometric properties of the scale were evaluated through the use of reliability analysis, factor analysis, and score differences based on women's experience of orgasm from receiving cunnilingus or from self-masturbation with a vibrator. Correlation analysis was used to explore the relationship between female genital self-image and scores on the Female Sexual Function Index (FSFI).ResultsThe scale was found to have sufficient reliability (Cronbach's alpha = 0.88) and one factor that explained 59.23% of the variance. Women who had ever experienced orgasm as a result of cunnilingus or self-masturbation with a vibrator and women who reported having had a gynecological exam in the previous 12 months had significantly higher FGSIS scores than those who had not (P < 0.001). Scores on the FGSIS were positively and significantly correlated with scores on all FSFI domains (P < 0.001), including the Total score, with the exception of the Desire domain.ConclusionThe FGSIS was initially found to be a reliable and valid measure though further research is needed to understand its properties in diverse populations. In addition, female genital self-image was found to be positively related to women's sexual function. Herbenick D, and Reece M. Development and validation of the female genital self image scale.     

Instructions to Rate Genital Vasocongestion Increases Genital and Self-Reported Sexual Arousal but not Coherence Between Genital and Self-Reported Sexual Arousal

IntroductionWomen are often reported to have a low coherence (often referred to as “discordance” in sexuality literature) between their genital response and self-reported sexual arousal.AimThe purpose of this study was to determine whether differing instructions for rating sexual arousal would increase the coherence between genital response and self-reported arousal in women.MethodsGenital responses were recorded, using vaginal photoplethysmography, from 32 young women while they fantasized in three different conditions. Conditions instructed women to rate their overall sexual arousal, any physical cues, and genital blood flow.Main Outcome MeasuresThe primary outcome measure was the coherence of vaginal pulse amplitude (VPA) and reported sexual response in the three conditions.ResultsUnexpectedly, both VPA response and self-reported sexual arousal were higher when women were asked to rate their genital blood flow. Examining only participants who reported at least some sexual arousal in all conditions (n = 17), coherence was highest when women were instructed to rate overall sexual arousal.ConclusionResults suggest that focusing on genital blood flow during sexual fantasy may increase women's (self-reported and genital) sexual response. Focusing on any physical arousal cues during sexual fantasy was associated with lower coherence of women's genital response and self-reported arousal compared with when they were instructed to rate their overall sexual arousal. Prause N, Barela J, Roberts V, and Graham C. Instructions to rate genital vasocongestion increases genital and self-reported sexual arousal but not coherence between genital and self-reported sexual arousal. J Sex Med 2013;10:2219–2231.     

Habituation of Sexual Responses in Men and Women: A Test of the Preparation Hypothesis of Women's Genital Responses

IntroductionLaboratory studies have revealed two well‐replicated sex differences in sexual arousal patterns: category specificity and sexual concordance. Men's genital responses are dependent on specific sexual cues and are concordant with subjective reports of arousal. Women's genital responses are much less dependent on specific sexual cues and are much less concordant with their subjective reports. The preparation hypothesis provides a functional explanation for these sex differences and posits that women's genital responses are not tied to sexual preferences but rather occur automatically in the presence of any sexual cue to protect the genital tissues from injuries incurred through sexual activity. This hypothesis leads to the expectation that women's genital responses may not habituate as quickly or as completely as men's.AimTo determine whether there is a sex difference in the habituation of genital responses and to further test the preparation hypothesis of women's genital responses.MethodsTwenty men and 20 women had their genital responses measured while they were exposed to nine consecutive presentations of the same erotic film clip (habituation), followed by two presentations of different erotic film clips (novelty), and followed by two presentations of the original erotic film clip (dishabituation).Main Outcome MeasuresGenital responses were measured continuously using penile strain gauges (assessing penile circumference) and vaginal probes (assessing vaginal pulse amplitude). Participants reported subjective sexual arousal, perceived genital arousal, and attention after each film clip presentation.ResultsMen and women displayed very similar patterns of genital responses, consistent with habituation and novelty effects. Effects of habituation and novelty were eliminated once subjective reports of attention were covaried.ConclusionContrary to the prediction from the preparation hypothesis of women's genital responses, men's and women's responses showed similar patterns of habituation upon repeated exposure. Future research should attempt to maintain participants' attention in order to further test the preparation hypothesis. Dawson SJ, Suschinsky KD, and Lalumière ML. Habituation of sexual responses in men and women: A test of the preparation hypothesis of women's genital responses. J Sex Med 2013;10:990-1000.     

Young women’s genital self-image and effects of exposure to pictures of natural vulvas

Introduction: Many women have doubts about the normality of the physical appearance of their vulvas. This study measured genital self-image in a convenience sample of college-educated women, and assessed whether exposure to pictures of natural vulvas influenced their genital self-image.

Method: Forty-three women were either shown pictures of natural vulvas (N?=?29) or pictures of neutral objects (N?=?14). Genital self-image was measured before and after exposure to the pictures and two weeks later. Sexual function, sexual distress, self-esteem and trait anxiety were measured to investigate whether these factors influenced genital self-image scores after vulva picture exposure.

Results: A majority of the participants felt generally positively about their genitals. Having been exposed to pictures of natural vulvas resulted in an even more positive genital self-image, irrespective of levels of sexual function, sexual distress, self-esteem and trait anxiety. In the women who had seen the vulva pictures, the positive effect on genital self-image was still present after two weeks.

Discussion: The results of this study seem to indicate that even in young women with a relatively positive genital self-image, exposure to pictures of a large variety of natural vulvas positively affects genital self-image. This finding may suggest that exposure to pictures of natural vulvas may also lead to a more positive genital self-image in women who consider labiaplasty.     

Does Size Matter? Genital Self-Image,Genital Size,Pornography Use and Openness Toward Cosmetic Genital Surgery in 3503 Swedish Men and Women

BackgroundDissatisfaction with the appearance and size of one's genitalia is a common issue, and the use of cosmetic genital surgery is increasing among people with normal genitalia.AimThis cross-sectional study aimed to investigate the distribution of genital self-image in a large sample of males and females, and whether selected factors could predict genital self-image.MethodsThree thousand five hundred three anonymous participants completed online questionnaires. Multiple linear regressions were used to identify the association between genital self-image and genital size (length of penis or protrusion of labia minora), consumption of sexually explicit material (SEM), sexual activity, avoidance and safety seeking behaviors, openness toward genital cosmetic surgery and age.OutcomesTotal scores on the Female and Male Genital Self Image Scale were used as the main outcome measures.ResultsOverall, 3.6% of females and 5.5% of males had a severely low genital self-image (defined as 2 SD below the mean) and 33.8% of all individuals reported dissatisfaction with the appearance of their genitalia, with 13.7% of females and 11.3% of males considering undergoing cosmetic genital surgery. Mean protrusion of labia minora and stretched flaccid penis length in the population was estimated to 0.76 cm (95% CI 0.63–0.89 cm) and 12.5 cm (95% CI 12.33–12.76 cm), respectively. A higher genital self-image score was predicted by having a larger penis or less protruding labia minora, but not by the degree of SEM consumption, although 93.6% of males and 57.5% of females had consumed SEM in the past three months. The degree of avoidance and safety seeking behaviors, sexual activity, and openness toward genital cosmetic surgery predicted a low genital self-image. Being older was associated with a better genital self-image in females.Clinical ImplicationsThe results show that a psychological intervention may be needed as an alternative to cosmetic genital surgery for people who are dissatisfied with the appearance of their genitals.Strengths and LimitationsThis is one of few available studies investigating the association between actual genital size and genital dissatisfaction. The vast sample size and high response rate are also strengths. Limitations include the cross-sectional design, and possible bias in the study sample due to self-selection.ConclusionOverall, a low genital self-image and dissatisfaction with one's genitalia is relatively common and is influenced not only by genital size, but also behaviors performed to alleviate worry about one's genitals.Hustad IB, Malmqvist K, Ivanova E, et al. Does Size Matter? Genital Self-Image, Genital Size, Pornography Use and Openness Toward Cosmetic Genital Surgery in 3503 Swedish Men and Women. J Sex Med 2022;19:1378–1386.     

The Female Genital Self-Image Scale (FGSIS): results from a nationally representative probability sample of women in the United States

IntroductionOver the past two decades, an expanding body of research has examined women's and men's genital self‐image. Support for the reliability and validity of the 7‐item Female Genital Self‐Image Scale (FGSIS) has been found in a convenience sample of women.AimsThe purpose of this study was to assess the reliability and validity of the FGSIS, its model of fit, and its association with women's scores on the Female Sexual Function Index (FSFI) in a nationally representative probability sample of women in the United States ages 18 to 60. A second purpose was to assess the temporal stability of the scale in a subset of this sample.MethodsA nationally representative sample of 3,800 women ages 18 to 60 were invited to participate in a cross‐sectional Internet‐based survey; 2,056 (54.1%) participated.Main Outcome MeasuresDemographic items (e.g., age, race/ethnicity, marital status, sexual orientation, geographic region), having had a gynecological examination in the past year, having performed a genital self‐examination in the past month, frequency of masturbation in the past month, vibrator use in the past month, the FGSIS, and the FSFI.ResultsAn abbreviated 4‐item version of the scale, the FGSIS‐4, was a better fit to the data than the original 7‐item scale. Women's scores on the FGSIS‐4 were significantly related to vibrator use, frequency of masturbation, having had a gynecological exam in the past year, having performed genital self examination in the past month, and all FSFI subscales.ConclusionMost of the participants felt generally positively about their genitals and female genital self‐image was significantly related to female sexual function, women's sexual behavior and their sexual and genital healthcare behaviors. In addition, the FGSIS‐4 has evidence of reliability, validity, and temporal stability in a nationally representative probability sample of women in the United States. Herbenick D, Schick V, Reece M, Sanders S, Dodge B, and Fortenberry JD. The female genital self‐image scale (FGSIS): Results from a nationally representative probability sample of women in the United States.     

Assessing Women's Sexual Arousal in the Context of Sexual Assault History and Acute Alcohol Intoxication

IntroductionFew studies have examined differences in women's sexual arousal based on sexual assault history (SAH) or in-the-moment alcohol intoxication. Only one has examined combined effects. Findings regarding the relationship between SAH and arousal are contradictory.AimWe aimed to determine the relationship between SAH, alcohol intoxication, and sexual arousal.MethodsWomen were randomly assigned to an alcohol (target blood alcohol level = 0.10%) or control condition and categorized as having an SAH or not. After beverage administration, all women watched erotic films while genital arousal (vaginal pulse amplitude; VPA) was measured. Afterward, self-reported sexual arousal was measured.Main Outcome MeasuresGenital response was measured by VPA using vaginal photoplethysmography while watching erotic films. Self-reported sexual arousal was assessed after watching erotic films.ResultsWomen with an SAH had smaller increases in genital arousal in response to the films than women without an SAH. Intoxicated women had smaller increases in genital arousal than sober women. However, no differences for SAH or intoxication were found in self-reported arousal.ConclusionSAH and alcohol intoxication are associated with smaller increases in genital arousal compared to women without an SAH and sober women, suggesting that these co-occurring factors impact sexual arousal. Gilmore AK, Schacht RL, George WH, Otto JM, Davis KC, Heiman JR, Norris J, and Kajumulo KF. Assessing women's sexual arousal in the context of sexual assault history and acute alcohol intoxication.     

The Relationship Between Sexual Concordance and Interoception in Anxious and Nonanxious Women

IntroductionSexual concordance refers to the association between physiological and self‐reported sexual arousal. Women typically exhibit lower sexual concordance scores than men. There is also a sex difference in interoception—awareness of (nonsexual) physiological states or responses—such that women, compared with men, tend to be less aware of and less accurate at detecting changes in their physiological responses. Women with anxiety problems tend to have better interoceptive abilities than nonanxious women.AimTo investigate whether women's lower sexual concordance is associated with interoception using a sample likely to show high variation in interoceptive abilities.MethodSixteen anxious and 15 nonanxious women were presented with twelve 90 seconds sexual and nonsexual film clips while their genital response, heart rate, and respiration rate were measured. A heartbeat mental tracking task was also employed.Main Outcome MeasuresGenital response was measured with a vaginal photoplethysmograph. Heart rate was measured with an electrocardiogram and respiration rate with a thermistor. Participants estimated their physiological responses after each film. A mental tracking task was also used to assess participants' awareness of heart rate. Within‐subject correlations were computed for each physiological/self‐reported response combination.ResultsOverall, sexual concordance (i.e., the correlation between genital responses and perceptions of genital response) was not significantly associated with heart rate awareness or respiration rate awareness. Anxious women did not exhibit significantly higher sexual concordance or heart rate awareness than nonanxious women; the nonanxious women actually exhibited higher respiration rate awareness.ConclusionThe results suggest that sexual concordance may be a distinct phenomenon from interoception and in need of its own explanation. Suschinsky KD and Lalumière ML. The relationship between Sexual concordance and interoception in anxious and nonanxious women. J Sex Med 2014;11:942–955.     

Pubic Hair Removal among Women in the United States: Prevalence,Methods, and Characteristics

IntroductionAlthough women's total removal of their pubic hair has been described as a “new norm,” little is known about the pubic hair removal patterns of sexually active women in the United States.AimsThe purpose of this study was to assess pubic hair removal behavior among women in the United States and to examine the extent to which pubic hair removal methods are related to demographic, relational, and sexual characteristics, including female sexual function.MethodsA total of 2,451 women ages 18 to 68 years completed a cross-sectional Internet-based survey.Main Outcome MeasuresDemographic items (e.g., age, education, sexual relationship status, sexual orientation), cunnilingus in the past 4 weeks, having looked closely at or examined their genitals in the past 4 weeks, extent and method of pubic hair removal over the past 4 weeks, the Female Genital Self-Image Scale (FGSIS) and the Female Sexual Function Index (FSFI).ResultsWomen reported a diverse range of pubic hair-grooming practices. Women's total removal of their pubic hair was associated with younger age, sexual orientation, sexual relationship status, having received cunnilingus in the past 4 weeks, and higher scores on the FGSIS and FSFI (with the exception of the orgasm subscale).ConclusionFindings suggest that pubic hair styles are diverse and that it is more common than not for women to have at least some pubic hair on their genitals. In addition, total pubic hair removal was associated with younger age, being partnered (rather than single or married), having looked closely at one's own genitals in the previous month, cunnilingus in the past month, and more positive genital self-image and sexual function. Herbenick D, Schick V, Reece M, Sanders S, and Fortenberry JD. Pubic hair removal among women in the United States: Prevalence, methods and characteristics.     

The Effect of Psychosexual Education on Promoting Sexual Function,Genital Self-Image,and Sexual Distress among Women with Rokitansky Syndrome: A Randomized Controlled Clinical Trial

Study ObjectiveTo assess the effectiveness of psychosexual education on promoting sexual function and genital self-image and reducing sexual distress through e-learning among women with Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome.DesignRandomized controlled trial.SettingImam Khomeini Hospital “Pelvic Floor Clinic” in Tehran.ParticipantsThirty-eight 15- to 49-year-old women with MRKH syndrome who had undergone surgical or nonsurgical vaginal reconstruction techniques more than 6 months before the intervention were assigned to 2 parallel intervention and control groups of 19 each.InterventionsPsychosexual education was delivered through e-learning for the intervention group over an 8-week period, with no limitations of time and space. Sexual function, genital self-image, and sexual distress were evaluated at baseline, and at 4 and 8 weeks after the intervention.Main Outcome MeasuresThe data collection tools included the Persian version of the Female Sexual Function Index, Female Genital Self-Image Scale, and the Revised Female Sexual Distress Scale.ResultsThe between group mean differences of sexual function, genital self-image, and sexual distress after 4 weeks (?1.2 [95% CI, ?2.1 to ?0.1], P = .025; ?1.9 [95% CI, ?2.9 to ?0.9], P < .001; 4.2 [95% CI, 2.0-6.4], P < .001, respectively), as well as after 8 weeks (?1.8 [95% CI, ?3.1 to ?0.5], P = .009; ?3.0 [95% CI, ?4.5 to ?1.5], P < .001; 6.7, 95% CI, 3.9-9.6], P <0.001, respectively) after baseline were significant.ConclusionPsychosexual education improved sexual function and genital self-image and reduced sexual distress in women with MRKH syndrome. Therefore, using this approach, we can raise individuals’ sexual knowledge and skills and correct their sexual beliefs and attitudes.     

Self‐Assessment of Genital Anatomy and Sexual Function within a Belgian,Dutch‐Speaking Female Population: A Validation Study

IntroductionData on self‐perceived genital anatomy and sensitivity should be part of the long‐term follow‐up of genitoplasty procedures. However, no normative data, based on a large sample, exist to date.AimsValidation of the Self‐Assessment of Genital Anatomy and Sexual Function, Female version (SAGAS‐F) questionnaire within a Belgian, Dutch‐speaking female population.MethodsSeven hundred forty‐nine women with no history of genital surgery (aged 18–69 years, median 25 years) completed an Internet‐based survey of whom 21 women underwent a gynecological examination as to correlate self‐reported genital sensitivity assessed in an experimental setting.Main Outcome MeasuresThe SAGAS‐F enables women to rate the sexual pleasure, discomfort, intensity of orgasm, and effort required for achieving orgasm in specified areas around the clitoris and within the vagina, as well as genital appearance. The latter was similarly evaluated by an experienced gynecologist, and women were asked to functionally rate the anatomical areas pointed out with a vaginal swab.ResultsSexual pleasure and orgasm were strongest, and effort to attain orgasm and discomfort was lowest when stimulating the clitoris and sides of the clitoris (P < 0.05). Vaginal sensitivity increased with increasing vaginal depth, but overall orgasmic sensitivity was lower as compared with the clitoris. Functional scores on the SAGAS‐F and during gynecological examination corresponded highly on most anatomical areas (P < 0.05). Gynecologist's ratings corresponded highly with the women's ratings for vaginal size (90%) but not for clitoral size (48%).ConclusionsReplication of the original pilot study results support the validity of the questionnaire. The SAGAS‐F discriminates reasonably well between various genital areas in terms of erotic sensitivity. The clitoris itself appeared to be the most sensitive, consistent with maximum nerve density in this area. Surgery to the clitoris could disrupt neurological pathways and compromise erotic sensation and pleasure. Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, and Hoebeke P. Self‐assessment of genital anatomy and sexual function in women (SAGAS‐F): Validation within a Belgian, Dutch‐speaking population. J Sex Med 2013;10:3006–3018.     

Sexual dysfunction in women

Sexuality is an integral componont of a woman's global well-being. Sexual dysfunction not only contributes to personal and interpersonal stress, but it also may herald other medical or psychosocial problems that significantly affect a woman's health. Many physicians feel uncomfortable or inadequately trained to discuss sexuality issues with their patients, but the vast majority of patients believe that it is appropriate for physicians to address sexual function within the context of routine health assessments. Even though many women experience sexual dysfunction, they may feel uncomfortable volunteering the information. It is crucial that health care providers avoid making assumptions about a patient's sexual behaviors or preferences and that they ask directly about sexual functioning and concerns. The physician can become more comfortable discussing sexual issues with patients by gaining an understanding of the normal sexual response and developing an approach to the evaluation and treatment of common sexual dysfunctions. Asking about sexual concerns and problems will provide the physician with an opportunity to educate patients and dispel sexual misconceptions. Furthermore, it will give patients “permission” to address sexual issues in a professional, confidential, and nonjudgmental setting.     

Association of lubricant use with women's sexual pleasure, sexual satisfaction, and genital symptoms: a prospective daily diary study

IntroductionAlthough lubricant use is commonly recommended to women for solo and partnered sexual activities, little is known about women's use of lubricant or their relationship to sexual pleasure and satisfaction.AimThe aim of this study was to assess: (i) how adult women used lubricant during partnered and solo sexual activities; (ii) relations between women's reports of sexual pleasure and satisfaction and their use of a lubricant during a particular sexual event; and (iii) to what extent lubricant use was associated with subsequent genital symptoms.MethodsA total of 2,453 women completed a 5‐week internet‐based, double‐blind prospective daily diary study in which they were assigned to use one of six water‐ or silicone‐based lubricants.Main Outcome MeasuresBaseline data included demographics, contraceptive use, and sexual behavior during the 4 weeks prior to study enrollment. Daily diary data included reports of penile–vaginal sex, penile–anal sex, solo sex, lubricant use, lubricant application, ratings of sexual pleasure and satisfaction, and genital symptoms.ResultsWater‐based lubricants were associated with fewer genital symptoms compared with silicone‐based lubricants. In addition, the use of a water‐based or silicone‐based lubricant was associated with higher ratings of sexual pleasure and satisfaction for solo sex and penile–vaginal sex. Water‐based lubricant use was associated with higher ratings of sexual pleasure and satisfaction for penile–anal sex as compared with no lubricant use.ConclusionThe water‐ and silicone‐based lubricants used in this study were associated with significantly higher reports of sexual pleasure and satisfaction and rarely associated with genital symptoms. Herbenick D, Reece M, Hensel D, Sanders S, Jozkowski K, and Fortenberry JD. Association of lubricant use with women's sexual pleasure, sexual satisfaction, and genital symptoms: A prospective daily diary study. J Sex Med 2011;8:202–212.     

Gender‐Specificity of Solitary and Dyadic Sexual Desire among Gynephilic and Androphilic Women and Men

IntroductionIncentive motivation theory proposes that sexual desire emerges from sexual arousal, and is triggered by sexually competent stimuli. Research demonstrates gender and sexual orientation differences in the features that contribute to the competency of sexual stimuli. Men's and gynephilic women's genital arousal tends to be gender‐specific with preferred gender eliciting significantly greater genital arousal than nonpreferred gender. In contrast, stimuli depicting preferred and nonpreferred gender elicit similar degrees of genital arousal among androphilic women, termed a gender‐nonspecific pattern. Given these differences in the features that elicit a sexual response, and that sexual desire is proposed to emerge from sexual arousal, the question remains as to whether sexual desire would emerge only through exposure to preferred stimuli or whether patterns of responsive desire would parallel those observed for genital arousal.AimThe study aims to examine patterns of dyadic and solitary sexual desire in response to stimuli differing in incentive value.MethodsThirty androphilic women, 21 gynephilic women, 21 gynephilic men, and 16 androphilic men participated in a sexual psychophysiological session. Participants viewed sexual stimuli that varied the gender of the actors and the intensity of sexual activities depicted.Main Outcome MeasuresParticipants reported their degree of desire for sex with a partner (dyadic desire) and desire to masturbate (solitary desire), before and after each film.ResultsMen and gynephilic women exhibited gender‐specific patterns of sexual desire. Androphilic women's dyadic desire showed significantly less differentiation between genders, and their solitary desire did not differentiate at all. No gender difference was observed for either type of desire. All groups reported greater desire as stimulus intensity increased.ConclusionsGender‐nonspecific sexual response is not limited to the sexual arousal patterns of androphilic women, but extends to include responsive sexual desire. Men and gynephilic women, however, show gender‐specific responsive sexual desire that parallels their sexual arousal patterns. Dawson SJ and Chivers ML. Gender specificity of solitary and dyadic sexual desire among gynephilic and androphilic women and men. J Sex Med 2014;11:980–994.     

Women's Sexual Desire and Arousal Disorders

IntroductionA committee of five was convened to update the chapter on women's sexual dysfunctions from the perspective of diagnostic issues, pathophysiology, assessment, and treatment.AimTo review the literature since 2003 and provide recommendations based on evidence.MethodsResearch databases, conference proceedings, and articles in press were read for relevant new data on these topics for hypoactive sexual desire disorder (HSDD), female sexual arousal disorder (FSAD), female orgasmic disorder (FOD), and persistent genital arousal disorder (PGAD).Main Outcome MeasuresRecommendations by five experts from five countries were formulated with associated grades.ResultsThe definitions of HSDD, FSAD, and FOD in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text-Revised are imperfect and have been criticized over the last decade. Proposed new criteria that take into account empirical findings and the diversity across women are recommended. There has been a flurry of new epidemiological studies on women's sexual dysfunction; studies also assessing distress consistenly find a much lower prevalence of dysfunction if distress is considered. Assessment of sexual difficulties is best achieved through a biopsychosocial clinical interview of the woman and her partner (if possible); though laboratory investigations, a physical examination, psychophysiological measurement, and self-report questionnaires can often supplement the interview information. There are currently no approved pharmacological treatments for women's sexual dysfunction in North America, though a number of promising agents have been studied. Evidence for the efficacy of psychological treatments is based on limited studies. There is an urgent need for more data on the assessment, etiology, and treatment of PGAD.ConclusionsSpecific recommendations for the assessment and treatment of women's desire, arousal, and orgasm disorders are forwarded; however, more research into these domains is needed. Brotto LA, Bitzer J, Laan E, Leiblum S, and Luria M. Women's sexual desire and arousal disorders.     

Associations Among Physiological and Subjective Sexual Response,Sexual Desire,and Salivary Steroid Hormones in Healthy Premenopausal Women

IntroductionFew studies have examined how sexual arousal influences healthy premenopausal women's hormones, limiting our understanding of basic physiology and our ability to transfer knowledge from clinical and nonhuman populations.AimTo examine how sexual arousal and steroid hormones (testosterone [T], cortisol [C], estradiol [E]) were linked, to see whether hormone levels influenced and/or changed in response to sexual arousal elicited via visual erotic stimuli in healthy women.MethodsParticipants included 40 healthy premenopausal women not using exogenous hormones.Main Outcome MeasuresChange in genital sexual arousal (vaginal pulse amplitude), change in subjective sexual arousal, sexual desire (via the Sexual Desire Inventory and Female Sexual Function Index scales), as well as T, C, and E via saliva samples taken before and following viewing of erotic stimuli as genital arousal was recorded via a vaginal photoplethysmograph.ResultsE increased in response to sexual stimuli but this was not statistically associated with genital sexual arousal, whereas C decreased in association with genital sexual arousal, and T showed no statistically significant change. Relationship status was linked to genital but not subjective sexual arousal such that dating women exhibited higher genital sexual arousal than single or partnered women. Results indicated that all three hormones were associated with self-reported genital arousal (via the Detailed Assessment of Sexual Arousal scales) and sexual desire in different domains, and both T and E were associated with self-reported orgasms.ConclusionFindings point to the need to examine multiple hormones in multiple ways (e.g., baseline, changes, stimulated) and question using erotic stimuli-induced arousal as a model for women's endocrine responses to sexuality. van Anders SM, Brotto L, Farrell J, and Yule M. Associations among physiological and subjective sexual response, sexual desire, and salivary steroid hormones in healthy premenopausal women. J Sex Med 2009;6:739–751.     

Correlation between an early sexual debut,and reproductive health and behavioral factors: a multinational European study

Objective To investigate whether women who made an early sexual debut differ from those with a later debut regarding genital signs and symptoms.

Methods The study included women who considered themselves gynecologically healthy and who attended 17 family planning centers in 13 European countries for contraceptive advice. There were 629 women who made their sexual debut at the age of 16 years or earlier (study population) and 927 women who had their first sexual intercourse at the age of 19 years or later (comparison group). Genital symptoms and signs, contraceptive use, smoking, and genital hygiene habits and previous genital infections were recorded on a structured patient record form. Detection of Chlamydia trachomatis was made by means of a polymerase chain reaction on first-void urine. The study was made, on average, 7–10 years after the women's sexual debut.

Results The mean age of first intercourse was 15.3 years for the study group versus 20.7 years for the control group (p < 0.001). The study population had significantly more symptoms, such as vaginal discharge and pruritus, and signs, such as abnormal discharge, erythema of the vaginal mucosa and lower genital tract infections, than the comparison group. Twice as many women in the study group were smokers and there was a ten-fold increase among these subjects of using low-pH solutions for genital hygiene. The prevalence of C. trachomatis infection did not differ between the two groups (p = 0.22).

Conclusion Age at first intercourse is not only a predictor of sexual risk behavior, but also a predictor, regarding both signs and symptoms, of future gynecological problems.