Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia

Background and AimThe goal was to evaluate the moderators of mindfulness-based cognitive therapy (MBCT) and cognitive behavioral therapy (CBT) to improve dyspareunia, reduce pain catastrophizing, and improve overall sexual function in women with provoked vestibulodynia (PVD). Both treatments effectively reduced self-reported pain, sexual dysfunction, and pain catastrophizing in women with PVD.MethodsA total of 130 women with PVD were assigned to CBT or MBCT.OutcomesPotential moderators included (i) PVD subtype (primary or secondary), (ii) baseline pain intensity, (iii) trait mindfulness, (iv) treatment credibility, (v) relationship duration, and (vi) age. Outcomes were pain intensity, sexual function, and pain catastrophizing at 4 time points: before and after treatment and 6- and 12-month follow-up. Moderation was tested using multilevel models, nesting 4 time points within participants. The interaction of the moderator, time effect, and treatment group was evaluated for significance, and a simple slope analysis of significant interactions was performed.ResultsPain reduction across 4 time points was the greatest in women who were younger, in relationships of shorter duration, and with greater baseline pain. Treatment credibility moderated pain intensity outcomes (B = 0.305, P < .01) where those with higher treatment credibility ratings (for that particular treatment) improved more in MBCT than CBT. PVD subtype moderated pain catastrophizing (B = 3.150, P < .05). Those with primary PVD improved more in the CBT condition, whereas women with secondary PVD improved more in the MBCT condition. Relationship length moderated sexual function (B = 0.195, P < .01). Women in shorter relationships improved more with MBCT, whereas women in longer relationships improved more on sexual function with CBT. No other tested variables moderated outcomes differentially across both treatment conditions.Clinical ImplicationsWomen who present with high credibility about mindfulness, in shorter relationships, and with secondary PVD might respond better to MBCT whereas those with primary PVD and longer relationships might respond better to CBT.Strengths & LimitationsClinical sample. Half the women who were not sexually active were omitted from analyses of sexual function.ConclusionOverall, treatment credibility, relationship length, and PVD subtype were found to moderate improvements differently in MBCT and CBT. These findings may assist clinicians in individualizing psychological treatment for women with PVD.Clinical Trial RegistrationThis clinical trial was registered with clinicaltrials.gov, NCT01704456.Brotto LA, Zdaniuk B, Rietchel L, et al. Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia. J Sex Med 2020;17:2247–2259.     

A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting

IntroductionChronic and distressing genito-pelvic pain associated with vaginal penetration is most frequently due to provoked vestibulodynia (PVD). Cognitive behavioral therapy (CBT) significantly reduces genital pain intensity and improves psychological and sexual well-being. In general chronic pain populations, mindfulness-based approaches may be as effective for improving pain intensity as CBT.AimTo compare mindfulness-based cognitive therapy (MBCT) with CBT in the treatment of PVD.MethodsTo ensure power of 0.95 to find medium effect size or larger in this longitudinal design, we enrolled 130 participants. Of these, 63 were assigned to CBT (mean age 31.2 years), and 67 to MBCT (mean age 33.7 years). Data from all participants who completed baseline measures were analyzed, with intent-to-treat analyses controlling for years since diagnosis.Main Outcome MeasuresOur primary outcome was self-reported pain during vaginal penetration at immediate post-treatment and at 6 months’ follow-up. Secondary endpoints included pain ratings with a vulvalgesiometer, pain catastrophizing, pain hypervigilance, pain acceptance, sexual function, and sexual distress.ResultsThere was a significant interaction between group and time for self-reported pain, such that improvements with MBCT were greater than those with CBT. For all other endpoints, both groups led to similar significant improvements, and benefits were maintained at 6 months.Clinical ImplicationsMindfulness is a promising approach to improving self-reported pain from vaginal penetration and is as effective as CBT for several psychological endpoints.Strength & LimitationsA strength of the present study was the robust sample size (n = 130 women) who had received confirmed clinical diagnoses of PVD.ConclusionThe present study showed mindfulness to be as effective for most pain- and sexuality-related endpoints in the treatment of PVD.Brotto LA, Bergeron S, Zdaniuk B, et al. A Comparison of Mindfulness-Based Cognitive Therapy Vs Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia in a Hospital Clinic Setting. J Sex Med 2019;16:909–923.     

Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis

BackgroundDyspareunia, one of the main symptoms of the chronic gynecological pelvic pain disorder endometriosis, may interfere with the likelihood of reaching an orgasm, yet for women with dyspareunia, no data on orgasm rates in different sexual activities are available.AimThe aim of this study was to evaluate the ability to reach an orgasm and its association with sexual satisfaction during different sexual activities in women with a chronic pelvic pain disorder and in healthy control women.MethodsA set of questionnaires including the brief index of sexual functioning and global sexual functioning was used to evaluate sexuality in women affected with endometriosis (n = 434) and a nonaffected control group (n = 434) recruited in German-speaking countries.OutcomesThe primary outcome measure of this study was the orgasm rate during different types of sexual activities.ResultsOnly the ability to have an orgasm during sexual intercourse (P = .002) but not during masturbation (P = .509) or partnered noncoital sexual activities (P = .229) is affected by endometriosis. Dyspareunia was associated with a reduced ability to experience an orgasm during intercourse for endometriosis patients (P = .020) and control women (P = .006). The ability to orgasm during noncoital sexual activities (P = .006) and sexual intercourse (P = .038) was associated with a higher sexual satisfaction in women with endometriosis. For controls, only the ability to achieve an orgasm with sexual intercourse was associated with sexual satisfaction (P = .038).Clinical implicationsSexual counselling as part of medical support could help couples living with chronic pelvic pain of the female partner integrate noncoital sexual activities in their sex lives, leading to fewer sex-related problems and higher sexual desire and satisfaction.Strengths and limitationsThis study is the first to examine different ways of achieving an orgasm and sexual satisfaction in a large group of women with endometriosis and a matched control group. The breadth of the questionnaire allowed a differentiated analysis of factors influencing the likelihood of achieving an orgasm and overall sexual satisfaction. The one limitation is that the length and the intimate nature of the questionnaire possibly resulted in reluctance to answer this part of the questionnaire.ConclusionPartnered noncoital sexual activities may represent an alternative to reach orgasm for women with endometriosis-related chronic pelvic pain or anorgasmia during sexual intercourse.Hämmerli S, Kohl-Schwartz A, Imesch P, et al. Sexual Satisfaction and Frequency of Orgasm in Women With Chronic Pelvic Pain due to Endometriosis. J Sex Med 2020;17:2417–2426.     

Visual Attention to Sexual Stimuli in Women With Clinical,Subclinical, and Normal Sexual Functioning: An Eye-Tracking Study

BackgroundVisual attention to sexual stimuli is an important means to facilitate sexual arousal and is thereby relevant for healthy sexual functioning. Experimental studies suggest that sexual dysfunction is associated with less attention toward sexual stimuli.AimThe goal of this study was to use an eye-tracking-based free-viewing paradigm to investigate whether women in the clinical range of sexual function attend to a genital area in visual sexual stimuli differently than women with subclinical sexual function or those with normal sexual functioning.MethodsToward this goal, 69 women (M_age = 27.77, SD = 8.00, range = 19–54) with clinical (n = 30), subclinical (n = 23), and normal (n = 16) levels of sexual functioning watched a series of 10 pictures depicting heterosexual couples during vaginal intercourse while their eye movements were recorded. Each picture was presented twice—once with a distracting object (eg, a to-do list or household appliance) present in the picture and once without—for 8 seconds, each.Outcomes5 eye-tracking measures indicative of different aspects of initial and sustained attention were analyzed.ResultsAs hypothesized, 3 out of 5 eye-tracking measures (ie, first fixation duration, number of first fixations, and total fixation duration) indicated that women in the clinical group attended less to the genital area in the pictures than women with normal sexual functioning. For 2 indices (ie, first fixation duration and total fixation duration), women with subclinical (vs normal) sexual functioning also attended less to the genital area. In contrast to our hypothesis, the presence of a distracting object did not influence attention to the genital area in either of the sexual function groups.Clinical ImplicationsThis study provides further evidence of the role of attentional biases in sexual dysfunction in women.Strengths and LimitationsEye-tracking methodology allows for a continuous measurement of visual attention; this is one of the first studies using this methodology to assess differences in visual attention in women with and without sexual dysfunction. However, the cross-sectional nature of this study prevents causal interpretation of findings.ConclusionFuture studies should use experimental paradigms to determine the causal role of visual attention for the development or maintenance of sexual dysfunction.Velten J, Milani S, Margraf J, et al. Visual Attention to Sexual Stimuli in Women With Clinical, Subclinical, and Normal Sexual Functioning: An Eye-Tracking Study. J Sex Med 2021;18:144–155.     

Internet-Administered Cognitive Behavioral Therapy for Hypersexual Disorder,With or Without Paraphilia(s) or Paraphilic Disorder(s) in Men: A Pilot Study

BackgroundHypersexual disorder (HD) is a condition in which the individual experiences loss of control over engagement in sexual behaviors, leading to negative effects on various areas of life. Paraphilias often present concomitantly with HD, and although cognitive behavioral therapy (CBT) has been proven to reduce engagement in hypersexual behavior, no studies have investigated the effects of Internet-administered CBT (ICBT) on HD, with or without paraphilia(s) or paraphilic disorder(s).AimTo investigate the effects of Internet-administered CBT on HD, with or without paraphilia(s) or paraphilic disorder(s).MethodsMale participants (n = 36) evaluated positive according to the proposed diagnostic HD criteria, with or without paraphilia(s) or paraphilic disorder(s), received 12 weeks of ICBT. Measures were administered weekly over the treatment period, with an additional follow-up measurement 3 months after completion of treatment. An assessment interview was performed 2 weeks after treatment.OutcomesThe primary outcome was the Hypersexual Behavior Inventory (HBI-19), and secondary outcomes were the Hypersexual Disorder: Current Assessment Scale (HD:CAS), the Sexual Compulsivity Scale (SCS), as well as a tentative composite of 6 Severity Self-rating Measures, for Paraphilic Disorders and depression (Montgomery-Åsberg Depression Rating Scale [MADRS-S]), psychological distress (Clinical Outcomes in Routine Evaluation Outcome Measure [CORE-OM]), and treatment satisfaction (CSQ-8).ResultsLarge, significant decreases in HD symptoms and sexual compulsivity were found, as well as moderate improvements in psychiatric well-being and paraphilic symptoms. These effects remained stable 3 months after treatment.Clinical ImplicationsICBT can ameliorate HD symptoms, psychiatric distress, and paraphilic symptoms, which suggests that the ICBT for HD, with or without paraphilia(s) or paraphilic disorder(s), may constitute a valuable addition of treatment options in clinical settings.Strengths and LimitationsThis is the first study evaluating the efficacy of ICBT on a sample of men suffering from HD. In addition, a proportion of the sample reported concomitant paraphilic interests and disorders, thus mirroring an everyday clinical practice in the field of sexual medicine. No control group was assigned, and some of the outcome measures are still to be validated. The long-term effects of ICBT and its efficacy in hypersexual women are unknown.ConclusionsThis study gives support for ICBT as an effective treatment option for HD. Future evaluations of the treatment program should include women and larger samples in randomized controlled procedures and investigate the long-term effects.Hallberg J, Kaldo V, Arver S, et al. Internet-Administered Cognitive Behavioral Therapy for Hypersexual Disorder, With or Without Paraphilia(s) or Paraphilic Disorder(s) in Men: A Pilot Study. J Sex Med 2020;17:2039–2054.     

Sexual Functions in Women With Stress Urinary Incontinence After Mid-Urethral Sling Surgery: A Systematic Review and Meta-Analysis of Prospective Randomized and Non-Randomized Studies

BackgroundStress urinary incontinence (SUI) is a common, distressing health issue which affects many women. Mid-urethral sling (MUS) surgeries are recommended as gold standard interventions, although evidence regarding their impact on female sexual function remains controversial.AimTo provide high-quality evidence of the impact of MUS surgeries on sexual functions in women with SUI.MethodsA systematic search of PubMed, Embase, and the Cochrane Library was conducted to identify studies assessing the effect of MUS treatments on sexual functions in women with SUI. The included studies were prospective randomized or non-randomized trials which assessed patients using 2 validated questionnaires, the Female Sexual Function Index (FSFI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Pre- and postoperative data regarding sexual function were extracted. Meta-analysis of comparable data was performed using Review Manager (version 5.3) software.Main outcome measuresThe relationship between MUS interventions and sexual functions was analyzed by pooling weighted mean differences (WMD) with 95% CI from studies which used either the FSFI or PISQ-12 questionnaires, before and after receiving surgical interventions.ResultsOf the 22 eligible studies, 13 utilized FSFI and 9 adopted the PISQ-12. Pooled analysis indicates that 6-month postoperative PISQ-12 scores were significantly higher than preoperative scores (WMD −3.31 points; 95% CI −5.32 to −1.30; P = .001). Similar results were found at the 12-month juncture (WMD −3.30 points; 95% CI −6.01 to −0.58; P = .02) and at 24 months (WMD −4.44 points; 95% CI −5.45 to −3.44; P < .00001). Likewise, pooled postoperative FSFI total scores were significantly higher than preoperative scores at 6 months (WMD −2.22 points; 95% CI −3.36 to −1.08; P = .00001) and 12 months (WMD −3.49 points; 95% CI −5.96 to −1.02; P = .006). Postoperative FSFI sub-scores also suggest that desire, arousal, orgasm, lubrication, satisfaction, and pain during sexual intercourse significantly improved postoperatively (all P < .05). Moreover, combined evidence highlighted a significant reduction in coital incontinence postoperatively (risk ratio 5.78; 95% CI 3.16–10.58; P < .00001).Clinical ImplicationsThese assessment tools might be more appropriately used to create opportunities for counseling.Strengths & LimitationsWe encountered substantial heterogeneity and insufficient long term follow-up data. There is also a distinct lack of standards, in terms of data recording and reporting across this evidence base which adds to the problems with the PISQ-12 and FSFI which, even though validated, appear unsophisticated and not necessarily fit-for-purpose.ConclusionThis meta-analysis confirms that sexual functions do improve after MUS surgeries for women with SUI.Lai S, Diao T, Zhang W, et al. Sexual Functions in Women With Stress Urinary Incontinence After Mid-Urethral Sling Surgery: A Systematic Review and Meta-Analysis of Prospective Randomized and Non-Randomized Studies. J Sex Med 2020;17:1956–1970.     

The Recurrent Pain and Sexual Sequelae of Provoked Vestibulodynia: A Perpetuating Cycle

IntroductionOptimal management of provoked vestibulodynia (PVD), thought to be the most common form of chronic dyspareunia, is unclear.AimTo integrate recent brain data on chronic pain circuitry with stress‐induced neuroendocrine mechanisms in the skin and the stress burden (allostatic load) of women with PVD; to also clarify the typical chronicity and negative sexual sequelae associated with PVD; and then review modulation of pain circuitry by cognitive therapy and mindfulness practice and apply to PVD management.MethodsReview of scientific publications in the areas of sexual medicine, pain, brain imaging, gynecology, stress response, mindfulness, and cognitive behavioral therapy (CBT).Main Outcome Measures(i) A model of PVD to reflect its etiology, typical chronicity, and the detrimental effects on sexual function; (ii) Interventions of sexual rehabilitation based on principles underlying changes associated with CBT and mindfulness practice.ResultsA model emerges which reflects how stress‐induced changes of pain amplification (central sensitization), characteristic of chronic pain conditions, may impair sexual response in addition to sexual dysfunction that arises from conscious pain avoidance and/or fear‐related inattention to sexual cues. Stress from low self‐acceptance may be a major component of the allostatic load present in women with PVD, only to be exacerbated by the sexual dysfunction precipitated by the pain of intercourse. Mindfulness‐based CBT appears promising to target both the pain and sexual suffering from PVD.ConclusionNew findings on brain activity associated with recurrent clinical pain, functional brain changes associated with CBT and mindfulness, plus new data on stress systems within the skin along with data on increased stress load in women with PVD, support the use of mindfulness‐based CBT for the recurrent pain and sexual suffering from PVD. Basson R. The recurrent pain and sexual sequelae of provoked vestibulodynia: A perpetuating cycle. J Sex Med 2012;9:2077–2092.     

Factors Associated With Specific Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition Sexual Dysfunctions in Breast Cancer Survivors: A Study of Patients and Their Partners

BackgroundMany women develop sexual problems after breast cancer (BC) treatment. Little is known about BC survivors with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) sexual dysfunction and their partners, and the factors associated with their sexual functioning.AimTo evaluate (i) patient-related and clinical factors associated with (a) specific DSM-IV sexual dysfunctions and (b) level of sexual functioning and sexual distress as reported by BC survivors and (ii) the association between the sexual functioning of BC survivors and that of their partners.MethodsWe analyzed baseline data from a study of the efficacy of online cognitive-behavioral therapy for sexual dysfunction in BC survivors.OutcomesWomen completed self-report questionnaires assessing sexual functioning, sexual distress, relationship intimacy, marital functioning, menopausal symptoms, body image, and psychological distress. Their partners completed questionnaires assessing sexual functioning.ResultsThe study included 169 BC survivors and 67 partners. The most prevalent female sexual dysfunctions were hypoactive sexual desire disorder (HSDD; 83%), sexual arousal disorder (40%), and dyspareunia (33%). Endocrine therapy was associated with HSDD (P = .003), and immunotherapy was associated with dyspareunia (P = .009). Older age was associated with lower sexual distress (P < .001). Depressive symptoms were highest in women with sexual arousal disorder (P = .004). An indication for erectile disorder was present in two thirds of partners. Lower overall partner sexual satisfaction was associated with lower overall BC survivor sexual functioning (P = .001), lower female arousal (P = .002), and lower female sexual satisfaction (P = .001). Poorer male erectile function was related to higher female sexual pain (P = .006). Partners of women who underwent breast reconstruction reported marginally significantly better orgasmic functioning (P = .012) and overall sexual functioning (P = .015) than partners of women who had undergone breast-conserving treatment.Clinical ImplicationsBC survivors and their partners experience sexual problems after BC treatment. This suggests that not only the BC survivor but also her partner could benefit from sexual counseling.Strengths and LimitationsThis is the first study focusing on BC survivors with a DSM-IV sexual dysfunction and their partners. The results cannot necessarily be generalized to women experiencing milder sexual problems or who have no interest in receiving sexual counseling.ConclusionEndocrine therapy and immunotherapy are relevant risk factors for HSDD and dyspareunia in BC survivors. The sexual functioning of women and their partners is affected, underscoring the importance of involving both partners in sexual counseling after BC treatment.Hummel SB, Hahn DEE, van Lankveld JJDM, et al. Factors Associated With Specific Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Sexual Dysfunctions in Breast Cancer Survivors: A Study of Patients and Their Partners. J Sex Med 2017;14:1248–1259.     

Variation in Orgasm Occurrence by Sexual Orientation in a Sample of U.S. Singles

IntroductionDespite recent advances in understanding orgasm variation, little is known about ways in which sexual orientation is associated with men's and women's orgasm occurrence.AimTo assess orgasm occurrence during sexual activity across sexual orientation categories.MethodsData were collected by Internet questionnaire from 6,151 men and women (ages 21–65+ years) as part of a nationally representative sample of single individuals in the United States. Analyses were restricted to a subsample of 2,850 singles (1,497 men, 1,353 women) who had experienced sexual activity in the past 12 months.Main Outcome MeasuresParticipants reported their sex/gender, self-identified sexual orientation (heterosexual, gay/lesbian, bisexual), and what percentage of the time they experience orgasm when having sex with a familiar partner.ResultsMean occurrence rate for experiencing orgasm during sexual activity with a familiar partner was 62.9% among single women and 85.1% among single men, which was significantly different (F_1,2848 = 370.6, P < 0.001, η² = 0.12). For men, mean occurrence rate of orgasm did not vary by sexual orientation: heterosexual men 85.5%, gay men 84.7%, bisexual men 77.6% (F_2,1494 = 2.67, P = 0.07, η² = 0.004). For women, however, mean occurrence rate of orgasm varied significantly by sexual orientation: heterosexual women 61.6%, lesbian women 74.7%, bisexual women 58.0% (F_2,1350 = 10.95, P < 0.001, η² = 0.02). Lesbian women had a significantly higher probability of orgasm than did either heterosexual or bisexual women (P < 0.05).ConclusionsFindings from this large dataset of U.S. singles suggest that women, regardless of sexual orientation, have less predictable, more varied orgasm experiences than do men and that for women, but not men, the likelihood of orgasm varies with sexual orientation. These findings demonstrate the need for further investigations into the comparative sexual experiences and sexual health outcomes of sexual minorities. Garcia JR, Lloyd EA, Wallen K, and Fisher HE. Variation in orgasm occurrence by sexual orientation in a sample of U.S. singles. J Sex Med 2014;11:2645–2652.     

Sexual Sensation Seeking,Sexual Compulsivity,and Gender Identity and Its Relationship With Sexual Functioning in a Population Sample of Men and Women

IntroductionDespite awareness of the importance of psycho-affective factors in the development of sexual problems, there is a lack of studies exploring the relation of sexual sensation seeking (SSS) and sexual compulsivity (SC) to sexual functioning. Because sex differences in SSS and SC have been reported, gender identity (GI; an individual’s own experience of his or her gender that is unrelated to the actual biological sex) might act as a moderator in this relation.AimTo understand the role of SSS and SC for men and women's sexual functioning and to explore whether these potential associations are moderated by GI.MethodsA population-based cross-sectional online survey targeted 279 individuals (69.2% women, 30.8% men; mean age = 32 years). Validated questionnaires, including the Sexual Sensation Seeking Scale, the Sexual Compulsivity Scale, the Female Sexual Function Index, the Premature Ejaculation Diagnostic Tool, and the International Index of Erectile Function, were applied.Main Outcome MeasuresVariations in SSS and SC and their association with sexual functioning were investigated using Spearman rank correlation. Moderation analyses were conducted using regression models in which the interaction terms between SSS and GI and between SCS and GI as predictors of sexual functioning were included.ResultsA statistically significant correlation between SSS and SC could be detected in men and women (r = 0.41 and 0.33, respectively; P < .001 for the two comparisons). In women, higher levels of SSS were associated with higher levels of desire, arousal, lubrication, and orgasm and less sexual pain (P < .05 for all comparisons). No moderating effect of GI could be detected. In men, GI was a significant moderator in the relation between SC and erectile function (β = 0.47; P < .001) and between SSS and erectile and ejaculatory function (β = −0.41 and 0.30; P < .001 for the two comparisons).ConclusionThe present study is the first to show a link between SSS and SC and sexual functioning. The results might have important clinical implications and can provide useful information for programs aimed at sexual health enhancement.     

Cognitive-Affective Factors and Female Orgasm: A Comparative Study on Women With and Without Orgasm Difficulties

BackgroundOrgasmic difficulties are one of the most common sexual complaints among women. Although models of sexual dysfunction propose that cognitive-affective factors are involved in the development and maintenance of sexual difficulties, there is a need to further examine how these factors are associated with orgasmic difficulties specifically.AimTo analyze differences between women who reported orgasm difficulties and controls in regard to sexual inhibition, sexual excitation, sexual beliefs, as well as negative automatic thoughts and affect during sexual activity.MethodsA total of 500 women, aged 18 to 72 years, completed a Web survey focused on cognitive-affective factors and sexual health. Two hundred fifty women reported orgasm difficulties and were compared with 250 age-matched women who reported no sexual difficulties.OutcomesDifferences between groups regarding sexual inhibition and sexual excitation (Sexual Inhibition/Sexual Excitation Scales–Short Form), sexual beliefs (Sexual Dysfunctional Beliefs Questionnaire), negative automatic thoughts (Automatic Thoughts Subscale of the Sexual Modes Questionnaire), and affect (Positive and Negative Affect Schedule) during sexual activity.ResultsWomen with orgasm difficulties scored higher on sexual inhibition than controls. They also reported more negative automatic thoughts during sexual activity (concerning failure and disengagement, sexual abuse, lack of affection from partner, passivity, body image) and less erotic thoughts. Women with orgasm difficulties reported experiencing higher negative affect and lower positive affect during sexual activity than women who reported no sexual difficulties. No significant differences were found regarding sexual excitation and endorsement of sexual beliefs.Clinical ImplicationsHelping women shift their focus from non-erotic, negative thoughts to erotic stimuli, as well as addressing sexual inhibition, can be relevant targets of interventions aimed at women's orgasm difficulties.Strengths & LimitationsStrengths of the study include the use of a large sample of women who reported orgasm difficulties, offering new insights into the clinical importance of these psychological processes. Limitations include the reliance on self-report measures and a relatively homogeneous sample regarding sexual orientation, education, and age.ConclusionResults highlight the role of cognitive-affective factors on women's orgasm difficulties and emphasize the potential benefit of cognitive-behavioral and/or mindfulness interventions for orgasm difficulties.Moura CV, Tavares IM, Nobre PJ. Cognitive-Affective Factors and Female Orgasm: A Comparative Study on Women With and Without Orgasm Difficulties. J Sex Med 2020;17:2220–2228.     

Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial

IntroductionDespite the importance of using penile injections as part of a penile rehabilitation program, men have difficulty complying with these programs.AimTo test a novel psychological intervention based on Acceptance and Commitment Therapy for erectile dysfunction (ACT-ED) to help men utilize penile injections.MethodsThis pilot randomized controlled trial (RCT) recruited men who were beginning a standard care (SC) structured penile rehabilitation program following radical prostatectomy. The SC program instructed patients to use penile injections 2 to 3 times per week. Participants were randomized to SC+ACT-ED or SC+enhanced monitoring (EM). Over 4 months, patients in the SC+ACT-ED group received SC plus 4 ACT sessions and 3 ACT phone calls; those in the EM group received SC plus 7 phone calls from an experienced sexual medicine nurse practitioner. Participants were assessed at study entry and at 4 and 8 months. For this pilot study, the goal was to determine initial efficacy (ie, effect sizes, where d = 0.2 is small, d = 0.5 is medium, and d = 0.8 is large).Main Outcome MeasurePrimary outcomes were feasibility and use of penile injections. Secondary outcomes were ED treatment satisfaction (ie, Erectile Dysfunction Inventory of Treatment Satisfaction, or EDITS), sexual Self-Esteem and Relationship (SEAR) quality, sexual bother (SB), and prostate cancer treatment regret.ResultsThe 53 participants were randomized (ACT, n = 26; EM, n = 27). The study acceptance rate was 61%. At 4 months, the ACT-ED group utilized more penile injections per week (1.7) compared to the EM group (0.9) (d = 1.25; P = .001) and was more adherent to penile rehabilitation compared to the EM group (ACT, 44%; EM, 10%; relative risk [RR], 4.4; P = .02). These gains were maintained at 8 months for injections per week (ACT, 1.2; EM, 0.7; d = 1.08; P = .03) and approached significance for adherence (ACT, 18%; EM, 0%; P = .10). At 4 months, ACT-ED, compared to EM, reported moderate effects for greater satisfaction with ED treatment (d = 0.41; P = .22), greater sexual self-esteem (d = 0.54; P = .07) and sexual confidence (d = 0.48; P = .07), lower sexual bother (d = 0.43; P = .17), and lower prostate cancer treatment regret (d = 0.74; P = .02). At 8 months, moderate effects in favor of ACT-ED were maintained for greater sexual self-esteem (d = 0.40; P = .19) and less treatment regret (d = 0.47; P = .16).Clinical ImplicationsACT concepts may help men utilize penile injections and cope with the effects of ED.Strengths and LimitationsStrengths include use of an innovative intervention utilizing ACT concepts and pilot RCT. Limitations include the pilot nature of the study (eg, small samples size, lack of statistical power).ConclusionACT-ED is feasible and significantly increases the use of penile injections. ACT-ED also shows promise (moderate effects) for increasing satisfaction with penile injections and sexual self-esteem while decreasing sexual bother and prostate cancer treatment regret.Nelson CJ, Saracino RM, Napolitano S, et al. Acceptance and Commitment Therapy to Increase Adherence to Penile Injection Therapy-Based Rehabilitation After Radical Prostatectomy: Pilot Randomized Controlled Trial. J Sex Med 2019; 19:1398–1408.     

Female Sexual Function in Young Women With Type 1 Diabetes and Additional Autoimmune Diseases

BackgroundFemale sexual dysfunctions (FSDs) are frequent concerns in women with type 1 diabetes (T1D), which is frequently associated with other autoimmune diseases (ADs).AimTo assess sexual function in young type 1 diabetic women with or without additional ADs.MethodsWomen with T1D aged 18–35 years with a stable couple relationship and no oral contraceptive use were enrolled. Diabetic women with concomitant ADs were also identified. All women completed the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale.OutcomesThe main outcome was the prevalence of FSD. The FSFI-single domain scores were also evaluated in diabetic women with or without additional ADs.ResultsThe global population included 154 diabetic women, of whom 66 (42%) had at least one additional AD. The prevalence of FSD was similar among diabetic women with and those without (30% vs 32%, P = .980) additional ADs. The FSFI-desire score was significantly lower among diabetic women with concomitant ADs than those without ADs [median (interquartile range), 4.1 (3.6, 4.8) vs 4.6 (4.0, 5.0), P = .042].Clinical ImplicationsAn early evaluation of sexual function in women with T1D and concomitant ADs should be encouraged.Strengths & LimitationsMajor strengths are the use of 2 validated tools to diagnose FSD and the relatively large number of subjects investigated. The limitations include the cross-sectional nature of the study, which does not allow to make inference regarding the cause and effect.ConclusionDiabetic women with additional ADs show an impairment in sexual desire as compared with those suffering only from diabetes.Longo M, Cirillo P, Scappaticcio L, et al. Female Sexual Function in Young Women With Type 1 Diabetes and Additional Autoimmune Diseases. J Sex Med 2021;18:219–223.     

Predictors of Sexual Desire and Sexual Function in Sedentary Middle-Aged Adults: The Role of Lean Mass Index and S-Klotho Plasma Levels. The FIT-AGEING Study

BackgroundUnhealthy lifestyle and aging negatively impact sexuality; consequently, the prevalence of sexual problems increases sharply in middle-aged adults, but the determinants of low sexual desire and sexual dysfunction are not fully elucidated.AimsTo investigate the association of cardiometabolic profile, free testosterone plasma levels, body composition, physical fitness, and S-Klotho plasma levels with sexual desire and sexual function in middle-aged sedentary adults.MethodsSeventy-four (39 women) sedentary middle-aged adults (45–65 years old) were recruited for the present cross-sectional study.OutcomesThe blood samples were collected in the morning (12 h of fasting) to determine cardiometabolic biomarkers and free testosterone and S-Klotho plasma levels. The cardiometabolic risk score was calculated based on the International Diabetes Federation's clinical criteria, quantitative insulin sensitivity check index, and homeostatic model assessment of insulin resistance index. A dual-energy X-ray absorptiometry scanner was used to determine the lean mass index (LMI) and the fat mass index. Maximal oxygen uptake was determined by a maximum treadmill test using indirect calorimetry. Muscular strength was measured with knee extensor isokinetic dynamometry (60° s⁻¹). Sexual desire was assessed with the Sexual Desire Inventory 2. Sexual function was assessed with the Massachusetts General Hospital-Sexual Functioning Questionnaire.ResultsAfter age adjustment, free testosterone plasma levels were associated with solitary sexual desire in women (R² = 0.193, β = 0.342, P = .044). The LMI was associated with solitary sexual desire in men (R² = 0.258, β = 0.445, P = .024) and sexual function in women (R² = 0.470, β = −0.607, P < .001). S-Klotho plasma levels were associated with solitary sexual desire and sexual function in men (R² = 0.412, β = 0.817, P = .001; R² = 0.193, β = −0.659, P = .021, respectively) and with dyadic sexual desire and sexual function in women (R² = 0.270, β = 0.508, P = .020; R² = 0.467, β = −0.676, P < .001, respectively).Clinical ImplicationsS-Klotho plasma levels may represent a potential new biomarker for sexual desire and sexual function. Lean body mass development may benefit sexual desire and sexual function.Strengths and LimitationsStrengths include the analysis of novel and diverse biomarkers of health for sexual desire and sexual function. Limitations include the cross-sectional design and a relatively small sample size; thus, results should be interpreted cautiously and in the study population context.ConclusionS-Klotho plasma levels were strongly associated with dyadic sexual desire, solitary sexual desire, and sexual function in sedentary middle-aged adults. The LMI was also positively associated with solitary sexual desire and sexual function in men and women, respectively.Dote-Montero M, De-la-O A, Castillo MJ, et al. Predictors of Sexual Desire and Sexual Function in Sedentary Middle-Aged Adults: The Role of Lean Mass Index and S-Klotho Plasma Levels. The FIT-AGEING Study. J Sex Med 2020;17:665–677.     

Association Between Marijuana Use and Sexual Frequency in the United States: A Population-Based Study

BackgroundMarijuana use is increasingly prevalent in the United States. Effects of marijuana use on sexual function are unclear, with contradictory reports of enhancement and detriment existing.AimTo elucidate whether a relation between marijuana use and sexual frequency exists using a nationally representative sample of reproductive-age men and women.MethodsWe analyzed data from cycle 6 (2002), cycle 7 (2006–2010), and continuous survey (2011–2015) administrations of the National Survey of Family Growth, a nationally representative cross-sectional survey. We used a multivariable model, controlling for demographic, socioeconomic, and anthropographic characteristics, to evaluate whether a relationship between marijuana use and sexual frequency exists.OutcomesSexual frequency within the 4 weeks preceding survey administration related to marijuana use and frequency in the year preceding survey administration.ResultsThe results of 28,176 women (average age = 29.9 years) and 22,943 men (average age = 29.5) were analyzed. More than 60% of men and women were Caucasian, and 76.1% of men and 80.4% of women reported at least a high school education. After adjustment, female monthly (incidence rate ratio [IRR] = 1.34, 95% CI = 1.07–1.68, P = .012), weekly (IRR = 1.36, 95% CI = 1.15–1.60, P < .001), and daily (IRR = 1.16, 95% CI = 1.01–1.32, P = .035) marijuana users had significantly higher sexual frequency compared with never users. Male weekly (IRR = 1.22, 95% CI = 1.06–1.41, P = .006) and daily (IRR = 1.36, 95% CI = 1.21–1.53, P < .001) users had significantly higher sexual frequency compared with never users. An overall trend for men (IRR = 1.08, 95% CI = 1.05–1.11, P < .001) and women (IRR = 1.07, 95% CI = 1.04–1.10, P < .001) was identified showing that higher marijuana use was associated with increased coital frequency.Clinical ImplicationsMarijuana use is independently associated with increased sexual frequency and does not appear to impair sexual function.Strengths and LimitationsOur study used a large well-controlled cohort and clearly defined end points to describe a novel association between marijuana use and sexual frequency. However, survey responses were self-reported and represent participants only at a specific point in time. Participants who did not answer questions related to marijuana use and sexual frequency were excluded.ConclusionA positive association between marijuana use and sexual frequency is seen in men and women across all demographic groups. Although reassuring, the effects of marijuana use on sexual function warrant further study.Sun AJ, Eisenberg ML. Association Between Marijuana Use and Sexual Frequency in the United States: A Population-Based Study. J Sex Med 2017;14:1342–1347.     

Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index

BackgroundA growing body of research investigates the sexual functioning status in women with contraceptives use; however, the evidence is still inconclusive.AimTo examine whether contraceptives use is associated with a higher risk of female sexual dysfunction (FSD).MethodsThe electronic databases MEDLINE, Embase, Cochrane Library databases, and PsychINFO were systematically screened for eligible studies before December 2019. We only included those studies assessing women's sexual functioning by the Female Sexual Function Index (FSFI). This study was registered on the PROSPERO (ID: CRD42020167723, http://www.crd.york.ac.uk/PROSPERO).OutcomesThe strength of the association between contraceptives use and risk of FSD was presented by calculating the standard mean dierences (SMDs) and the relative risk (RR) with a 95% confidence interval (CI). The pooled results were calculated using a random-effects model.ResultsA total of 12 studies (7 cross-sectional studies, 3 cohorts, and 1 case-control study) involving 9,427 participants were included. The mean age in the contraceptive users ranged from 22.5 ± 2.4 years to 38.2 ± 4.6 years, while the mean age in the nonusers was 22.5 ± 2.4 years to 36.0 ± 1.0 years. Pooled results showed that no significant difference in the total FSFI scores was observed between contraceptives use and noncontraception (SMD = −1.03, 95% CI: −2.08 to 0.01, P = .053; heterogeneity: I² = 98.2%, P < .001). In line with this finding, the pooled RR also yielded no association between contraception use and the risk of FSD (RR = 1.29, 95% CI: 0.72–2.28, P = .392; heterogeneity: I² = 76.0%, P = .0015). However, the subscale sexual desire showed a significant reduction in women who received contraceptives than those did not use contraception (SMD = −1.17, 95% CI: −2.09 to −0.24, P = .014; heterogeneity: I² = 97.7%, P < .001), while no significant differences were found in sexual arousal, lubrication, orgasm, satisfaction, and pain domain.Clinical ImplicationsThough evidence from this meta-analysis did not support an association between contraceptives use and the risk of FSD, the sexual desire could be significantly impaired by contraceptives use.Strengths & LimitationsThis is the first meta-analysis quantifying the relationship between contraceptives use and the risks of FSD. However, substantial heterogeneities were presented across the included studies.ConclusionNo direct association between contraceptives use and the risk of FSD was found. Nevertheless, declining sexual desire was significantly associated with contraceptives use. Additional double-blind, randomized, placebo-controlled trials are still warranted.Huang M, Li G, Liu J, et al. Is There an Association Between Contraception and Sexual Dysfunction in Women? A Systematic Review and Meta-analysis Based on Female Sexual Function Index. J Sex Med 2020;17:1942–1955.     

When Is Enough Enough? Orgasm's Curvilinear Association With Relational and Sexual Satisfaction

BackgroundCurvilinearity has been found for sexual frequency, but research has not examined whether curvilinear associations exist for other aspects of sexual relationships like orgasm consistency.AimWe examined whether there is curvilinearity and the nature of that curvilinearity between orgasm consistency and sexual and relational satisfaction for men and women.MethodsWith pooled samples of 1,619 and 1,695 men and women from Amazon's Mechanical Turk, we examined the differences of orgasm consistency values and both sexual satisfaction and relationship satisfaction through analysis of variance. We then tested for curvilinearity between orgasm consistency and sexual and relational satisfaction with regression analyses.OutcomesFor men we found no evidence of a curvilinear relationship, but for women we found a curvilinear relationship between orgasm consistency values and both sexual satisfaction and relationship satisfaction.ResultsAcross tests, the overall picture suggests that there is no curvilinear association for men, but there is for women. For women, with each unit increase in orgasm consistency, the increase in sexual satisfaction and relationship satisfaction became progressively smaller. Past the 61-80% threshold for orgasm consistency, there was little gain in sexual satisfaction and no gain in relational satisfaction.Clinical TranslationPhysicians, therapists, and educators can reorient women's orgasm expectations by explaining that having regular orgasms—not necessarily always—is associated with satisfaction in their relationship and sexual experience.Strengths & LimitationsConverging large samples and data analytic techniques evinced the curvilinear association between orgasm consistency and both relational and sexual satisfaction for women. However, this study is cross-sectional and correlational, which limits the conclusions we can draw from it.ConclusionWhile men's orgasm consistency is linearly associated with relational and sexual satisfaction, more consistent orgasms seem to be associated with women's sexual and relational satisfaction, to a point.Leavitt CE, Leonhardt ND, Busby DM, et al. When Is Enough Enough? Orgasm's Curvilinear Association With Relational and Sexual Satisfaction. J Sex Med 2021;18:167–178.