Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women

BackgroundIn the professional literature and among our professional societies, female sexual dysfunction nomenclature and diagnostic criterion sets have been the source of considerable controversy. Recently, a consensus group, supported by the International Society for Women’s Sexual Health, published its recommendations for nosology and nomenclature, which included only one type of arousal dysfunction, female genital arousal disorder, in its classification system. Subjective arousal was considered an aspect of sexual desire and not part of the arousal phase.AimTo advocate for the importance of including subjective arousal disorder in the diagnostic nomenclature in addition to the genital arousal subtype.MethodsWe reviewed how the construct of subjective arousal was included in or eliminated from the iterations of various diagnostic and statistical manuals. The Female Sexual Function Index (FSFI) was used to examine the relations among subjective arousal, genital arousal, and desire in women with and without sexual arousal concerns.Main Outcome MeasuresSexual arousal through a self-report Film Scale, physiologic sexual arousal through vaginal photoplethysmography in response to an erotic film, and the FSFI.ResultsThe clinical literature and experience support differentiating subjective arousal from desire and genital arousal. Correlations between the FSFI domains representing desire and subjective arousal, although sufficient to suggest relatedness, share approximately 58% of the variance between constructs—a lower shared variance than FSFI domains representing subjective arousal and orgasm. Similarly, when looking at FSFI individual items best representative of sexual desire and subjective arousal, the large majority of the variance in subjective arousal was unexplained by desire. A third line of evidence showed no significant difference in levels of subjective arousal to erotic films between sexually functional women and women with desire problems. If desire and subjective arousal were the same construct, then one would expect to see evidence of low subjective arousal in women with low sexual desire.Clinical ImplicationsOptimized treatment efficacy requires differentiating mental and physical factors that contribute to female sexual dysfunction.Strengths and LimitationsSupport for our conclusion is based on clinical qualitative evidence and quantitative evidence. However, the quantitative support is from only one laboratory at this time.ConclusionThese findings strongly support the view that female sexual arousal disorder includes a subjective arousal subtype and that subjective arousal and desire are related but not similar constructs. We advocate for the relevance of maintaining subjective arousal disorder in the diagnostic nomenclature and present several lines of evidence to support this contention.Althof SE, Meston CM, Perelman M, et al. Opinion Paper: On the Diagnosis/Classification of Sexual Arousal Concerns in Women. J Sex Med 2017;14:1365–1371.     

A Systematic Review on Mindfulness Meditation–Based Interventions for Sexual Dysfunctions

IntroductionMindfulness-based therapies (MBT) are more and more frequently used in the treatment of sexual dysfunctions; therefore, it seems very important to assess evidence-based data on the clinical efficacy of these interventions.AimTo provide a systematic review of published studies into the efficacy of MBT in the treatment of sexual dysfunctions.MethodsThe material for the analysis was obtained by searching 3 internet databases: EBSCO, PubMed, and ResearchGate. Articles describing therapeutic interventions on the basis of mindfulness and their efficiency in reducing sexual dysfunction symptoms in men and women were sought.Main Outcome Measures15 original research articles were included to the review: 4 articles were devoted to the analysis of the efficiency of the mindfulness-based therapy in the reduction of sexual dysfunction related to pain in the genital-pelvic area, 10 to desire or sexual arousal disorders or both in women, and 1 to erectile dysfunction in men.ResultsStudies indicate that MBT led to improvement in subjectively evaluated arousal and desire, sexual satisfaction, and a reduction of fear linked with sexual activity, as well as improving the consistency between the subjectively perceived arousal and genital response in women. The research indicated that MBT did not make a significant change in a reduction of pain during sexual activities. Evidence-based data were found on the efficacy of MBT in the treatment of male erectile dysfunction in 1 study.Clinical ImplicationsMBT could be effectively used in the treatment of female sexual dysfunction, specifically to improve sexual arousal/desire and satisfaction and to reduce sexual dysfunction associated with anxiety and negative cognitive schemas.Strengths & LimitationsThe few studies available are affected by several methodologic limitations, including small numbers of participants, patient selection, application of complex therapeutic interventions, and a lack of homework assessment, which makes definite conclusions difficult to draw.ConclusionThe effects of MBT in female sexual dysfunctions are promising. In future studies, the mindfulness-based monotherapies should be implemented to verify their potential in reducing symptoms of sexual dysfunction. More research is needed to explore the potential of MBT in the treatment of male sexual dysfunction.Jaderek I, Lew-Starowicz M. A Systematic Review on Mindfulness Meditation–Based Interventions for Sexual Dysfunctions. J Sex Med 2019;16:1581–1596.     

Feasibility of a Brief Online Psychoeducational Intervention for Women With Sexual Interest/Arousal Disorder

BackgroundLow sexual desire and arousal are the most common sexual concerns in women, but most women lack access to effective treatment such as cognitive behavioral therapy. Web-based psychological interventions, which are economical, private, easily accessible, and potentially effective, may increase the reach of evidence-based treatment.AimTo determine the feasibility of translating cognitive behavioral therapy for the most common female sexual dysfunction, Female Sexual Interest/Arousal Disorder, into an online format. The present study examined the feasibility of an introductory psychoeducational module of eSense, an online program currently being developed that is based on existing empirically supported in-person treatments, which delivers content to the user in a visually appealing and interactive manner.MethodsSixteen cisgender women (M age = 31.9) with female sexual arousal/interest disorder worked through a pilot module of eSense inperson at a sexual health laboratory.OutcomesQualitative semistructured interviews and online questionnaires were used to assess participants’ experiences of usability of the platform, clarity/relevance of the content, satisfaction with the experience, and any changes in clinical outcomes of sexual function and distress.ResultsParticipants reported a high level of satisfaction with the website’s functionality and presentation. They reported greater knowledge, felt validated and more hopeful, and were eager to continue the remaining modules. Participants also reported notable prepost improvements in sexual desire, arousal, and satisfaction.Clinical ImplicationsInitial user-experience assessment may represent a method of simultaneously improving online interventions and providing therapeutic education to participants.Strengths & LimitationsThis is one of the first studies, to our knowledge, to test a graphics-rich, interactive online intervention for sexual difficulties that does not require direct contact with expert providers or support groups. Limitations include the high level of education, motivation, and technical fluency of the sample and the potentially confounding effect of the researcher’s presence during interviews. Because this was a feasibility study, the sample size was small, and no control group was included, limiting conclusions about efficacy and generalizability.ConclusionThe format of eSense appears to be feasible and usable, lending support to the growing evidence that it is possible to take in-person therapeutic interventions online.Zippan N, Stephenson KR, Brotto LA, Feasibility of a Brief Online Psychoeducational Intervention for Women With Sexual Interest/Arousal Disorder. J Sex Med 2020;17:2208–2219.     

Partner Responses to Low Desire: Associations With Sexual,Relational, and Psychological Well-Being Among Couples Coping With Female Sexual Interest/Arousal Disorder

BackgroundThe experience of distressing low sexual interest/arousal—female sexual interest/arousal disorder (FSIAD)—is prevalent in women of all ages and is associated with poorer sexual, relationship, and psychological well-being than women without this difficulty. Women who are partnered are almost 5 times more likely to be distressed by low desire and to receive a diagnosis of FSIAD than unpartnered women, indicating that interpersonal factors are highly relevant, although largely neglected in past research.AimIn a dyadic cross-sectional and longitudinal study, we examined whether partner responses to FSIAD were associated with the sexual, relationship, and psychological well-being of couples, and whether any effects persisted 1 year later.MethodsWomen diagnosed with FSIAD (N = 89) completed a validated measure of perceived partner positive vs negative responses to their low sexual interest/arousal and their partners reported on their own responses, as well as measures of sexual desire, sexual satisfaction, relationship satisfaction, sexual distress, and anxiety. 1 year later, couples (N = 66) completed the outcome measures again. Data were analyzed according to the Actor-Partner Interdependence Model.OutcomesOutcomes included were the Sexual Desire Inventory–Solitary and Partner-Focused Subscales; Global Measure of Sexual Satisfaction; Female Sexual Distress Scale; Couple Satisfaction Index; and State-Trait Anxiety Inventory–Short-Form.ResultsWhen women with FSIAD perceived more positive partner responses (eg, warm, supportive, compassionate) than negative responses (eg, hostile, unsupportive, indifferent), they were more satisfied with the relationship and they and their partners reported lower anxiety. When partners reported more positive than negative responses, they had greater relationship and sexual satisfaction and lower sexual distress and anxiety. Exploratory analyses revealed that women's perceptions of their partners' responses accounted for the link between partners' own responses and women's relationship satisfaction and anxiety. Partner responses did not predict any change in outcomes over time.Clinical ImplicationsFindings support interpersonal conceptualizations of FSIAD and may inform the development of future couple-based interventions.Strengths & LimitationsThis study is one of the few dyadic investigations of FSIAD, as diagnosed via a clinical interview. Significant associations were only observed cross-sectionally, limiting causal conclusions. There was limited power to detect longitudinal effects.ConclusionMore positive responses to women's low sexual interest/arousal by partners is linked to better adjustment among couples affected by FSIAD.Rosen NO, Corsini-Munt S, Dubé JP, et al. Partner Responses to Low Desire: Associations With Sexual, Relational, and Psychological Well-Being Among Couples Coping With Female Sexual Interest/Arousal Disorder. J Sex Med 2020;17:2168–2180.     

Focusing "hot" or focusing "cool": attentional mechanisms in sexual arousal in men and women

IntroductionKnowledge about the regulation of sexual emotion may add to the understanding of sexual problems such as diminished sexual desire and hypersexuality.AimTo investigate the regulation of sexual arousal by means of attentional focus in healthy sexually functional men and women.MethodUsing a habituation design with attentional strategies, it was investigated whether a focus on hot, emotional information of sexual stimuli would sustain or amplify sexual responses, whereas a focus on cool, cognitive information would weaken sexual responses.Main Outcome MeasuresGenital response (in women measured by vaginal photoplethysmography assessing vaginal pulse amplitude, and in men measured by mechanical penile strain gauge assessing penile circumference) and subjective report of sexual arousal and absorption.ResultsAttenuation of sexual feelings by attentional focus was observed, with stronger sexual feelings under the hot focus condition than under the cool focus condition. Also, sexual feelings diminished during repeated erotic stimulation, and increased with the introduction of novel stimulation, indicating habituation and novelty effects. Contrary to the expectations, the hot attentional focus did not preclude habituation of sexual arousal.ConclusionsAttentional focus has substantial regulatory effects on subjective sexual arousal. Taking a participant and emotion‐oriented focus rather than a spectator and stimulus‐oriented focus while viewing erotic stimuli, enhances feelings of sexual arousal. Implications for the treatment of hypoactive sexual desire, sexual arousal disorder, and hypersexuality are discussed, as well as future directions for studying regulation of sexual emotion. Both S, Laan E, and Everaerd W. Focusing “hot” or focusing “cool”: Attentional mechanisms in sexual arousal in men and women.     

Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women

BackgroundSexual dysfunction is common in midlife women and can have a significant negative impact on quality of life. Although treatments exist, there is little research on which sexual function outcomes and treatments midlife women prefer.AimTo better understand the sexual function outcomes that were most important to sexually active women 45 to 60 years old and the types of treatments they would prefer from individual interviews and focus groups.MethodsTwenty individual interviews and three focus groups (N = 39) were led by a trained facilitator, audio recorded, and transcribed. Two investigators developed a codebook, and the primary investigator coded all data. A second investigator coded five randomly selected interviews to ensure intercoder reliability. Codes relating to outcomes and treatment preferences were examined to identify central themes.ResultsThe mean age was 52.8 years (range = 45–59). When asked what they would want a sexual dysfunction treatment to do, women sought solutions to specific sexual problems: low desire, vaginal pain and dryness, and decreased arousal or ability to achieve orgasm. However, when asked about the most important aspect of their sex life, most women indicated emotional outcomes, such as enhanced intimacy with their partner, were most important to them. Most women preferred behavioral over pharmaceutical treatments, citing concerns about side effects. These women felt that behavioral treatments might be better equipped to address physical and psychological aspects of sexual problems.Clinical implicationsThis study highlights the importance of considering not only physical but also emotional outcomes when evaluating and treating sexual dysfunction in midlife women. It also emphasizes the importance of developing behavioral treatments in addition to pharmaceutical treatments.Strengths and LimitationsBy using a qualitative approach, this study allowed women the time and space to speak their own words about their experiences with sexuality at midlife. In addition, different racial and ethnic groups and menopausal statuses were represented. Limitations include limited generalizability, as is true for most qualitative research. In addition, although most women did endorse sexual problems, we did not exclude women with no sexual complaints.ConclusionsMidlife women value physical and emotional outcomes with regard to sexual function. Many midlife women in this sample expressed a preference for behavioral approaches over pharmaceutical approaches for the treatment of sexual dysfunction.Thomas HN, Hamm M, Hess R, et al. Patient-Centered Outcomes and Treatment Preferences Regarding Sexual Problems: A Qualitative Study Among Midlife Women. J Sex Med 2017;14:1011–1017.     

Sexual Arousal and Desire: Interrelations and Responses to Three Modalities of Sexual Stimuli

IntroductionTraditionally, sexual desire is understood to occur spontaneously, but more recent models propose that desire responds to sexual stimuli.AimsTo experimentally assess whether sexual stimuli increased sexual desire; to compare how sexual arousal and desire responded to three modalities of sexual stimuli: erotic story, unstructured fantasy, and the Imagined Social Situation Exercise (ISSE).MethodsIn an online study, participants (128 women, 98 men) were randomly assigned to one of four arousal conditions (ISSE, story, fantasy, or neutral), and then completed desire measures. In the ISSE, participants imagined and wrote about a positive sexual encounter with a self‐defined attractive person.Main Outcome MeasuresSexual arousal (perceived genital, psychological, and perceived autonomic), anxiety, positive and negative affect, and state sexual desire via self‐report measures pre‐ and post‐condition; “trait” desire via the Sexual Desire Inventory post‐condition.ResultsAll three sexual conditions significantly increased sexual arousal and positive affect compared with the neutral condition, with trends for higher arousal to unstructured fantasy than the ISSE or story conditions. Sexual conditions significantly increased scores on state measures of sexual desire. In addition, sexual context influenced measurement of “trait” solitary sexual desire in women, such that women reported significantly higher trait desire after the neutral and ISSE conditions vs. fantasy.ConclusionResults highlight the responsiveness of sexual desire, problems with measurement of desire as a long‐term trait, trade‐offs of using the ISSE and other stimuli in sexuality research, and the need to address context in discussions of women's and men's desire. Goldey KL and van Anders SM. Sexual arousal and desire: Interrelations and responses to three modalities of sexual stimuli. J Sex Med 2012;9:2315–2329.     

How Cannabis Alters Sexual Experience: A Survey of Men and Women

IntroductionCannabis is reported to enhance sexual function; yet, previous studies have shown that physiological and subjective indices of sexual arousal and motivation were associated with decreased availability of circulating endocannabinoid concentrations.AimTo explain this contradiction, we evaluated which aspects of sexual experience were enhanced or diminished by cannabis use.MethodsWe used an online questionnaire with a convenience sample of people who had experience with cannabis. We asked questions regarding various aspects of sexual experience and whether they are affected by cannabis. We also asked about sexual dysfunction.Main Outcome MeasureAspects of participant sexual experience enhanced by cannabis.ResultsWe analyzed results from 216 questionnaires completed by people with experience using cannabis with sex. Of these, 112 (52.3%) said they used cannabis to alter their sexual experience. Eighty-two participants (38.7%) said sex was better, 34 (16.0%) said it was better in some ways and worse in others, 52 (24.5%) said it was sometimes better, and only 10 (4.7%) said it was worse. Of 202 participants, 119 (58.9%) said cannabis increased their desire for sex, 149 of the 202 participants (73.8%) reported increased sexual satisfaction, 144 of 199 participants (74.3%) reported an increased sensitivity to touch, and 132 of 201 participants (65.7%) reported an increased intensity of orgasms. Out of 199 participants, 139 (69.8%) said they could relax more during sex, and 100 of 198 participants (50.5%) said they were better able to focus. Of the 28 participants who reported difficulty reaching orgasm, 14 said it was easier to reach orgasm while using cannabis, but only 10 said that sex was better.Clinical ImplicationsThe information in this study helps clarify which aspects of sexual function can be improved or interfered with by cannabis use.Strengths & LimitationsWe asked about specific sexual effects of cannabis and were therefore able to understand the paradox of how cannabis can both improve and detract from sexual experience. Limitations of this study include bias that may have been introduced because the sample included only people who responded to the advertisements; it may not represent the general population of people who use cannabis. Moreover, over one-third of our sample said they use cannabis daily and so represent heavier than average users.ConclusionMany participants in our study found that cannabis helped them relax, heightened their sensitivity to touch, and increased intensity of feelings, thus enhancing their sexual experience, while others found that cannabis interfered by making them sleepy and less focused or had no effect on their sexual experience.Wiebe E, Just A. How Cannabis Alters Sexual Experience: A Survey of Men and Women. J Sex Med 2019; 16:1758–1762.     

A Randomized Study Comparing Video-Based Mindfulness-Based Cognitive Therapy With Video-Based Traditional Cognitive Behavioral Therapy in a Sample of Women Struggling to Achieve Orgasm

IntroductionThis study examines the effectiveness of integrating mindfulness-based techniques within therapy for women suffering to achieve orgasm. Although widely applied in psychotherapy, this approach has only recently been introduced in the treatment of female sexual dysfunction.AimTo compare the effectiveness of a video-based self-administered treatment, rooted within the cognitive behavioral treatment (CBT) framework, with a video-based self-administered mindfulness treatment applying cognitive behavioral sexual therapy (mindfulness-based cognitive therapy), the latter of which was specifically created to increase women's ability to achieve orgasm.MethodsA convenience sample of 65 women suffering from difficulties to achieve orgasm, aged 18 to 58 years (mean = 32.66, standard deviation = 9.48), were randomly allocated using a randomization procedure to either a mindfulness-based cognitive therapy (N = 35) or CBT (N = 30) group. Each participant completed questionnaires before and after the start of treatment and 2 months after its completion.Main Outcome MeasureWe applied repeated-measure general linear models to compare the 2 groups (ie, between participant factor) on each dependent variable across time (ie, the within-participant factor). Compare mean analyses for paired samples were only conducted when the interaction effect between condition and time was significant (ie, P <.05).ResultsStatistical analyses show that women in both groups presented increased sexual functioning (P = .001) and decreased sexual distress (P < .001), as well as improved desire, arousal, orgasm, and sexual satisfaction (P < .05) after their respective treatments. Contrary to our hypothesis, significant reductions in sexual pain were only observed in CBT participants.Clinical ImplicationsTo the best of our knowledge, this is the first study to apply a randomized allocation procedure to evaluate the effectiveness of a video-based mindfulness intervention for women struggling to achieve orgasm. These results should guide clinicians' decisions with respect to evaluating the relevance and the real added value of proposing mindfulness exercises to their patients with such difficulties.ConclusionWhen women suffering from difficulties to achieve orgasm are randomly assigned to a mindfulness group or an active control, improvements in sexual functioning and reductions in sexual distress can be observed after both treatments.Adam F, De Sutter P, Day J, et al. A Randomized Study Comparing Video-Based Mindfulness-Based Cognitive Therapy With Video-Based Traditional Cognitive Behavioral Treatment in a Sample of Women Struggling to Achieve Orgasm. J Sex Med 2020;17:312–324.     

Female Sexual Dysfunction—Medical and Psychological Treatments,Committee 14

IntroductionSince the millennium we have witnessed significant strides in the science and treatment of female sexual dysfunction (FSD). This forward progress has included (i) the development of new theoretical models to describe healthy and dysfunctional sexual responses in women; (ii) alternative classification strategies of female sexual disorders; (iii) major advances in brain, hormonal, psychological, and interpersonal research focusing on etiologic factors and treatment approaches; (iv) strong and effective public advocacy for FSD; and (v) greater educational awareness of the impact of FSD on the woman and her partner.AimsTo review the literature and describe the best practices for assessing and treating women with hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.MethodsThe committee undertook a comprehensive review of the literature and discussion among themselves to determine the best assessment and treatment methods.ResultsUsing a biopsychosocial lens, the committee presents recommendations (with levels of evidence) for assessment and treatment of hypoactive sexual desire disorder, female sexual arousal disorder, and female orgasmic disorders.ConclusionThe numerous significant strides in FSD that have occurred since the previous International Consultation of Sexual Medicine publications are reviewed in this article. Although evidence supports an integrated biopsychosocial approach to assessment and treatment of these disorders, the biological and psychological factors are artificially separated for review purposes. We recognize that best outcomes are achieved when all relevant factors are identified and addressed by the clinician and patient working together in concert (the sum is greater than the whole of its parts).Kingsberg SA, Althof S, Simon JA, et al. Female Sexual Dysfunction—Medical and Psychological Treatments, Committee 14. J Sex Med 2017;14:1463–1491.     

The Mediating Role of Sexual Behavior in Event-Level Associations Between Sexual Difficulties and Sexual Satisfaction in Newlywed Mixed-Sex Couples

Introduction

Many sexual difficulties encountered by couples in their day-to-day lives, although of insufficient intensity and persistence to warrant a clinical diagnosis of sexual disorder, are nevertheless frequent and a source of individual and relational distress.

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.     

Repetitive Transcranial Magnetic Stimulation as a Potential Tool to Reduce Sexual Arousal: A Proof of Concept Study

BackgroundHypersexuality and hyposexuality occur frequently, often in a variety of psychiatric disorders, and are difficult to treat. While there is meta-analytic evidence for the significant effect of non-invasive brain stimulation on drug and food craving, no study has investigated the potential of this technique to modulate sexual behavior.AimHere, we tested the hypothesis that a single session of high-frequency repetitive transcranial magnetic stimulation (rTMS) over the dorsolateral prefrontal cortex (DLPFC) would reduce sexual arousal.MethodsWe employed a randomized, double-blind, sham-controlled crossover study design. 19 healthy male participants received high-frequency rTMS over the left DLPFC, high-frequency rTMS over the right DLPFC, and sham rTMS (each 10 Hz; 110% resting motor threshold; 60 trains with 50 pulses) in randomized and counterbalanced order with a 1-week interval between stimulation sessions to avoid carryover effects. Participants were exposed to neutral and sexual cues before and after each intervention and rated their sexual arousal after each block of cue presentation.Main Outcome MeasureEfficacy of the respective intervention was operationalized by the change of subjective sexual arousal according to a rating scale.ResultsrTMS of the right DLPFC significantly reduced subjective sexual arousal (t₁₈ = 2.282, P = .035). In contrast, neither sham rTMS nor rTMS of the left DLPFC affected sexual arousal (P > .389). Greater rTMS-induced reduction of subjective sexual arousal was observed in participants with higher trait-based dyadic sexual desire within the last 12 months (r = −0.417, P = .038).Clinical ImplicationNon-invasive brain stimulation might hold potential for influencing hypersexual behavior.Strength & LimitationThis was a randomized, double-blind, sham-controlled crossover study with subjective but no physiological measures of sexual arousal.ConclusionThe results indicate that 1 session of high-frequency rTMS (10 Hz) of the right DLPFC could significantly reduce subjective sexual arousal induced by visual stimuli in healthy subjects. On this basis, future studies with larger sample sizes and more stimulation sessions are needed to explore the therapeutic potential of rTMS in hypersexual behavior.Schecklmann M, Sakreida K, Oblinger B, et al. Repetitive Transcranial Magnetic Stimulation as a Potential Tool to Reduce Sexual Arousal: A Roof of Concept Study. J Sex Med 2020;17:1553–1559.     

Sexual Behavior,Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study

BackgroundOne of the most prominent etiological theories of gender incongruence in trans women proposes a paraphilic erotic target location error (ie, autogynephilia) as a causal factor in gynephilic (ie, exclusively gynephilic and bisexual) trans women. We hypothesized that a paraphilic erotic target location should manifest itself in various aspects of sexual behavior, solitary and dyadic sexual desire, and psychosexual experience.AimTo compare sexual behavior, sexual desire, and psychosexual experience of exclusively gynephilic and bisexual trans women with that of androphilic trans women to explore whether their sexuality differs substantially.MethodsTrans women diagnosed with gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders–5) were recruited at 4 transgender healthcare centers in Germany. The present study analyzed items on sexual behavior, desire, and experience of a self-report questionnaire, collected as part of a cross-sectional multicenter study.Main OutcomesMultiple aspects of sexuality were examined using self-constructed items. Sexual desire was measured using the Sexual Desire Inventory and psychosexual experience using the Multidimensional Sexuality Questionnaire.ResultsSignificantly more exclusively gynephilic than androphilic trans women reported a history of sexual arousal in relation to cross-dressing. However, little evidence was found that gynephilic and androphilic sexual desire, behavior, and psychosexual experience differ profoundly. Interestingly, a statistically non-significant trend indicated that gynephilic trans women who had not yet undergone gender affirming surgery showed the highest levels of sexual desire (solitary and dyadic), whereas the opposite was the case for androphilic trans women.Clinical TranslationData of this study indicate that sexual orientation does not appear to be a good predicator for sexual behavior, desire, and psychosexual experience in trans women.Strengths and LimitationsWe investigated sexual desire and experience using standardized and evaluated measures such as the Sexual Desire Inventory and Multidimensional Sexuality Questionnaire. Future studies with a larger sample size should investigate how different gender affirming medical intervention might have diverging influences on sexual behavior, desire, and experience.ConclusionUltimately, this study found little evidence for the hypothesis that sexual behavior, sexual desire, and psychosexual experience differ substantially in gynephilic (exclusively gynephilic and bisexual) and androphilic trans women.Laube JS, Auer M, Biedermann SV, et al. Sexual Behavior, Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study. J Sex Med 2020;17:1182–1194.     

Reduced Labial Temperature in Response to Sexual Films with Distractors among Women with Lower Sexual Desire

IntroductionSexual desire variation traditionally has been treated as due to variance in affective response to sexual stimulation, but differences in attention to the stimuli may better account for differences in sexual desire.AimDetermine whether sexual desire varies due to attention biases towards sexual stimuli.Main outcome measuresSexual arousal was quantified by physiological (labia minus temperature) and experienced (continuously adjusting a potentiometer) indicators.MethodsTwenty-two women who varied in their level of sexual desire attended one laboratory session during which they viewed a neutral nature film, a sexual film, and a sexual film with distractors while their labial temperature and self-reported sexual arousal were recorded.ResultsParticipants reported and displayed lower sexual arousal during the sexual stimulus with distractors as compared to the sexual film without distractors. While all women reported lower sexual arousal to the sexual film with distractors, women with relatively lower sexual desire also reported lower sexual arousal to the sexual film with no distractors than women with higher sexual desire. Physiologically, women with lower sexual desire exhibited lower labial temperature.ConclusionsSince the predicted lower self-reported and physiological sexual arousal to the sexual stimulus with distractors for the women with lower sexual desire did not emerge, this study does not support that sexual desire levels vary due to differential attention to sexual stimuli. Prause N, and Heiman J. Reduced labial temperature in response to sexual films with distractors among women with lower sexual desire.     

Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer

BackgroundAndrogen deprivation therapy (ADT) administered against metastatic prostate cancer has significant side effects including sexual dysfunction.AimTo assess sexual interest and motivators for sex during ADT and to find out what model of sexuality best describes the sexual experience for men during this treatment.MethodsA questionnaire was mailed to patients who had received ADT for ≥6 months. Patients were asked to choose all relevant entities from a list of sexual motivators and between models of sexuality described by Masters and Johnson (excitement and physical experiences), Kaplan (sexual desire), and Basson (intimacy and closeness to partner). Erectile function was assessed by the Erection Hardness Scale, and sexual satisfaction was measured on a scale from 0 to 10.OutcomesSexual activity, erectile function, sexual satisfaction, and motivators for sexual interest in the study subjects as well as the proportion of participants who endorsed either of the 3 models of sexuality.ResultsA total of 173 men were invited, and 76 returned the questionnaires (44%). The median age was 76 (range 69–80) years, and the median duration of ADT was 30 months. A total of 62 men had been sexually active before ADT, and of these, 2 were still active. Another 29 were interested in sexual activity. 3 men endorsed the Masters and Johnson model, whereas the remaining participants did not endorse any of the models. The motivators for sexual interest were feeling an emotional connection to the partner (n = 16), sexual desire (n = 10), satisfaction of the partner (n = 8), fear that the partner would leave (n = 4), achieving orgasm (n = 3), and a desire to feel masculine (n = 1). No one was interested in sexual activity to reduce stress or to maintain confidence. Only 1 patient had erections sufficient for penetrative intercourse, and the median sexual satisfaction for the entire group was 0 (interquartile range: 0–5).Clinical ImplicationsSexuality and sexual function should be addressed in men undergoing ADT.Strengths & LimitationsThe main strength of our study is that we are the first to explore both motivators for sexual activity and endorsement of sexual models in men undergoing ADT. The study is limited by the relatively low number of participants and the response rate of 44%.ConclusionADT is detrimental to sexual function. However, many patients maintain an interest in sexual activity, which does not fit our established models. Rather, factors such as keeping an emotional connection with a partner play a role.Fode M, Mosholt KS, Nielsen TK, et al. Sexual Motivators and Endorsement of Models Describing Sexual Response of Men Undergoing Androgen Deprivation Therapy for Advanced Prostate Cancer. J Sex Med 2020;17:1538–1543.     

A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer

Goal

The goal of this study was to evaluate a mindfulness-based cognitive behavioral intervention for sexual dysfunction in gynecologic cancer survivors compared to a wait-list control group.

Methods

Thirty-one survivors of endometrial or cervical cancer (mean age 54.0, range 31-64) who self-reported significant and distressing sexual desire and/or sexual arousal concerns were assigned either to three, 90-minute mindfulness-based cognitive behavior therapy sessions or two months of wait-list control prior to entering the treatment arm. Validated measures of sexual response, sexual distress, and mood, as well as laboratory-evoked physiological and subjective sexual arousal were assessed at pre-, one month post-, and 6-months following treatment.

Results

There were no significant effects of the wait-list condition on any measure. Treatment led to significant improvements in all domains of sexual response, and a trend towards significance for reducing sexual distress. Perception of genital arousal during an erotic film was also significantly increased following the intervention despite no change in physiologically-measured sexual arousal.

Conclusions

A brief mindfulness-based intervention was effective for improving sexual functioning. Geographic restrictions permitted only a select sample of survivors to participate, thus, the generalizability of the findings is limited. Future studies should aim to develop online modalities for treatment administration to overcome this limitation.     

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.     

Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study

IntroductionStudies about sexual functioning in trans persons have mainly focused on sexual functioning after genital gender-affirming surgery, have had small sample sizes, and have not explored the broad range of possible sexual dysfunctions. Measuring sexual functioning in trans persons during transitioning is important to determine the kind of care trans persons may need in order to regain their sexual health.AimThe first aim of the present study was to explore the prevalence of sexual function disturbances and dysfunctions (with distress) in trans women and trans men 4 to 6 years after initial clinical entry. The second aim was to compare the prevalence of sexual dysfunctions among the various treatment trajectories and between trans persons with or without further genital treatment intentions.MethodsAn online follow-up questionnaire was filled out by 518 trans persons (307 identifying predominantly feminine, 211 identifying predominantly masculine) as a part of the European Network for the Investigation of Gender Incongruence initiative. All participants had their initial clinical appointments in gender clinics in Ghent, Amsterdam, or Hamburg.Main Outcome MeasureThe main outcome measures were the prevalence of sexual dysfunctions and medical treatment data, measured via self-report items.ResultsThe most frequent sexual dysfunctions experienced by trans women and trans men were difficulties initiating and seeking sexual contact (26% and 32%, respectively) and difficulties achieving an orgasm (29% and 15%, respectively). Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire. Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often. No significant differences were found between participants with or without further genital treatment intentions.Clinical implicationsClinicians should consider sexual counseling after medical treatments, paying particular attention to potential social and psychological barriers to the sexual health of their patients.Strengths & LimitationsThis study included all trans persons irrespective of treatment decisions, and focused on a broad range of potential sexual difficulties taking the distress criteria into account. Limitations include the cross-sectional design, the limited power for the comparison of treatment groups and the absence of validated questionnaires about sexual functioning for transgender persons.ConclusionSexual dysfunctions among trans men and women were very common among the various treatment groups and were unrelated to intentions to have further genital treatment. Although medical treatment may be helpful or even essential to developing good sexual health, a significant group of trans persons experienced sexual dysfunctions after genital surgery.Kerckhof ME, Kreukels BPC, Nieder TO, et al. Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study. J Sex Med 2019; 16:2018–2019.