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.     

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.     

Sexual Arousal in Women with Provoked Vestibulodynia: The Application of Laser Doppler Imaging to Sexual Pain

IntroductionWomen with provoked vestibulodynia (PVD) report lower sexual arousal than nonaffected women, however, laboratory studies of arousal have reported contradictory results about whether group differences exist in genital and subjective arousal.AimTo examine genital and subjective sexual arousal in women with and without PVD.MethodsEligible women with and without PVD (N = 42) attended a laboratory session that included an interview, questionnaire completion, and genital imaging. A direct measure of superficial blood flow—laser Doppler imaging—was used to assess vulvar blood flow levels while participants watched three films, including an erotic film. Participants answered questions about their level of sexual arousal before, during, and after the erotic film.Main Outcome MeasuresAverage vulvar blood flow levels during the baseline and erotic films, numerical ratings of subjective sexual arousal and anxiety, as well as questionnaire measures of arousal.ResultsThere was a significant group difference in genital arousal, whereby the PVD group showed a lower genital response to the erotic film, as well as a significant interaction between baseline blood flow and group membership. Separate group regression analyses demonstrated that baseline blood flow explained a substantial amount of the variance in erotic film blood flow in the control group (70%), while only 27% was explained by this variable in the PVD group. There were no differences in subjective sexual arousal or anxiety between the groups. Across questionnaire measures, women with PVD reported lower sexual arousal than the control group.ConclusionsThe results suggest that women with PVD show lower genital responsiveness than nonaffected women to sexual stimuli in a laboratory setting and that their genital arousal is likely impacted by a number of biopsychosocial factors. Boyer SC, Pukall CF, and Chamberlain SM. Sexual arousal in women with provoked vestibulodynia: The application of laser Doppler imaging to sexual pain. J Sex Med 2013;10:1052-1064.     

The Sensitivity of Continuous Laboratory Measures of Physiological and Subjective Sexual Arousal for Diagnosing Women with Sexual Arousal Disorder

IntroductionPast findings on the diagnostic sensitivity of vaginal photoplethysmography are limited by testing among women with heterogeneous sexual dysfunctions and by the use of statistical techniques that are unable to assess how changes in subjective arousal are associated with changes in physiological arousal.AimsThe aims of this study were to: (i) test the sensitivity of vaginal photoplethysmography and continuous measures of subjective sexual arousal in differentiating between women with and without sexual arousal or orgasm dysfunction; and (ii) examine the diagnostic utility of measuring the synchrony between genital and subjective sexual responses.MethodsSexual arousal was assessed in sexually healthy women (n = 12), women with orgasm disorder (OD; n = 12), and 38 women who met the criteria for the three subcategories of sexual arousal dysfunction described by Basson et al. (i.e., genital sexual arousal disorder [GAD; n = 9], subjective sexual arousal disorder [SAD; n = 13], and combined genital and subjective arousal disorder [CAD; n = 16]).Main Outcome MeasuresPhysiological sexual arousal was assessed using vaginal photoplethysmography, and subjective sexual arousal was measured continuously and using a Likert-scale in response to sexual videos.ResultsWomen with GAD showed the lowest and women with CAD showed the highest levels of vaginal pulse amplitude response to erotic stimuli. Women with sexual arousal disorder showed significantly lower levels of subjective sexual arousal to erotic stimuli than did sexually healthy women. Relations between subjective and physiological measures of sexual arousal were significantly weaker among women with sexual arousal disorder than sexually healthy women or women with OD.ConclusionPreliminary support was provided for the diagnostic utility of measuring the synchrony between subjective and genital arousal in women with sexual arousal disorder. Findings do not support the sensitivity of using vaginal photoplethysmography, or continuous or Likert-scale measures of subjective arousal for differentiating between subtypes of women with sexual arousal disorder. Meston CM, Rellini AH, and McCall K. The sensitivity of continuous laboratory measures of physiological and subjective sexual arousal for diagnosing women with sexual arousal disorder.     

Sexual Arousal in East Asian and Euro-Canadian Women: A Psychophysiological Study

IntroductionStudies of ethnic differences in self-report measures of sexuality have shown East Asian women to be more sexually conservative and less sexually experienced than Caucasian women. There is also strong evidence supporting the notion of ethnic group differences in general measures of nonsexual psychophysiological arousal; however, there have been no previous studies exploring ethnicity and physiological sexual arousal.AimThe objective of this study was to explore group differences in self-reported and physiological sexual arousal in Euro-Canadian and East Asian women living in Canada; we also aimed to explore the association between level of acculturation (both mainstream and heritage) and sexual arousal in East Asian women only.MethodsSeventy-five women (N = 38 Euro-Canadian, N = 37 East Asian) completed a battery of questionnaires and underwent psychophysiological sexual arousal testing using the vaginal photoplethysmograph. They also completed a self-report measure of subjective arousal before and after erotic stimulus exposure.Main Outcome MeasuresAll women completed the Female Sexual Function Index, Vancouver Index of Acculturation, and Sexual Beliefs and Information Questionnaire. Change in genital sexual arousal (vaginal pulse amplitude; VPA), and change in subjective sexual arousal were measured during exposure to erotic stimuli.ResultsThe groups did not differ in the percent increase in VPA induced by erotic stimuli, nor was there a correlation between VPA and subjective sexual arousal. Among East Asian women alone, neither heritage nor mainstream acculturation was correlated with change in VPA.ConclusionsEast Asian and Euro-Canadian women who show similar ratings of sexual behaviors and self-reported sexual arousal do not differ in physiological or subjective arousal induced by erotic stimuli in the laboratory. Yule M, Woo JST, and Brotto LA. Sexual arousal in East Asian and Euro-Canadian women: A psychophysiological study.     

A Psychophysiological Investigation of Sexual Arousal in Women with Lifelong Vaginismus

IntroductionRelatively little is known about the subjective reactions of women with lifelong vaginismus to erotic stimuli and genital arousal has never been investigated. Reports of maladaptive cognitions and fears regarding sexuality and intercourse suggest that anxiety may interfere with sexual arousal in women with vaginismus.AimsTo examine the genital and subjective responses to sexually explicit film stimuli of women with lifelong vaginismus compared with women with lifelong dyspareunia and women with no pain.MethodsForty‐five women (15 vaginismus, 15 dyspareunia, and 15 no pain) viewed two neutral and two erotic film sets, one depicting sexual activity without vaginal penetration and the other depicting intercourse, over two testing sessions.Main Outcome MeasuresVulvar temperature was recorded using an infrared camera. Participants completed a measure of subjective responses after viewing each film.ResultsAll groups experienced increased vulvar temperature during the erotic films regardless of activity depicted. In response to the erotic films, the vaginismus group reported less mental arousal than the no‐pain group and a range of negative subjective responses, including threat and disgust. Overall, participants showed concordance between peak subjective sexual arousal and temperature change from baseline to peak arousal.ConclusionDespite negative subjective responses, women with vaginismus responded with increased genital sexual arousal to erotic films. The resilience of genital arousal may have resulted from moderate levels of anxiety experienced in the laboratory setting facilitating sexual response regardless of subjective appraisal; however, anxiety experienced in a dyadic context may interfere more substantially.     

The Effects of Experimentally-Induced Sad and Happy Mood on Sexual Arousal in Sexually Healthy Women

IntroductionIn depressed women, common sexual difficulties include decreased sexual desire, sexual arousal and orgasmic difficulties, reduced sexual satisfaction, and reduced sexual pleasure. Experimental research on the influence of depressed mood on genital and subjective sexual arousal in women is scarce.AimTo investigate the effects of sad mood on genital and subjective sexual arousal in sexually healthy women, using a mood induction procedure.MethodThirty-two subjects received a sad mood and a happy mood induction, on two different days, using a within subjects design. The mood induction procedure was a combination of the Velten procedure and music. In the Velten procedure, the subject is asked to read sad or happy self-referent sentences and to experience the mood suggested by these sentences. Immediately following mood induction, the subjects were exposed to an erotic film clip.Main Outcome MeasureGenital arousal was assessed using vaginal photoplethysmography. Self-report ratings of sad and happy mood, subjective sexual arousal and affective reactions were collected before and after the erotic clip.ResultsThe sad and happy mood ratings indicated that the mood inductions affected mood as intended. No difference in genital sexual arousal was found between the sad and happy mood conditions. Subjects reported significantly less subjective sexual arousal and positive affect and marginally significant fewer genital sensations and more negative affect in the sad mood condition than in the happy mood condition.ConclusionsThe results provide empirical support for the idea that mood can impact on subjective sexual arousal in women. ter Kuile MM, Both S, and van Uden J. The effects of experimentally-induced sad and happy mood on sexual arousal in sexually healthy women.     

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

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

Laser Doppler Imaging of Genital Blood Flow: A Direct Measure of Female Sexual Arousal

IntroductionFemale sexual arousal is a challenging construct to measure, partly because of the subtle nature of its indicators, vaginal lubrication and genital swelling. As a result, many instruments have been used in an attempt to accurately measure it; however, problems are associated with each. Furthermore, the relationship between subjective and physiological indicators of arousal appears to be influenced by the instrument used to measure physiological arousal. Specifically, instruments measuring physiological arousal internally yield lower correlations between measures of physiological and subjective arousal than instruments examining the external genitals. Laser Doppler imaging (LDI) is a direct measure of external genital blood flow.AimThe purpose of this study was to investigate the usefulness of LDI for measuring genital blood flow in women in response to erotic visual stimuli, and to explore the relationship between physiological and subjective sexual arousal.MethodSixty-five participants watched three 15-minute films during LDI scanning.Main Outcome MeasuresTwo nature films (measuring acclimatization and baseline blood flow levels) and one randomly assigned experimental film (erotic, anxiety, humor, or neutral) were used. Participants rated their level of subjective arousal following the third film.ResultsResults indicated a significant effect of film condition on genital blood flow, P < 0.001, with the erotic condition differing significantly from the other three conditions. In terms of the relationship between physiological and subjective sexual arousal, physiological arousal was significantly predicted by subjective ratings of sexual arousal (P < 0.001).ConclusionsLDI appears to be able to differentiate blood flow during erotic and nonerotic conditions. In addition, physiological sexual arousal was significantly predicted by women's reported subjective sexual arousal. These findings suggest that LDI is a useful instrument for measuring female sexual arousal, and that women may be more aware of their level of physiological arousal than previously assumed. Waxman SE, and Pukall CF. Laser Doppler imaging of genital blood flow: A direct measure of female sexual arousal. J Sex Med 2009;6:2278–2285.     

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

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

One Session of Autogenic Training Increases Acute Subjective Sexual Arousal in Premenopausal Women Reporting Sexual Arousal Problems

Background

Below average heart rate variability (HRV) has been associated with sexual arousal dysfunction and overall sexual dysfunction in women. Autogenic training, a psychophysiologic relaxation technique, has been shown to increase HRV. In a recent study, sexually healthy women experienced acute increases in physiologic (ie, genital) and subjective sexual arousal after 1 brief session of autogenic training.

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.     

ORIGINAL RESEARCH—ANATOMY/PHYSIOLOGY: Induction of Sexual Arousal in Women Under Conditions of Institutional and Ambulatory Laboratory Circumstances: A Comparative Study

IntroductionMeasuring under naturally occurring circumstances increases ecological validity. We developed an ambulatory psychophysiological laboratory that allows experiments to be performed at home.AimsTo compare institutional laboratory task measures with ambulatory laboratory task measures.Main Outcome MeasuresVaginal pulse amplitude (VPA), clitoral blood volume (CBV), subjective report of sexual arousal, preconscious attentional bias for erotic stimuli, subjective reports about feeling at ease, tense, anxious or inhibited.MethodsVPA and CBV were measured in eight women with hypoactive sexual desire disorder (HSDD) and eight healthy controls while exposed to neutral and erotic film clips both in the institute's laboratory and at home. Before and after film clip presentations, subjects performed an emotional Stroop task and completed two questionnaires.ResultsIn healthy controls, genital measures of sexual arousal were significantly increased at home compared with the institutional laboratory, whereas no differences were observed between the institutional laboratory and the at home measurements in women with HSDD. The responses at home were significantly higher in healthy controls compared with women with HSDD. Subjective experience of genital responding increased at home for both groups of women. Concordance between subjective experience and genital sexual arousal was more pronounced in the institutional laboratory setting. Preconscious attentional bias was stronger in the institutional laboratory for both groups of women. Healthy controls felt more at ease and less inhibited at home while subjects with HSDD did not.ConclusionsThe use of an ambulatory laboratory is a valuable tool allowing psychophysiological (sex) research under more natural circumstances (e.g., a participant's home). In this study, the increase in ecological validity resulted in a qualitative differentiation between the healthy controls and the women with HSDD in the home setting, which is not apparent in the artificial setting of the institutional laboratory. Bloemers J, Gerritsen J, Bults R, Koppeschaar H, Everaerd W, Olivier B, and Tuiten A. Induction of sexual arousal in women under conditions of institutional and ambulatory laboratory circumstances: A comparative study.     

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.     

The Influence of Testosterone Combined with a PDE5-inhibitor on Cognitive,Affective, and Physiological Sexual Functioning in Women Suffering from Sexual Dysfunction

IntroductionWomen with female sexual dysfunction have a reduced sensitivity to sexual stimuli. Activation of central mechanisms may open a window for phosphodiesterase type 5 inhibitors (PDE5) to be effective; as a consequence, the combination of testosterone and a PDE5 inhibitor will restore sexual function.AimTo demonstrate that the combination of testosterone and vardenafil will increase the sensitivity for sexual stimuli and will improve the desire and arousal components of the sexual response.MethodsIn a double-blind randomly assigned placebo-controlled crossover design, 28 women with desire and/or arousal disorder underwent four different drug treatments on four separate experimental days. A masked version of the emotional Stroop task with sexual and nonsexual words was used to measure sensitivity for sexual content. Neutral and erotic film fragments were used to determine genital–physiological and subjective reactions.Main Outcome MeasuresA masked version of the emotional Stroop task, vaginal pulse amplitude. For subjective measurement, responses were collected continuously with a lever and two self-report measures were used.ResultsIn two subgroups, which were differentiated on the basis of their initial preconscious attentional bias for sexual cues, a different sexual response profile was found. In an initially low-attention group, preconscious attentional bias for sexual cues increased under the testosterone condition. In these women, the combination of testosterone and vardenafil caused an improvement in genital response and subjective indices of sexual functioning. In the group that had initially a high attention for sexual cues, preconscious attentional bias for sexual cues decreased under the condition of testosterone. In these women, the combination of testosterone and vardenafil had no effect on any of the indices of their sexual functioning.ConclusionIn women suffering from low sexual desire—associated with low attention for sexual cues—the combination of testosterone and vardenafil may be a promising new treatment. van der Made F, Bloemers J, Yassem WE, Kleiverda G, Everaerd W, van Ham D, Olivier B, Koppeschaar H, and Tuiten A. The influence of testosterone combined with a PDE5-inhibitor on cognitive, affective, and physiological sexual functioning in women suffering from sexual dysfunction. J Sex Med 2009;6:777–790.     

Predictors of Men's Sexual Response to Erotic Film Stimuli: The Role of Affect and Self‐Reported Thoughts

IntroductionBoth emotions and cognitions seem to play a role in determining sexual arousal. However, no studies to date have tested the effects of self‐reported thoughts on subjective sexual arousal and genital response using psychophysiological methods.AimThe aim of the present study was to evaluate the role of self‐reported thoughts and affect during exposure to erotic material in predicting subjective and genital responses in sexually healthy men.MethodsTwenty‐seven men were presented with two explicit films, and genital responses, subjective sexual arousal, self‐reported thoughts, and positive and negative affect were assessed.Main Outcome MeasuresMen's genital responses, subjective sexual arousal, affective responses, and self‐reported thoughts during exposure to sexual stimulus were measured.ResultsRegression analyses revealed that genital responses were predicted by self‐reported thoughts (explaining 20% of the variance) but not by affect during exposure to erotic films. On the other hand, subjective sexual arousal was significantly predicted by both positive and negative affect (explaining 18% of the variance) and self‐reported thoughts (explaining 37% of the variance). Follow‐up analyses using the single predictors showed that “sexual arousal thoughts” were the only significant predictor of subjective response (β = 0.64; P < 0.01) and that “distracting/disengaging thoughts” were the best predictor of genital response (β = −0.51; P < 0.05).ConclusionsThe findings of this study suggest that both affect and sexual arousal thoughts play an important role in men's subjective sexual response, whereas genital response seems to be better predicted by distracting thoughts. Oliveira C, Laja P, Carvalho J, Quinta Gomes A, Vilarinho S, Janssen S, and Nobre PJ. Predictors of men's sexual response to erotic film stimuli: The role of affect and self‐reported thoughts. J Sex Med 2014;11:2701–2708.     

Hormones and Sexuality in Postmenopausal Women: A Psychophysiological Study

Sexual function, including vaginal atrophy, and hormonal status, were studied in 42 naturally postmenopausal women. Vaginal pulse amplitude and subjective sexual responses during self-induced erotic fantasy and during erotic films were compared with responses of a small number of premenopausal women. As predicted, vaginal atrophy was related to estrogens but not to complaints of vaginal dryness and dyspareunia. No significant relationship was found between hormones and sexual function. Unexpectedly, most of the few correlations that did reach significance involved prolactin. The fact that prolactin was negatively associated with sexual desire, sexual arousal and vaginal lubrication during sexual activity, suggests that psychosocial factors are more important titan hormone levels in postmenopausal sexual function. Comparisons with a number of premenopausal women revealed that although postmenopausal women displayed lower vaginal pulse amplitude responses prior to erotic stimulation than the premenopausal women, this difference disappeared during subsequent erotic stimulation. We argued that this finding can be interpreted as being supportive of the notion that complaints of vaginal dryness and dyspareunia should not be attributed to vaginal atrophy associated with menopause. Rather, vaginal dryness and dyspareunia seem to reflect sexual arousal problems.     

Extinction of Aversive Classically Conditioned Human Sexual Response

IntroductionResearch has shown that acquired subjective likes and dislikes are quite resistant to extinction. Moreover, studies on female sexual response demonstrated that diminished genital arousal and positive affect toward erotic stimuli due to aversive classical conditioning did not extinguish during an extinction phase. Possible resistance to extinction of aversive conditioned sexual responses may have important clinical implications. However, resistance to extinction of aversive conditioned human sexual response has not been studied using extensive extinction trials.AimThis article aims to study resistance to extinction of aversive conditioned sexual responses in sexually functional men and women.MethodsA differential conditioning experiment was conducted, with two erotic pictures as conditioned stimulus (CSs) and a painful stimulus as unconditioned stimuli (USs). Only one CS (the CS+) was followed by the US during the acquisition phase. Conditioned responses were assessed during the extinction phase.Main Outcome MeasurePenile circumference and vaginal pulse amplitude were assessed, and ratings of affective value and subjective sexual arousal were obtained. Also, a stimulus response compatibility task was included to assess automatic approach and avoidance tendencies.ResultsMen and women rated the CS+ more negative as compared with the CS−. During the first trials of the extinction phase, vaginal pulse amplitude was lower in response to the CS+ than in response to the CS−, and on the first extinction trial women rated the CS+ as less sexually arousing. Intriguingly, men did not demonstrate attenuated genital and subjective sexual response.ConclusionsAversive conditioning, by means of painful stimuli, only affects sexual responses in women, whereas it does not in men. Although conditioned sexual likes and dislikes are relatively persistent, conditioned affect eventually does extinguish. Brom M, Laan E, Everaerd W, Spinhoven P, and Both S. Extinction of aversive classically conditioned human sexual response. J Sex Med 2015;12:916–935.     

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.     

Toward Personalized Sexual Medicine (Part 2): Testosterone Combined with a PDE5 Inhibitor Increases Sexual Satisfaction in Women with HSDD and FSAD,and a Low Sensitive System for Sexual Cues

IntroductionLow sexual desire in women may result from a relative insensitivity of the brain for sexual cues. Administration of sublingual 0.5 mg testosterone (T) increases the sensitivity of the brain to sexual cues. Sexual stimulation in the brain is necessary for phosphodiesterase type 5 inhibitor (PDE5i)-mediated increase in genital sexual response. Accordingly, a single dose of T+PDE5i might enhance sexual responsiveness, especially in women with low sensitivity for sexual cues.AimTo assess the hypothesis that treatment with on-demand use of T+PDE5i improves sexual functioning, particularly in women who suffer from Hypoactive Sexual Desire Disorder (HSDD) as the result of a relative insensitivity for sexual cues.MethodsIn a randomized, double-blind, placebo-controlled, crossover design, 56 women with HSDD underwent three medication treatment regimes (placebo, T+PDE5i, and T with a serotonin _1A receptor agonist; see also parts 1 and 3), which lasted 4 weeks each. In a participant-controlled ambulatory psychophysiological experiment at home (the first week of each drug treatment), physiological and subjective indices of sexual functioning were measured. In a bedroom experiment (the subsequent 3 weeks), sexual functioning was evaluated following each sexual event after the self-administration of study medication. Subjective evaluation of sexual functioning was also measured by weekly and monthly reports.Main Outcome MeasuresSubjective: sexual satisfaction, experienced genital arousal, sexual desire. Physiological: vaginal pulse amplitude. Cognitive: preconscious attentional bias.ResultsT+PDE5i, as compared with placebo, significantly improved physiological and subjective measures of sexual functioning during ambulatory psychophysiological lab conditions at home and during the sexual events, in women with low sensitivity for sexual cues.ConclusionsThe present study demonstrated that on-demand T+PDE5i is a potentially promising treatment for women with HSDD, particularly in women with low sensitivity for sexual cues. Poels S, Bloemers J, van Rooij K, Goldstein I, Gerritsen J, van Ham D, van Mameren F, Chivers M, Everaerd W, Koppeschaar H, Olivier B, and Tuiten A. Toward personalized sexual medicine (part 2): Testosterone combined with a PDE5 inhibitor increases sexual satisfaction in women with HSDD and FSAD, and a low sensitive system for sexual cues. J Sex Med 2013;10:810–823.