Rosemary Basson

The Female Sexual Response: A Different Model

Clarification of womens sexual response during long-term relationships is needed. I have presented a model that more accurately depicts the responsive component of womens desire and the underlying motivational forces that trigger it. The variety of arousal/ orgasm responses is also acknowledged. The purpose is both to prevent diagnosing dysfunction when the response is simply different from the traditional humansex-response cycle and to more clearly define subgroups ofdysfunction.Thelatter wouldappear tobe necessary before progress in newer treatment modalities, including pharmacological, can be made.

Definitions of women's sexual dysfunction reconsidered: Advocating expansion and revision

In light of various shortcomings of the traditional nosology of womens sexual disorders for both clinical practice and research, an international multi-disciplinary group has reviewed the evidence for traditional assumptions about womens sexual response. It is apparent that fullfillment of sexual desire is an uncommon reason/incentive for sexual activity for many women and, in fact, sexual desire is frequently experienced only after sexual stimuli have elicited subjective sexual arousal. The latter is often poorly correlated with genital vasocongestion. Complaints of lack of subjective arousal despite apparently normal genital vasocongestion are common. Based on the review of existing evidence-based research, many modifications to the definitions of womens sexual dysfunctions are recommended. There is a new definition of sexual interest/desire disorder, sexual arousal disorders are separated into genital and subjective subtypes and the recently recognized condition of persistent sexual arousal is included. The definition of dyspareunia reflects the possibility of the pain precluding intercourse. The anticipation and fear of pain characteristic of vaginismus is noted while the assumed muscular spasm is omitted given the lack of evidence. Finally, a recommendation is made that all diagnoses be accompanied by descriptors relating to associated contextual factors and to the degree of distress.

A Mindfulness-Based Group Psychoeducational Intervention Targeting Sexual Arousal Disorder in Women

INTRODUCTION Despite their widespread prevalence, there are no existing evidence-based psychological treatments for women with sexual desire and arousal disorder. Mindfulness, the practice of relaxed wakefulness, is an ancient eastern practice with roots in Buddhist meditation which has been found to be an effective component of psychological treatments for numerous psychiatric and medical illnesses. In recent years, mindfulness has been incorporated into sex therapy and has been found effective for genital arousal disorder among women with acquired sexual complaints secondary to gynecologic cancer. AIM The aim of this study was to adapt an existing mindfulness-based psychoeducation (PED) to a group format for women with sexual desire/interest disorder and/or sexual arousal disorders unrelated to cancer. METHODS Twenty-six women participated in three 90-minute sessions, spaced 2 weeks apart, with four to six other women. Group PED was administered by one mental health trained provider and one gynecologist with post graduate training and experience in sexual medicine. MAIN OUTCOME MEASURES Prior to and following the group, women viewed audiovisual erotic stimuli and had both physiological (vaginal pulse amplitude) and subjective sexual arousal assessed. Additionally, they completed self-report questionnaires of sexual response, sexual distress, mood, and relationship satisfaction. RESULTS There was a significant beneficial effect of the group PED on sexual desire and sexual distress. Also, we found a positive effect on self-assessed genital wetness despite little or no change in actual physiological arousal, and a marginally significant improvement in subjective and self-reported physical arousal during an erotic stimulus. A follow-up comparison of women with and without a sexual abuse history revealed that women with a sexual abuse history improved significantly more than those without such history on mental sexual excitement, genital tingling/throbbing, arousal, overall sexual function, sexual distress, and on negative affect while viewing the erotic film. Moreover, there was a trend for greater improvement on depression scores among those with a sexual abuse history. CONCLUSIONS These data provide preliminary support for a brief, three-session group psychoeducational intervention for women with sexual desire and arousal complaints. Specifically, women with a history of sexual abuse improved more than women without such a history. Participant feedback indicated that mindfulness was the most effective component of the treatment, in line with prior findings. However, future compartmentalization trials are necessary in order to conclude this more definitively.

Sexual sequelae of general medical disorders

That sexual symptoms can signal serious underlying disease confirms the importance of sexual enquiry as an integral component of medical assessment. Data on sexual function are sparse in some medical specialties. However, increased scientific understanding of the central and peripheral physiology of sexual response could help to identify the pathophysiology of sexual dysfunction from disease and medical interventions, and also to ameliorate or prevent some dysfunctions. Many common general medical disorders have negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex. Chronic disease also interferes indirectly with sexual function, by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency. Current approaches to assessment of sexual dysfunction are based on models that combine psychological and biological aspects.

Sexual dysfunction in men and women with endocrine disorders

Endocrine disease frequently interrupts sexual function, and sexual dysfunction may signal serious endocrine disease. Diabetic autonomic neuropathy and endothelial dysfunction impair erectile function, and phosphodiesterase inhibition produces only moderate benefit. The effect of diabetes on womens sexual function is complex: the most consistent finding is a correlation between sexual dysfunction and depression. Reductions in testosterone level in men are associated with low sexual desire and reduced nocturnal erections and ejaculate volume, all of which improve with testosterone supplementation. The age-dependent decline in testosterone production in men is not associated with precise sexual symptoms, and supplementation has not been shown to produce sexual benefit. In women, sexual dysfunction has not been associated with serum testosterone, but this may be confounded by limitations of assays at low concentrations and by the greater importance of intracellular production of testosterone in women than in men. Testosterone supplementation after menopause does improve some aspects of sexual function in women, but long-term outcome data are needed. More research on the sexual effects of abnormal adrenal and thyroid function, hyperprolactinaemia, and metabolic syndrome should also be prioritised. We have good data on local management of the genital consequences of oestrogen lack, but need to better understand the potential role of systemic oestrogen supplementation from menopause onwards in sexually symptomatic women.

Female sexual response: the role of drugs in the management of sexual dysfunction

A large component of womens sexual desire is responsive rather than spontaneous. Therefore, womens motivation and ability to find and respond to sexual stimuli to experience sexual arousal and subsequent sexual desire is crucial, but complex. In ongoing relationships, a womans motivation appears to be largely influenced by her emotional intimacy with her partner and her wish to enhance it. Drugs (including androgen replacement therapy) aimed at increasing womens spontaneous sexual wanting (less characteristic of women in long‐term relationships) or their arousability may have a role if other psychologic factors affecting arousability are addressed in tandem. A womans sexual arousal is composite and complex, correlating well with how mentally exciting she finds the sexual stimulus and its context and poorly with objective genital blood flow changes. Drugs aimed at increasing the latter, including phosphodiesterase inhibitors, may have a role if there is prior careful enquiry as to whether genital engorgement is present but not attended to or is physically absent. Psycho‐physiologic studies to date suggest the former is common in women presenting with arousal disorder.

Sexual psychophysiology and effects of sildenafil citrate in oestrogenised women with acquired genital arousal disorder and impaired orgasm: a randomised controlled trial

Objective Some postmenopausal women lose genital sexual responsivity despite preserved subjective sexual arousal from non‐genital stimuli. When oestrogen replacement is without benefit, both the underlying pathophysiology and management of this acquired genital female sexual arousal disorder are unclear. We aimed to study the effect of sildenafil on sexual arousal and orgasmic functioning of such women. Secondly, we aimed to explore the concordance between a detailed historical assessment of genital response in real life, with laboratory vaginal photoplethysmographic assessment of genital vasocongestion.

Sexual function in chronic illness

INTRODUCTION Direct and indirect effects of chronic disease on sexual health are frequent and complex, but guidelines for their optimal management are lacking. With improved surgical and medical treatment of the underlying disease, the numbers of men and women needing assessment and management of associated sexual dysfunction are increasing. AIM To provide recommendations/guidelines for the clinical management of sexual dysfunction within the context of chronic illness. METHODS An international consultation in collaboration with the major sexual medicine associations assembled 186 multidisciplinary experts from 33 countries into 25 committees. Nine experts from four countries compiled the recommendations of sexual dysfunction in chronic illness and cancer with four focusing on neurological, renal, and psychiatric disease and lower urinary tract symptoms (LUTS). Searches were conducted using Medline, Embase, Lilacs, and Pubmed databases. MAIN OUTCOME MEASURES Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS Some conclusions concerning prevalence and pathophysiology of sexual dysfunction in the context of neurological disorders, end-stage renal failure, LUTS, and psychiatric disease were made. Optimal assessment of the multiple factors affecting sexuality when one or both partners are chronically ill is outlined. Evidence-based recommendations for management are presented. Comorbid depression is frequent and independently determines prevalence of sexual dysfunction in many conditions. CONCLUSIONS There is need for more research and scientific reporting on prevalence, pathophysiology, and optimal treatment of sexual dysfunction associated with chronic illness. Screening for and managing comorbid depression is strongly recommended.

A model of women's sexual arousal.

A model of female sexual arousal shows the composite emotion of subjective sexual arousal, which results from conscious appraisal of sexual stimuli and their context in the presence of positive affective and cognitive feedback. Genital feedback augments the subjective arousal to a variable degree. Genital congestion can be triggered by sexual stimuli in the absence of subjective arousal. Then the congestion either is ignored or not interpreted as sexual. An anhedonic or even a dysphoric response to the sensations of genital congestion are further possibilities. This model allows for various subtypes of arousal disorder and thus facilitates a choice of therapeutic intervention.

Women's Sexual Desire—Disordered or Misunderstood?

A new model of womens sexual response moves the focus from spontaneous drive with its markers of sexual thoughts, fantasies, and conscious urge to be sexual to an inherently responsive cycle. The model reflects intimacy-based sexual motivation, processing of sexual stimuli to arousal, cognitive, and affective appraisal of that arousal. Sexual desire to continue the physical experience is accessed later. Providing that the outcome is emotionally and physically satisfying, emotional intimacy with the partner is increased. Any spontaneous sexual drive augments this intimacy-based cycle. Analysis of one or many breaks in the cycle has therapeutic implications.