Ethical challenges in research on sexual dysfunction.

Despite more than a century of research on sexual dysfunction, there has been limited attention to ethical concerns. This is problematic because sex research involves complex ethical questions that generate confusion for ethics review and have not been addressed by ethical guidelines. We analyze two questions. First, does sexual content raise the risk profile of a research protocol? We argue that there is nothing inherent in sexual content that makes a study high risk and that many sexual dysfunction studies involve no more than minimal risk. Second, we ask whether research interventions that involve seeing participants undressed or having physical contact with a research subject are permissible? We argue that these interventions raise an important ethical challenge-they often involve sexual dysfunction researchers engaging in interventions that would not be conducted in their standard practice. To resolve this, we propose an expertise-based account of the permissibility of sexual dysfunction research.

The Biopsychosocial Puzzle of Painful Sex.

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered.

Exploring Male Multiple Orgasm in a Large Online Sample: Refining Our Understanding.

BACKGROUND: The scientific literature on multiple orgasm in males is small. There is little consensus on a definition, and significant controversy about whether multiple orgasm is a unitary experience. AIMS: This study has 2 goals: (i) describing the experience of male multiple orgasm; (ii) investigating whether there are different profiles of multiple orgasm in men. METHODS: Data from a culturally diverse online convenience sample of 122 men reporting multiple orgasm were collected. Data reduction analyses were conducted using principal components analysis (PCA) on 13 variables of interest derived from theory and the existing literature. A K-means cluster analysis followed, from which a 4-cluster solution was retained. RESULTS: While the range of reported orgasms varied from 2 to 30, the majority (79.5%, N = 97) of participants experienced between 2 and 4 orgasms separated by a specific time interval during which further stimulation was required to achieve another orgasm. Most participants reported maintaining their erections throughout and ejaculating with every orgasm. Age was not a significant correlate of the multiple orgasm experience which occurred more frequently in a dyadic context. Four different profiles of multiorgasmic men were described. STRENGTHS & LIMITATIONS: This study constitutes a rare attempt to collect systematic self-report data concerning the experience of multiple orgasm in a relatively large sample. Limitations include the lack of validated measures, memory bias associated with self-reported data and retrospective designs, the lack of a control group and of physiological measurement. CONCLUSION: Our study suggests that multiple orgasm in men is not a unitary phenomenon and sets the stage for future self-report and laboratory study. Griffin-Mathieu G, Berry M, Shtarkshall RA, Amsel R, Binik YM, Gérard M. Exploring Male Multiple Orgasm in a Large Online Sample: Refining Our Understanding. J Sex Med 2021;XX:XXX-XXX.

A Descriptive and Longitudinal Analysis of Pain During Intercourse in Pregnancy.

INTRODUCTION: Pain during vaginal intercourse in pregnancy has largely been ignored despite physiological and psychological components of pregnancy that may be associated with its onset and persistence. AIM: The current study aimed to determine the prevalence and the characteristics of clinically significant pain during intercourse in the second (18-24 weeks) and third (32-36 weeks) trimesters of pregnancy. METHODS: Pregnant women (N = 501) recruited from a local women's hospital completed an online survey in the second and third trimesters of their pregnancy regarding the presence, intensity, and characteristics of pain during intercourse. Women with clinically significant pain (ie, pain greater than or equal to 4 of 10 on a numerical rating scale) were grouped according to whether the pain was resolved, persistent, or new onset across the 2 pregnancy time points. Following guidelines outlined by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), we conducted a descriptive analysis assessing the intensity and characteristics (eg, quality, onset, degree of improvement over time, and treatment strategies utilized) of clinically significant pain during intercourse. MAIN OUTCOME MEASURE: The main outcome measures in this study were the prevalence, intensity, and characteristics of clinically significant pain during intercourse. RESULTS: Overall, 21% of pregnant women (106/501) reported clinically significant pain during intercourse. We found that 22% (N = 16/106) of women who had this pain at 20 weeks reported that it had resolved at 34 weeks, 33% (40/106) reported persistent pain at both time points, and 46% (50/106) reported new onset of pain during intercourse at 34 weeks. The majority of women across all pain groups reported that the pain began during pregnancy and remained at the same intensity. Most women reported not using any pain management strategies to cope with their pain. CLINICAL IMPLICATIONS: One in 5 women experienced clinically significant pain during intercourse in pregnancy, with the majority of women not seeking treatment. STRENGTHS & LIMITATIONS: This study is the first to comprehensively assess and describe the prevalence and characteristics of clinically significant pain during intercourse across 2 time points in pregnancy using IMMPACT guidelines. Small sample sizes in our pain groups may limit the generalizability of pain characteristics. CONCLUSION: Findings suggest that many pregnant women in this study experienced significant pain during intercourse in pregnancy. Understanding the characteristics of this pain may improve its identification by health care providers and inform better prevention and treatment recommendations. Rossi MA, Mooney KM, Binik YM, et al. A Descriptive and Longitudinal Analysis of Pain During Intercourse in Pregnancy. J Sex Med 2019;16:1966-1977.

How Hot Are They? Neural Correlates of Genital Arousal: An Infrared Thermographic and Functional Magnetic Resonance Imaging Study of Sexual Arousal in Men and Women.

BACKGROUND: The few studies that have examined the neural correlates of genital arousal have focused on men and are methodologically hard to compare. AIM: To investigate the neural correlates of peripheral physiologic sexual arousal using identical methodology for men and women. METHODS: 2 groups (20 men, 20 women) viewed movie clips (erotic, humor) while genital temperature was continuously measured using infrared thermal imaging. Participants also continuously evaluated changes in their subjective arousal and answered discrete questions about liking the movies and wanting sexual stimulation. Brain activity, indicated by blood oxygen level-dependent (BOLD) response, was measured using functional magnetic resonance imaging. OUTCOMES: BOLD responses, genital temperature, and subjective sexual arousal. RESULTS: BOLD activity in a number of brain regions was correlated with changes in genital temperature in men and women; however, activation in women appeared to be more extensive than in men, including the anterior and posterior cingulate cortex, right cerebellum, insula, frontal operculum, and paracingulate gyrus. Examination of the strength of the correlation between BOLD response and genital temperature showed that women had a stronger brain-genital relation compared with men in a number of regions. There were no brain regions in men with stronger brain-genital correlations than in women. CLINICAL TRANSLATION: Our findings shed light on the neurophysiologic processes involved in genital arousal for men and women. Further research examining the specific brain regions that mediate our findings is necessary to pave the way for clinical application. STRENGTHS AND LIMITATIONS: A strength of the study is the use of thermography, which allows for a direct comparison of the neural correlates of genital arousal in men and women. This study has the common limitations of most laboratory-based sexual arousal research, including sampling bias, lack of ecologic validity, and equipment limitations, and those common to neuroimaging research, including BOLD signal interpretation and neuroimaging analysis issues. CONCLUSIONS: Our findings provide direct sex comparisons of the neural correlates of genital arousal in men and women and suggest that brain-genital correlations could be stronger in women. Parada M, Gérard M, Larcher K, et al. How Hot Are They? Neural Correlates of Genital Arousal: An Infrared Thermographic and Functional Magnetic Resonance Imaging Study of Sexual Arousal in Men and Women. J Sex Med 2018;15:217-229.

Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia.

BACKGROUND: Pelvic floor muscle (PFM) dysfunctions are reported to be involved in provoked vestibulodynia (PVD). Although heightened PFM tone has been suggested, the relative contribution of active and passive components of tone remains misunderstood. Likewise, alterations in PFM contractility have been scarcely studied. AIMS: To compare PFM tone, including the relative contribution of its active and passive components, and muscular contractility in women with PVD and asymptomatic controls. METHODS: Fifty-six asymptomatic women and 56 women with PVD participated in the study. The PVD diagnosis was confirmed by a gynecologist based on a standardized examination. OUTCOMES: PFM function was evaluated using a dynamometric speculum combined with surface electromyography (EMG). PFM general tone was evaluated in static conditions at different vaginal apertures and during repeated dynamic cyclic stretching. The active contribution of tone was characterized using the ratio between EMG in a static position and during stretching and the proportion of women presenting PFM activation during stretching. Contribution of the passive component was evaluated using resting forces, stiffness, and hysteresis in women sustaining a negligible EMG signal during stretching. PFM contractility, such as strength, speed of contraction, coordination, and endurance, also was assessed during voluntary isometric efforts. RESULTS: Greater PFM resting forces and stiffness were found in women with PVD compared with controls, indicating an increased general tone. An increased active component also was found in women with PVD because they presented a superior EMG ratio, and a larger proportion of them presented PFM activation during stretching. Higher passive properties also were found in women with PVD. Women with PVD also showed decreased strength, speed of contraction, coordination, and endurance compared with controls. CLINICAL IMPLICATIONS: Findings provide further evidence of the contribution of PFM alterations in the etiology of PVD. These alterations should be assessed to provide patient-centered targeted treatment options. STRENGTHS AND LIMITATIONS: The use of a validated tool investigating PFM alterations constitutes a strength of this study. However, the study design does not allow the determination of the sequence of events in which these muscle alterations occurred-before or after the onset of PVD. CONCLUSION: Findings support the involvement of active and passive components of PFM tone and an altered PFM contractility in women with PVD. Morin M, Binik YM, Bourbonnais D, et al. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med 2017;14:592-600.

Neural Representation of Subjective Sexual Arousal in Men and Women.

INTRODUCTION: Studies investigating brain indices of sexual arousal have begun to elucidate the brain's role in processing subjective arousal; however, most research has focused on men, used discrete ratings of subjective arousal, and used stimuli too short to induce significant arousal in women. AIM: To examine brain regions modulated by changes in subjective sexual arousal (SSA) rating intensity in men and women. METHODS: Two groups (20 men, 20 women) viewed movie clips (erotic or humorous) while continuously evaluating changes in their SSA using a Likert-like scale (0 = not aroused, 10 = most aroused) and answering discrete questions about liking the movies and wanting sexual stimulation. Brain activity was measured using functional magnetic resonance imaging. MAIN OUTCOME MEASURES: Blood oxygen level-dependent responses and continuous and discrete measurements of sexual arousal. RESULTS: Erotic movies induced significant SSA in men and women. No sex difference in mean SSA was found in response to the erotic movies on continuous or discrete measurements. Several brain regions were correlated with changes in SSA. Parametric modulation with rating intensity showed a specific group of regions within the parietal lobe that showed significant differences in activity among low, medium, and high SSA. CONCLUSION: Multiple regions were concordant with changes in SSA; however, a subset of regions in men and women was modulated by SSA intensity, a subset previously linked to attentional processes, monitoring of internal body representation, and processing of sensory information from the genitals. This study highlights that similar brain regions are activated during subjective assessment of sexual arousal in men and women. The data further highlight the fact that SSA is a complex phenomenon made up of multiple interoceptive and attentional processes.

Female Partners of Men With Peyronie's Disease Have Impaired Sexual Function, Satisfaction, and Mood, While Degree of Sexual Interference Is Associated With Worse Outcomes.

INTRODUCTION: Peyronie's disease (PD) causes penile deformity and can result in sexual dysfunction and psychological distress. Currently, nothing is known about the psychosexual impact on the partners of men with PD. Research carried out on the partners of men with other chronic illnesses suggests that the partners of men with PD might have increased rates of sexual dysfunction and decreased sexual satisfaction. AIMS: To examine (i) sexual functioning, sexual satisfaction, negative affect, and relationship satisfaction of men with PD and their female partners and (ii) the effect of male-perceived sexual interference on partners' outcomes. METHODS: Forty-four men diagnosed with PD and their female partners completed a questionnaire package. MAIN OUTCOME MEASURES: Each partner filled out the Revised Dyadic Adjustment Scale, the Positive and Negative Affect Scale, the Global Measure of Sexual Satisfaction, and the Female Sexual Function Index (women) or the International Index of Erectile Function (men). RESULTS: Overall, partners of men with PD were found to have decreased sexual function, sexual satisfaction, and mood compared with population-based norms. Men and their partners showed non-distressed levels of relationship satisfaction. The degree to which PD interfered with sexual activity was an important correlate of outcomes. Increased sexual interference was associated with lower sexual function and satisfaction for the person experiencing interference. Sexual interference also was associated with negative affect and relationship satisfaction in partners and the person experiencing interference. CONCLUSION: PD is associated with negative psychosexual and psychosocial effects on those with the disease and their partners. As a result, assessment and intervention should include the two members of the couple.

Pain reduces sexual motivation in female but not male mice.

Chronic pain is often associated with sexual dysfunction, suggesting that pain can reduce libido. We find that inflammatory pain reduces sexual motivation, measured via mounting behavior and/or proximity in a paced mating paradigm, in female but not male laboratory mice. Pain was produced by injection of inflammogens zymosan A (0.5 mg/ml) or λ-carrageenan (2%) into genital or nongenital (hind paw, tail, cheek) regions. Sexual behavior was significantly reduced in female mice experiencing pain (in all combinations); male mice similarly treated displayed unimpeded sexual motivation. Pain-induced reductions in female sexual behavior were observed in the absence of sex differences in pain-related behavior, and could be rescued by the analgesic, pregabalin, and the libido-enhancing drugs, apomorphine and melanotan-II. These findings suggest that the well known context sensitivity of the human female libido can be explained by evolutionary rather than sociocultural factors, as female mice can be similarly affected.

Clitorodynia: A Descriptive Study of Clitoral Pain.

INTRODUCTION: Clitorodynia is classified as a type of localized vulvodynia. Our knowledge of this problem is limited to case studies and one published report. AIMS: The objective of the present study was to describe quantitatively the clinical characteristics of clitoral pain, to assess interference with sexual function, and to investigate whether clitoral pain is a unitary category. METHODS: One hundred twenty-six women with clitoral pain completed an online questionnaire that assessed demographic information, descriptive pain characteristics, intensity and impact on daily activities, sexual function, and gynecological and medical histories. MAIN OUTCOME MEASURES: The main outcome measures used for the study are the following: clitoral pain characteristics (e.g., intensity, duration, quality, distress, etc.), short-form McGill pain questionnaire-2, and the female sexual function index. RESULTS: Clitoral pain is characterized by frequent and intense pain episodes that can either be provoked or unprovoked, and causes significant impairment in both daily and sexual function. The pain can be localized to the clitoris only or can occur with other genital pain. Comorbidity with other chronic pain disorders is common. A cluster analysis suggested two distinct patterns of clitoral pain, one localized and one generalized. CONCLUSION: Our findings indicate that women with clitoral pain suffer from significant, distressing, and often long-term pain, which interferes with sexual and daily activities. Two subtypes of clitoral pain may exist, each with distinct pain characteristics and subjective experiences.

Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder.

Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.

How hot is he? A psychophysiological and psychosocial examination of the arousal patterns of sexually functional and dysfunctional men.

INTRODUCTION: Despite much theorizing about the interchangeability of desire and arousal, research has yet to identify whether men with desire vs. arousal disorders can be differentiated based on their psychophysiological patterns of arousal. Additionally, little research has examined the relationship between subjective (SA) and genital arousal (GA) in sexually dysfunctional men. AIMS: To compare patterns of SA and GA in a community sample of men meeting DSM-IV-TR criteria for hypoactive sexual desire disorder (HSDD), erectile dysfunction (ED), both HSDD and ED (ED/HSDD), and healthy controls. METHODS: Seventy-one men (19 controls, 13 HSDD, 19 ED, 20 ED/HSDD) completed self-report measures and watched two 15-minute film clips (neutral and erotic), while GA and SA were measured both continuously and discretely. MAIN OUTCOME MEASURES: Groups were compared on genital temperature (as an indicator of GA), SA, and psychosocial variables (i.e., body image, emotion regulation, sexual attitudes, sexual inhibition/excitation, mood, and trauma). RESULTS: Genital temperature increased for all groups during the erotic condition, yet men with ED and ED/HSDD showed less GA than men without erectile difficulties. All groups increased in SA during the erotic condition, yet ED/HSDD men reported less SA than controls or ED men. SA and GA were highly correlated for controls, and less strongly correlated for clinical groups; men with ED showed low agreement between SA and GA. Groups also differed on body image, sexual inhibition/excitation, sexual attitudes and alexithymia. CONCLUSION: Low desire vs. arousal sufferers have unique patterns of response, with those with both difficulties showing greatest impairment. Results have important implications for the diagnosis and treatment of these disorders.

Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using 4D ultrasound.

INTRODUCTION: It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias. AIM: The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain-free methodology, transperineal four-dimensional (4D) ultrasound. METHODS: Fifty-one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction. MAIN OUTCOME MEASURES: Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data. RESULTS: Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control. CONCLUSION: Using a reliable and pain-free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength.

A subtype based analysis of urological chronic pelvic pain syndrome in men.

PURPOSE: The current conceptualization of urological chronic pelvic pain syndrome in men recognizes a wide variety of pain, psychosocial, sexual and urological symptoms and markers that may contribute to decreased quality of life. Unfortunately, this syndrome is difficult to clearly define and treat due to heterogeneous symptom profiles. We systematically describe these heterogeneous symptoms and investigated whether they could be subtyped into distinct syndromes. MATERIALS AND METHODS: A total of 171 men diagnosed with urological chronic pelvic pain syndrome completed validated questionnaires, a structured genital pain interview, digital pain threshold testing and urological assessment. Pain interview results are systematically presented as descriptive information. We used k-means cluster analysis to define subtypes. RESULTS: Seven homogenous, distinct clusters were defined, each with a remarkably different symptom presentation. These clusters were described and related to previous hypotheses of urological chronic pelvic pain syndrome etiology. CONCLUSIONS: These clusters may represent distinct subtypes of urological chronic pelvic pain syndrome that can be used to guide treatment more effectively. Defining subtypes may also improve our understanding of the underlying mechanisms of urological chronic pelvic pain syndrome.

The index of male genital image: a new scale to assess male genital satisfaction.

PURPOSE: Male genital image is related to overall body image, psychosocial variables and sexual health. Unfortunately, little scientific literature exists on male genital image, while scales to measure it tend to be limited in scope, not well validated and are based on homogenous populations. We evaluated the reliability and validity of a comprehensive scale that would be useful in clinical settings and as a research outcome. MATERIALS AND METHODS: Items were generated from the literature and examined in the research group. Five experts rated items for content validity. The Index of Male Genital Image questionnaire was created. This questionnaire and a number of other psychosocial and health related questions were combined into an online survey and posted on male health discussion boards. Main study outcome measures were a custom designed survey of demographics, physical measurements, health and sexual history, and biopsychosocial variables as well as the Index of Male Genital Image and Body Areas Satisfaction Scale. RESULTS: A total of 636 men responded with data suitable for analysis. A final 14-item scale was created after item deletions. Factor analysis revealed a 6-factor solution and a total scale score. The final scale was simple to administer, had good reliability and construct validity, and appeared appropriate for use in healthy and clinical populations. CONCLUSIONS: The Index of Male Genital Image appears to be a promising measure of male genital image. Health and psychosocial variables were related to measure scores.

Is a sexual dysfunction domain important for quality of life in men with urological chronic pelvic pain syndrome? Signs "UPOINT" to yes.

PURPOSE: Clinical phenotyping to guide treatment for urological chronic pelvic pain syndrome is a promising strategy. The UPOINT (urinary, psychosocial, organ specific, infection, neurological/systemic and tenderness of the pelvic floor) phenotyping system evaluates men and women on 6 domains. However, this study focused on men only. Due to the high prevalence of sexual dysfunction in men with urological chronic pelvic pain syndrome, debate exists about the usefulness of adding an (S) (sexual dysfunction) domain to UPOINT. We examined the usefulness in terms of quality of life and delineated urological chronic pelvic pain syndrome subcategories using UPOINT(S) domains. MATERIALS AND METHODS: We assessed 162 men using UPOINT criteria and after adding the sexual dysfunction domain. Using multiple regression analysis UPOINT(S) criteria were then compared to quality of life, as measured by the SF-36® health outcome survey and Chronic Prostatitis Symptoms Index. Sample subgroups were assessed using k-means cluster analysis. RESULTS: The total number of UPOINT(S) domains correlated with SF-36 and Chronic Prostatitis Symptoms Index scores. Using regression analysis the 2 significant predictors of SF-36 scores were the psychosocial and sexual domains. Men with sexual dysfunction had significantly worse quality of life than men without the condition. In addition, 6 potentially clinically meaningful subgroups were identified using cluster analysis. Sexual dysfunction was differentially present in these groups. CONCLUSIONS: Adding a sexual dysfunction domain to UPOINT may help improve quality of life in men treated for urological chronic pelvic pain syndrome.

Pleasure and pain: the effect of (almost) having an orgasm on genital and nongenital sensitivity.

INTRODUCTION: The effect of sexual arousal and orgasm on genital sensitivity has received little research attention, and no study has assessed sensation pleasurableness as well as painfulness. AIM: To clarify the relationship between sexual arousal, orgasm, and sensitivity in a healthy female sample. METHODS: Twenty-six women privately masturbated to orgasm and almost to orgasm at two separate sessions, during which standardized pressure stimulation was applied to the glans clitoris, vulvar vestibule, and volar forearm at three testing times: (i) baseline; (ii) immediately following masturbation; and (iii) following a subsequent 15-minute rest period. MAIN OUTCOME MEASURES: Touch thresholds (tactile detection sensitivity), sensation pleasurableness ratings (pleasurable sensitivity), and pain thresholds (pain sensitivity). RESULTS: Pleasurableness ratings were higher on the glans clitoris than the vulvar vestibule, and at most testing times on the vulvar vestibule than the volar forearm; and at baseline and immediately after masturbation than 15 minutes later, mainly on the genital locations only. Pain thresholds were lower on the genital locations than the volar forearm, and immediately and 15 minutes after masturbation than at baseline. After orgasm, genital pleasurableness ratings and vulvar vestibular pain thresholds were lower than after masturbation almost to orgasm. Post-masturbation pleasurableness ratings were positively correlated with pain thresholds but only on the glans clitoris. Hormonal contraception users had lower pleasurableness ratings and pain thresholds on all locations than nonusers. There were no significant effects for touch thresholds. CONCLUSIONS: Masturbation appears to maintain pleasurable genital sensitivity but increase pain sensitivity, with lower genital pleasurable sensitivity and higher vulvar vestibular pain sensitivity when orgasm occurs. Findings suggest that enhancing stimulation pleasurableness, psychological sexual arousal and lubrication mitigate normative increases in pain sensitivity during sexual activity, and underscore the importance of measuring both pleasure and pain in sensation research.

Women with provoked vestibulodynia experience clinically significant reductions in pain regardless of treatment: results from a 2-year follow-up study.

INTRODUCTION: Provoked vestibulodynia (PVD) is a prevalent genital pain syndrome that has been assumed to be chronic, with little spontaneous remission. Despite this assumption, there is a dearth of empirical evidence regarding the progression of PVD in a natural setting. Although many treatments are available, there is no single treatment that has demonstrated efficacy above others. AIMS: The aims of this secondary analysis of a prospective study were to (i) assess changes over a 2-year period in pain, depressive symptoms, and sexual outcomes in women with PVD; and (ii) examine changes based on treatment(s) type. METHODS: Participants completed questionnaire packages at Time 1 and a follow-up package 2 years later. MAIN OUTCOME MEASURES: Visual analog scale of genital pain, Global Measure of Sexual Satisfaction, Female Sexual Function Index, Beck Depression Inventory, Dyadic Adjustment Scale, and sexual intercourse attempts over the past month. RESULTS: Two hundred thirty-nine women with PVD completed both time one and two questionnaires. For the sample as a whole, there was significant improvement over 2 years on pain ratings, sexual satisfaction, sexual function, and depressive symptoms. The most commonly received treatments were physical therapy, sex/psychotherapy, and medical treatment, although 41.0% did not undergo any treatment. Women receiving no treatment also improved significantly on pain ratings. No single treatment type predicted better outcome for any variable except depressive symptoms, in which women who underwent surgery were more likely to improve. DISCUSSION: These results suggest that PVD may significantly reduce in severity over time. Participants demonstrated clinically significant pain improvement, even when they did not receive treatment. Furthermore, the only single treatment type predicting better outcomes was surgery, and only for depressive symptoms, accounting for only 2.3% of the variance. These data do not demonstrate the superiority of any one treatment and underscore the need to have control groups in PVD treatment trials, otherwise improvements may simply be the result of natural progression.

Disentangling desire and arousal: a classificatory conundrum.

A controversial proposal to collapse sexual disorders of desire and arousal is forthcoming in the diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Yet, no study has attempted to empirically distinguish these disorders by using explicit criteria to recruit and compare distinct groups of low desire and arousal sufferers. The goal of the current study was to test the feasibility of finding medically healthy men and women meeting clearly operationalized DSM-IV-TR criteria for disorders of desire and/or arousal and compare them to matched controls. To assess operational criteria, participants completed a comprehensive telephone screening interview assessing DSM-IV-TR and DSM-5 criteria, as well as standardized self-report measures of sexual functioning. The use of operationalized DSM-IV-TR criteria to recruit participants led to the exclusion of over 75% of those reporting sexual difficulties, with the primary reason for exclusion being failure to meet at least one central diagnostic criterion. The application of the DSM-5 criteria was even more restrictive and led to the exclusion of all but four men and one woman using the original four-symptom criteria, and four men and five women using the revised three-symptom criteria. Cluster analyses supported the distinction between desire and genital arousal difficulties, and suggest that different groups with distinct clusters of symptoms may exist, two of which are consistent with the DSM-5 criteria. Overall, results highlight the need for revisions to the diagnostic criteria, which, as they stand, do not capture the full range of many people's sexual difficulties.

Biopsychosocial predictors of postmenopausal dyspareunia: the role of steroid hormones, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment.

INTRODUCTION: Although dyspareunia experienced after menopause is widely attributed to declining estrogen levels and vulvovaginal atrophy, critical reviews of the literature have suggested that these factors are incomplete as explanatory mechanisms. Little is known about psychosocial factors that may also be implicated in postmenopausal dyspareunic pain. AIM: To determine the extent to which levels of estrogens and progesterone, vulvovaginal atrophy, cognitive-emotional factors, and dyadic adjustment are predictive of postmenopausal dyspareunic pain intensity. METHODS: A total of 182 postmenopausal dyspareunia sufferers underwent a structured interview concerning sociodemographic status as well as medical and pain histories, gynecological examination, cytological evaluation, a blood draw, and answered a series of self-report questionnaires. Given the large number of genital and pelvic pain variables measured, a principal components analysis was undertaken to identify a smaller number of components representing meaningful dimensions of genital and pelvic pain. MAIN OUTCOME MEASURES: Pain severity ratings during intercourse were obtained using the McGill Pain Questionnaire. Pain ratings were also obtained during gynecological assessment. Serum estrone, estradiol, and progesterone levels were measured via immunoassay. The Vaginal Atrophy Index and maturation value were used to determine vulvovaginal atrophy severity. Participants completed the Pain Catastrophizing Scale, State-Trait Anxiety Inventory, The Beck Depression Inventory-II, and Dyadic Adjustment Scale. RESULTS: Hormone levels were not found to be consistent predictors of pain severity. Maturation value and cognitive-emotional variables (e.g., catastrophization, depression, anxiety) were significant predictors of vestibular pain, which affected over 90% of our sample. Relationship adjustment variables were inversely associated with pain severity within several genital locations. CONCLUSIONS: Results suggest that the traditional hypoestrogen and vulvovaginal atrophy conceptualization of postmenopausal dyspareunia is an insufficient explanatory model, and that pain is also influenced by cognitive, affective, and dyadic factors.