Addition of testosterone to endocrine care for transgender women: a dose-finding and feasibility trial.

OBJECTIVE: Transgender women who underwent gonadectomy have lower serum testosterone concentrations than cisgender women. There is uncertainty regarding the dosing and side effects of supplementation of testosterone in transgender women. This study aimed to assess the feasibility of dosing testosterone to the cisgender female physiological range in transgender women. In addition, we explored changes in cardiovascular parameters, virilizing side effects and clinical symptoms. DESIGN: This is an open-label, single-arm feasibility study. Participants initially went through a dose-titration phase with two week intervals from 0.07-0.09-0.13 mL (277-318-403 µg bio-available testosterone) testosterone 2% gel to establish a dose leading to serum testosterone concentrations between 1.5 and 2.5 nmol/L. This dose was then continued for eight weeks. METHODS: Participants applied daily transdermal testosterone 2% gel (Tostran®) at the prescribed dosage. Testosterone was measured every two to four weeks. Laboratory analyses, side effects, and clinical symptoms were evaluated. RESULTS: In total, twelve participants were included. Most participants required a dose of 0.07 mL (277 µg bio-available testosterone) or 0.09 mL (318 µg bio-available testosterone) to reach serum testosterone concentrations of 1.5-2.5 nmol/L. Continuing this dose, testosterone concentrations remained stable throughout the study. Changes in clinical outcomes were in the desired direction and side effects were mild. CONCLUSIONS: The use of testosterone supplementation in transgender women seems feasible and safe in the short term. Although dosing requires personalized titration, stable testosterone levels can be established. A blinded, placebo-controlled, randomized clinical trial is needed to study the clinical benefit.

Excitation Transfer Between Sexual Arousal and Other Emotions in a Community Sample.

Excitation transfer, the transfer of arousal from one emotion to another, might be a mechanism in the development of unusual sexual interests. In this pilot study, we investigated whether we could induce excitation transfer between various emotions and sexual arousal in a laboratory setting with 30 male volunteers. We induced low-level sexual arousal in four different emotional states (aggression/dominance, endearment, fear, disgust) and a neutral state. Sexual arousal was measured using penile plethysmography and self-report. Although there was no mean group effect, possibly due to large interindividual variations, 60% of the subjects showed more sexual arousal in response to sexual stimulation in at least one of the emotional states than in the neutral state. Excitation transfer was most prominent with aggression/dominance and least prominent with disgust. Genital excitation transfer was strongly related to lower penile reactivity and to higher self-reported erotophilia. This pilot study paves the way for further research into excitation transfer as a mechanism to increase the salience of stimuli that otherwise would not have been sexual in nature.

Crossroad decisions in deep endometriosis treatment options: a qualitative study among patients.

OBJECTIVE: To study the experiences, considerations, and motivations of patients with endometriosis in the decision-making process for deep endometriosis (DE) treatment options. DESIGN: Qualitative study using semi-structured in-depth focus group methodology. SETTING: University medical center. PATIENT(S): A total of 19 Dutch women diagnosed with DE between 27 and 47 years of age. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Focus group topics were disease impact and motives for treatment, expectations of the treatment process, and important factors in the decision process. RESULT(S): Women reported that pain, fertility, and strong fear of complications are important decisive factors in the treatment process. The goal of conceiving a child is considered important, however, sometimes doctors emphasize this topic too much. It emerged that complication counseling is frequently about surgical complications, whereas side effects of hormonal treatments are neglected. Shared decision making and information about treatment options, complications, and side effects are not always optimal, making it difficult to make a well-considered choice. Despite negative experiences encountered after surgery, the positive effect of surgery ensures that most women do not regret their choice. CONCLUSION(S): In the treatment decision process for patients with DE, pain is almost always the most important decisive factor. The wish to conceive and strong fear of complications can change this choice. Doctors should understand the importance of fertility for the majority of women, but, also, if this is not considered paramount, respect that view. To improve shared decision making, exploration of treatment goals, training of healthcare providers, and better patient information provision are desirable.

The effect of differential disgust conditioning and subsequent extinction versus counterconditioning procedures on women's sexual responses to erotic stimuli.

Recent theoretical accounts point to disgust as an important factor in the development and persistence of sexual dysfunctions. This study tested if (i) contingent disgust experiences can render initially sexually arousing stimuli disgusting, and (ii) such acquired disgust responses could be best neutralized via a CS-only extinction or a counterconditioning procedure. Participants (N = 74) were exposed to a differential conditioning procedure that was followed by either a CS-only extinction or a counterconditioning procedure. Erotic films served as the CS+/CS-. A disgusting film served as the US. During the extinction procedure, the CS+ was no longer followed by the disgusting US. During counterconditioning the CS+ was paired with positive stimuli. After conditioning, the CS + elicited lower genital arousal and was rated as significantly more disgusting, less pleasant, and less sexually arousing than the CS-. These diminished genital and subjective sexual arousal responses to the CS+ were successfully restored after both the extinction and the counterconditioning procedure, whereas conditioned feelings of disgust and behavioral avoidance persisted. There was no evidence for differential effectiveness of either procedure. Thus, sexual responses can be attenuated by learned sex-disgust associations and restored by extinction and counterconditioning procedures, but conditioned feelings of disgust seem more resistant.

Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study.

INTRODUCTION: The prevalence of polycystic ovary syndrome (PCOS) is 10-15% in women of reproductive age. Its characteristics are (i) clinical or biochemical hyperandrogenism, (ii) oligomenorrhea or amenorrhea, and (iii) polycystic ovaries on ultrasound. PCOS is associated with lower quality of life, depression, anxiety, diabetes, and cardiovascular disease. Treatment commonly entails oral contraceptive use to lower endogenous androgen levels. Androgen levels and comorbidities may affect sexual function. Previous studies have addressed a limited range of possible contributing factors. We will assess sexual function as well as genital and self-reported sexual arousal in a laboratory setting in women with PCOS compared to an age-matched healthy control group. Modulation by biopsychosocial factors mentioned will be studied. METHODS: This is a multicenter prospective case control study. The study population includes healthy women with and without PCOS, aged 18-40 years, in a stable heterosexual relationship for at least 6 months. Power is calculated at 67 participants in each group. Anticipating a drop out of 10%, 150 participants will be recruited. MAIN OUTCOME MEASURES: The main outcomes measured are sexual function using the Female Sexual Function Index, Sexual Desire Inventory, and Female Sexual Distress Scale-Revised; genital sexual arousal measured as vaginal pulse amplitude; and self-reported sexual arousal in response to erotic stimuli in a laboratory setting. The mediators that will be investigated include testosterone, free androgen levels, oral contraceptive use, sensitivity to androgens (using CAG repeat length), body mass index, body image, mental health, and self-esteem. CONCLUSION: Strengths of this study are the inclusion of a broad range of biopsychosocial outcome measures including DNA analysis, a healthy control group, and standardized assessment of genital and self-reported sexual arousal in a laboratory setting. With the design of this study we aim to provide an insight into which biopsychosocial factors associated with PCOS are related to sexual function, and how sexual function may be affected by treatment. These new insights may help to improve clinical management of PCOS while improving the quality of life. Pastoor H, Both S, Timman R, et al. Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study. Sex Med 2020;8:718-729.

Evidence for Persistence of Sexual Evaluative Learning Effects.

INTRODUCTION: Several studies demonstrated that genital arousal and enhanced positive affect toward neutral stimuli due to sexual conditioning did not extinguish during a brief extinction phase, but other studies showed contrasting results. Possible resistance to extinction of conditioned human sexual response has, however, not been studied using extensive extinction trials. AIM: To study resistance to extinction of conditioned sexual response in men and women. METHODS: Healthy sexually functional men (N = 34) and women (N = 32) participated in a differential conditioning experiment, with neutral pictures as conditioned stimuli (CSs) and genital vibrostimulation as unconditioned stimulus. Only one CS (the CS+) was followed by the unconditioned stimulus during the acquisition phase. MAIN OUTCOME MEASURE: Penile circumference and vaginal pulse amplitude were assessed, and ratings of affective value and subjective sexual arousal were obtained. In addition, a stimulus response compatibility task was included to assess automatic approach and avoidance tendencies. RESULTS: Men and women rated the CS+ as more positive than the CS- during all 24 extinction trials and demonstrated a slight tendency to approach the CS+ directly after the extinction procedure. Participants rated the CS+ as more sexually arousing than the CS- during 20 extinction trials. No evidence was found for conditioned genital sexual response. CLINICAL IMPLICATIONS: Learned sexual evaluations may be difficult to modify through an extinction procedure; therefore, unwanted but persistent subjective sexual evaluations may be better targeted by interventions such as the deployment of emotion regulation strategies. STRENGTH & LIMITATIONS: Extensive extinction trials were used; however, only relatively short-term effects within one experimental session were studied and there was no (unpaired) control condition. CONCLUSION: The results provide evidence that conditioned sexual likes are relatively persistent, also at the behavioral level. Both S, Brom M, Laan E, et al. Evidence for Persistence of Sexual Evaluative Learning Effects. J Sex Med 2020;17:505-517.

Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM).

INTRODUCTION: Hormonal contraception is available worldwide in many different forms. Fear of side effects and health concerns are among the main reasons for not using contraceptives or discontinuing their use. Although the safety and efficacy of contraceptives have been extensively examined, little is known about their impact on female sexual function, and the evidence on the topic is controversial. AIM: To review the available evidence about the effects of hormonal contraceptives on female sexuality in order to provide a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine. METHODS: A comprehensive review of the literature was performed. MAIN OUTCOME MEASURE: Several aspects of female sexuality have been investigated, including desire, orgasmic function, lubrication and vulvovaginal symptoms, pelvic floor and urological symptoms, partner preference, and relationship and sexual satisfaction. For each topic, data were analyzed according to the different types of hormonal contraceptives (combined estrogen-progestin methods, progestin-only methods, and oral or non-oral options). RESULTS: Recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria and specific statements on this topic, summarizing the European Society of Sexual Medicine position, were developed. CLINICAL IMPLICATIONS: There is not enough evidence to draw a clear algorithm for the management of hormonal contraception-induced sexual dysfunction, and further studies are warranted before conclusions can be drawn. A careful baseline psychological, sexual, and relational assessment is necessary for the health care provider to evaluate eventual effects of hormonal contraceptives at follow-up. STRENGTHS & LIMITATIONS: All studies have been evaluated by a panel of experts who have provided recommendations for clinical practice. CONCLUSION: The effects of hormonal contraceptives on sexual function have not been well studied and remain controversial. Available evidence indicates that a minority of women experience a change in sexual functioning with regard to general sexual response, desire, lubrication, orgasm, and relationship satisfaction. The pathophysiological mechanisms leading to reported sexual difficulties such as reduced desire and vulvovaginal atrophy remain unclear. Insufficient evidence is available on the correlation between hormonal contraceptives and pelvic floor function and urological symptoms. Both S, Lew-Starowicz M, Luria M, et al. Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1681-1695.

Sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgical neovagina.

BACKGROUND: Sexual dysfunction is prevalent in women with Mayer-Rokitansky-Küster-Hauser syndrome after the creation of a neovagina. Insight into the physiologic response of the neovagina during sexual arousal is lacking, although this would help in the understanding of sexual function of these patients. The physiologic sexual response of the vagina can be measured objectively by vaginal photoplethysmography to assess vaginal blood flow. OBJECTIVE: Testing whether the physiologic and subjective sexual response in women with Mayer-Rokitansky-Küster-Hauser syndrome with a neovagina differs from the response in women with a natal vagina. STUDY DESIGN: Vaginal blood flow (vaginal pulse amplitude) and subjective sexual responses during neutral and erotic film viewing were assessed in premenopausal women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgically created neovagina (n=15) and were compared with responses of an age-matched control group (n=21). RESULTS: All women with Mayer-Rokitansky-Küster-Hauser syndrome had created their neovagina themselves by dilation. Women with Mayer-Rokitansky-Küster-Hauser syndrome showed a significantly smaller vaginal pulse amplitude compared with control subjects during neutral film viewing (P=.002). In both groups, vaginal pulse amplitude increased significantly during erotic film viewing, but this increase was significantly smaller in the Mayer-Rokitansky-Küster-Hauser syndrome group (P<.005). Levels of subjective sexual arousal did not significantly differ between the 2 groups (P>.2). CONCLUSION: Women with Mayer-Rokitansky-Küster-Hauser syndrome with a nonsurgically created neovagina showed a weaker vaginal blood flow response during visual sexual stimulation and poorer basal blood flow compared with control subjects. The differences in vaginal blood flow may be related to less vascularization and innervation of the neovagina compared with the natal vagina. The weaker vaginal sexual response can play a role in sexual dysfunction; however, despite the weaker vaginal response, women with Mayer-Rokitansky-Küster-Hauser syndrome did not differ in their level of subjective sexual arousal. Future studies may compare vaginal blood flow and subjective sexual response of women with Mayer-Rokitansky-Küster-Hauser syndrome with nonsurgically and surgically created vaginas.

Recent Developments in Psychopharmaceutical Approaches to Treating Female Sexual Interest and Arousal Disorder.

PURPOSE OF REVIEW: This review summarizes the recent literature and empirical studies on psychopharmacological approaches to treating female sexual interest/arousal disorder (FSIAD). RECENT FINDINGS: Several new drugs for FSIAD that are intended to increase sexual responsiveness by influencing central excitatory and inhibitory neuromodulatory processes are under development. Studies on flibanserin resulted in the first approved medication for the treatment of low sexual desire in premenopausal women. New drugs under development are testosterone combined with sildenafil or buspiron, bremelanotide, BP101, and nasal testosterone (TBS-2). SUMMARY: Although pharmacological enhancement of sexual responsiveness may be potentially helpful in the treatment of FSIAD, the observed effects of flibanserin and other new drugs under development seem limited in terms of clinical significance. Given the multifactorial character of FSIAD, it may be important to integrate psychopharmacological treatment with sex therapy for optimal treatment efficacy.

Effects of Aversive Classical Conditioning on Sexual Response in Women With Dyspareunia and Sexually Functional Controls.

INTRODUCTION: In dyspareunia-a somatically unexplained vulvovaginal pain associated with sexual intercourse-learned pain-related fear and inhibited sexual arousal are supposed to play a pivotal role. Based on research findings indicating that enhanced pain conditioning is involved in the etiology and maintenance of chronic pain, in the present study it was hypothesized that enhanced pain conditioning also might be involved in dyspareunia. AIM: To test whether learned associations between pain and sex negatively affect sexual response; whether women with dyspareunia show stronger aversive learning; and whether psychological distress, pain-related anxiety, vigilance, catastrophizing, and sexual excitation and inhibition were associated with conditioning effects. METHODS: Women with dyspareunia (n = 36) and healthy controls (n = 35) completed a differential conditioning experiment, with one erotic picture (the CS+) paired with a painful unconditional stimulus and one erotic picture never paired with pain (the CS-). MAIN OUTCOME MEASURES: Genital sexual response was measured by vaginal photoplethysmography, and ratings of affective value and sexual arousal in response to the CS+ and CS- were obtained. Psychological distress, pain cognitions, and sexual excitation and inhibition were assessed by validated questionnaires. RESULTS: The two groups showed stronger negative affect and weaker subjective sexual arousal to the CS+ during the extinction phase, but, contrary to expectations, women with dyspareunia showed weaker differential responding. Controls showed more prominent lower genital response to the CS+ during acquisition than women with dyspareunia. In addition, women with dyspareunia showed stronger expectancy for the unconditional stimulus in response to the safe CS-. Higher levels of pain-related fear, pain catastrophizing, and sexual inhibition were associated with weaker differential conditioning effects. CONCLUSIONS: Pairing of sex with pain negatively affects sexual response. The results indicate that a learned association of sex with pain and possibly deficient safety learning play a role in dyspareunia. Both S, Brauer M, Weijenborg P, Laan E. Effects of Aversive Classical Conditioning on Sexual Response in Women With Dyspareunia and Sexually Functional Controls. J Sex Med 2017;14:687-701.

The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A).

INTRODUCTION: The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects. AIM: To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant. CONCLUSION: Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.

The effect of a dopamine antagonist on conditioning of sexual arousal in women.

RATIONALE: Dopamine (DA) plays a key role in reward-seeking behaviours. Accumulating evidence from animal and human studies suggests that human sexual reward learning may also depend on DA transmission. However, research on the role of DA in human sexual reward learning is completely lacking. OBJECTIVES: To investigate whether DA antagonism attenuates classical conditioning of sexual response in humans. METHODS: Healthy women were randomly allocated to one of two treatment conditions: haloperidol (n = 29) or placebo (n = 29). A differential conditioning paradigm was applied with genital vibrostimulation as unconditional stimulus (US) and neutral pictures as conditional stimuli (CSs). Genital arousal was assessed, and ratings of affective value and subjective sexual arousal were obtained. RESULTS: Haloperidol administration affected unconditional genital responding. However, no significant effects of medication were found for conditioned responding. CONCLUSIONS: No firm conclusions can be drawn about whether female sexual reward learning implicates DA transmission since the results do not lend themselves to unambiguous interpretation.

The Influence of Emotion Upregulation on the Expectation of Sexual Reward.

INTRODUCTION: Emotion regulation research has shown successful altering of unwanted aversive emotional reactions. Cognitive strategies can also downregulate expectations of reward arising from conditioned stimuli, including sexual stimuli. However, little is known about whether such strategies can also efficiently upregulate expectations of sexual reward arising from conditioned stimuli, and possible gender differences therein. AIM: The present study examined whether a cognitive upregulatory strategy could successfully upregulate sexual arousal elicited by sexual reward-conditioned cues in men and women. METHODS: Men (n = 40) and women (n = 53) participated in a study using a differential conditioning paradigm, with genital vibrostimulation as unconditioned stimulus (US) and sexually relevant pictures as conditional stimuli. MAIN OUTCOME MEASURES: Penile circumference and vaginal pulse amplitude were assessed and ratings of US expectancy, affective value, and sexual arousal value were obtained. Also a stimulus response compatibility task was included to assess automatic approach and avoidance tendencies. RESULTS: Evidence was found for emotion upregulation to increase genital arousal response in the acquisition phase in both sexes, and to enhance resistance to extinction of conditioned genital responding in women. In men, the emotion upregulatory strategy resulted in increased conditioned positive affect. CONCLUSION: The findings support that top-down modulation may indeed influence conditioned sexual responses. This knowledge may have implications for treating disturbances in sexual appetitive responses, such as low sexual arousal and desire.

d-Cycloserine reduces context specificity of sexual extinction learning.

BACKGROUND: d-Cycloserine (DCS) enhances extinction processes in animals. Although classical conditioning is hypothesized to play a pivotal role in the aetiology of appetitive motivation problems, no research has been conducted on the effect of DCS on the reduction of context specificity of extinction in human appetitive learning, while facilitation hereof is relevant in the context of treatment of problematic reward-seeking behaviors. METHODS: Female participants were presented with two conditioned stimuli (CSs) that either predicted (CS+) or did not predict (CS-) a potential sexual reward (unconditioned stimulus (US); genital vibrostimulation). Conditioning took place in context A and extinction in context B. Subjects received DCS (125mg) or placebo directly after the experiment on day 1 in a randomized, double-blind, between-subject fashion (Placebo n=31; DCS n=31). Subsequent testing for CS-evoked conditioned responses (CRs) in both the conditioning (A) and the extinction context (B) took place 24h later on day 2. Drug effects on consolidation were then assessed by comparing the recall of sexual extinction memories between the DCS and the placebo groups. RESULTS: Post learning administration of DCS facilitates sexual extinction memory consolidation and affects extinction's fundamental context specificity, evidenced by reduced conditioned genital and subjective sexual responses, relative to placebo, for presentations of the reward predicting cue 24h later outside the extinction context. CONCLUSIONS: DCS makes appetitive extinction memories context-independent and prevents the return of conditioned response. NMDA receptor glycine site agonists may be potential pharmacotherapies for the prevention of relapse of appetitive motivation disorders with a learned component.

Sexual Dysfunctions in Men and Women with Inflammatory Bowel Disease: The Influence of IBD-Related Clinical Factors and Depression on Sexual Function.

INTRODUCTION: Inflammatory bowel disease (IBD) is likely to have an impact on sexual function because of its symptoms, like diarrhea, fatigue, and abdominal pain. Depression is commonly reported in IBD and is also related to impaired sexual function. This study aimed to evaluate sexual function and its association with depression among patients with IBD compared with controls. METHODS: IBD patients registered at two hospitals participated. The control group consisted of a general practitioner practice population. The web-based questionnaire included the Female Sexual Function Index (FSFI) for women and the International Index of Erectile Function (IIEF) for men. Other variables evaluated were depression, disease activity, IBD-related quality of life, body image, and fatigue. RESULTS: In total, 168 female and 119 male patients were available for analysis (response rate 24%). Overall, patients with IBD did not significantly differ in prevalence of sexual dysfunctions from controls: female patients 52%, female controls 44%, male patients and male controls both 25%. However, men and women with an active disease scored significantly lower than patients in remission and controls, indicating impaired sexual functioning during disease activity. Significant associations were found between active disease, fatigue, depressive mood, quality of life, and sexual function for both male and female patients. The association between disease activity and sexual function was totally mediated by depression. CONCLUSION: Male and female IBD patients with an active disease show impaired sexual function relative to patients in remission and controls. Depression is the most important determinant for impaired sexual function in IBD.

Sexual Response in Women with Type 1 Diabetes Mellitus: A Controlled Laboratory Study Measuring Vaginal Blood Flow and Subjective Sexual Arousal.

Previous studies have indicated that women with diabetes mellitus are at higher risk to develop sexual dysfunctions. In the current study, we hypothesized that lower genital arousal response-as a consequence of diabetes-related damage to nerves and blood vessels-might play a part in these higher prevalence rates. Vaginal blood flow, subjective sexual response, and clitoral sensitivity were compared between women with diabetes and healthy controls, and associations with diabetes complications were investigated. In pre- and postmenopausal women with type 1 diabetes (n = 42) and healthy controls (n = 46), vaginal blood flow was measured as vaginal pulse amplitude (VPA). VPA was assessed at rest, during erotic film viewing, and during vibrotactile clitoral stimulation. Subjective sexual arousal was measured using a questionnaire. Clitoral sensitivity was assessed by a vibration perception test. Data on diabetes complications were obtained from medical records, and neuropathy was assessed by quantitative sensory testing. VPA, subjective sexual arousal, and clitoral sensitivity were not significantly different between women with diabetes and controls. Nevertheless, women with diabetes who had retinopathy showed significantly lower VPA than women without retinopathy, and women with diabetes who had neuropathy showed significantly higher sensation thresholds for vibrotactile clitoral stimulation. The results do not support the hypothesis of a disrupted genital arousal response in women with diabetes. However, the observed associations between retinopathy and vaginal blood flow, and between neuropathy and clitoral sensitivity, suggest that diabetes-related complications might adversely affect the physiological basis of female sexual response.

The influence of emotion down-regulation on the expectation of sexual reward.

Emotion regulation research has shown successful altering of unwanted aversive emotional reactions. Cognitive strategies can also regulate expectations of reward arising from conditioned stimuli. However, less is known about the efficacy of such strategies with expectations elicited by conditioned appetitive sexual stimuli, and possible sex differences therein. In the present study it was examined whether a cognitive strategy (attentional deployment) could successfully down-regulate sexual arousal elicited by sexual reward-conditioned cues in men and women. A differential conditioning paradigm was applied, with genital vibrostimulation as unconditioned stimulus (US) and sexually relevant pictures as conditional stimuli (CSs). Evidence was found for emotion down-regulation to effect extinction of conditioned sexual responding in men. In women, the emotion down-regulatory strategy resulted in attenuated conditioned approach tendencies towards the CSs. The findings support that top-down modulation may indeed influence conditioned sexual responses. This knowledge may have implications for treating disturbances in sexual appetitive responses.

Extinction of aversive classically conditioned human sexual response.

INTRODUCTION: Research 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. AIM: This article aims to study resistance to extinction of aversive conditioned sexual responses in sexually functional men and women. METHODS: A 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 MEASURE: Penile 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. RESULTS: Men 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. CONCLUSIONS: Aversive 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.

Extinction and renewal of conditioned sexual responses.

INTRODUCTION: Extinction involves an inhibitory form of new learning that is highly dependent on the context for expression. This is supported by phenomena such as renewal and spontaneous recovery, which may help explain the persistence of appetitive behavior, and related problems such as addictions. Research on these phenomena in the sexual domain is lacking, where it may help to explain the persistence of learned sexual responses. METHOD: Men (n = 40) and women (n = 62) participated in a differential conditioning paradigm, with genital vibrotactile stimulation as US and neutral pictures as conditional stimuli (CSs). Dependent variables were genital and subjective sexual arousal, affect, US expectancy, and approach and avoid tendencies towards the CSs. Extinction and renewal of conditioned sexual responses were studied by context manipulation (AAA vs. ABA condition). RESULTS: No renewal effect of genital conditioned responding could be detected, but an obvious recovery of US expectancy following a context change after extinction (ABA) was demonstrated. Additionally, women demonstrated recovery of subjective affect and subjective sexual arousal. Participants in the ABA demonstrated more approach biases towards stimuli. CONCLUSIONS: The findings support the context dependency of extinction and renewal of conditioned sexual responses in humans. This knowledge may have implications for the treatment of disturbances in sexual appetitive responses such as hypo- and hypersexuality.