Cindy M. Meston and Amelia M. Stanton 

Assessment and Treatment of Female Sexual Interest/Arousal Disorder

The assessment of sexual interest in women is difficult due to the subjective and complex nature of sexual desire. In her model of the female sexual response, Basson (2000) described the concept of receptive desire. She explained that, though many women do not seek out sexual activity, they respond sexually when approached by partner. Basson was the first to suggest that level of responsiveness to sexual stimuli was indicative of desire in women. Assessing for low sexual desire may include inquiring about sexual thoughts, fantasies, and daydreams; examining the degree to which patients seek out sexually suggestive material; questioning how often patients have the urge to masturbate or engage in sensual self-touching; and determining level of motivation for partnered sexual activity. Overall, assessment of sexual desire needs to be carefully considered within the context of the dyadic relationship, and must take into consideration factors known to affect sexual functioning such as the person’s age, religion, culture, the length of the relationship, the partner’s sexual function, and the context of the person’s life.

In the assessment of sexual arousal, levels of physiological sexual arousal can be assessed indirectly using a vaginal photoplethysmograph to assess vaginal blood engorgement, as well as by sonograms (pictures of internal organs derived by sound waves bouncing off organs and other tissues), thermograms (images of radiation in the long-infrared range of the electromagnetic spectrum) and fMRI (imaging techniques that track changes in blood concentration in inner organs) to assess blood engorgement in the genitals. However these techniques are more commonly used for research purposes than as clinical diagnostic tools.

Assessment of sexual interest and sexual arousal should comprise a complete sexual, medical, and psychosocial history, which can be obtained through standardized interviews and validated self-administered questionnaires. The clinician should explore the onset of the sexual problem taking into account dates of surgeries, medication changes, and

diagnoses of medical conditions. It is also important to assess the context of the problem, especially situations or cues that have stimulated sexual desire in the past. If a person reports specific cues for sexual desire, it should be determined if they are now absent from his or her life, no longer of interest, or are now unacceptable for some reason. It is also imperative to explore the person’s feelings about his or her current sexual partner to look for relationship factors that could be contributing to the sexual difficulties. Laboratory testing may be warranted given the close relationship between androgens and sexual desire. A complete psychosocial history should include: situational problems, relationship history, sexual problems of the partner, mood, sexual satisfaction, and psychological disorders.

Treatment

For women experiencing low sexual desire as a result of biologically compromised natural levels of androgens, treatment with testosterone replacement therapy can be an effective option. Currently, there are no testosterone products that have been approved by the FDA for the treatment of low sexual desire in women. However, many clinicians prescribe “off label” use of testosterone, in the form of patches or pills, for women with low sexual desire (Kingsberg & Knudson, 2011). One estimate suggests that 4.1 million prescriptions for off-label testosterone are made annually in the United States (Davis & Braunstein, 2012). The use of transdermal testosterone for reduced sexual desire in surgically menopausal women was approved by the European Medicines Agency in 2010, but has yet to be approved by the FDA or by Health Canada.

Other hormonal therapies for low sexual desire include estrogen treatment and tibolone therapy. Estrogen treatment is particularly efficacious for desire problems that stem from vulvovaginal atrophy. Given the established relationship between low levels of estrogen and atrophy, estrogen therapy is the first line treatment for this particular condition (Tan, Bradshaw, & Carr, 2012). Tibolone is a 19-nor testosterone derivative and a selective tissue estrogenic activity regulator that is metabolized into metabolites with estrogenic, progestagenic, and androgenic properties (Brotto & Luria, 2014). Available in 90 countries (but not in the United States), Tibolone therapy has been shown to increase sexual desire and lubrication. Nijland and colleagues (2008) demonstrated an overall improvement in sexual function in women receiving Tibolone. There are some concerns, however, that Tibolone may increase the risk of breast cancer recurrence (Kenemans et al., 2009) and stroke (Cummings et al., 2008) in older women.

Since the success of using PDE5 inhibitors (e.g., Viagra, Levitra, Cialis) to treat erectile dysfunction, researchers have attempted to find a comparable drug for women who are experiencing sexual desire or arousal problems. Flibanserin (Addyi) was approved by the FDA in 2015 after studies showed that the drug increased subjective reports of sexually satisfying events. Flibanserin acts on different neurotransmitters in the brain; the drug increases levels of norepinephrine and dopamine and reduces levels of serotonin.

There is some research on other nonhormonal, centrally acting investigational medications for low desire and arousal problems in women. Buproprion, sometimes used to counteract sexual dysfunction secondary to SSRI treatment, led to a modest improvement in sexual interest and arousal among nondepressed premenopausal women and among premenopausal women complaining of low sexual desire (Segraves, Clayton, Croft, Wolf, & Warnock, 2004). Intranasal bremelanotide has also shown limited evidence of beneficial effects on sexual desire in women (Brotto & Luria, 2014) .

Physiological aspects of low sexual arousal are most commonly treated with topical lubricants that help mask impairments in vaginal lubrication. They do not, however, enhance genital/clitoral blood flow or genital sensations that are often decreased, and they have not been shown to impact psychological sexual arousal. Evidence from limited placebo- controlled studies indicates that Viagra increases genital engorgement in healthy, premenopausal women (Laan, Smith, Boolell, & Quirk, 2002), and in postmenopausal women with severe levels of genital arousal concerns (Rosemary Basson, & Brotto, 2003). Despite reports of increased physiological sexual arousal, studies in general have not found that these drugs positively impact a woman’s psychological experience of sexual arousal. This suggests that, for women, psychological factors such as relationship satisfaction, mood state, and sexual scenarios may play a more important role in feelings of sexual desire and arousal than do physiological genital cues. If this is the case, drugs that target increasing vasocongestion are likely to be most effective in women with genital sexual arousal disorder whose primary complaint is decreased genital responding, experienced as decreases in lubrication and/or feelings of vaginal fullness or engorgement. This would most likely be women who are postmenopausal, who have undergone ophorectomy, or who suffer from arterial vascular problems. For some women, if a drug increases vaginal engorgement, to the extent that it is detected and labeled as a sexual feeling, this may also enhance their feelings of more general, psychological arousal.

Studies on vasodilator drugs for women have revealed a notable placebo effect on women’s sexual arousal. That is, up to 40% of women in

the placebo group of randomized clinical trials for Viagra and other pharmacological agents report significant improvements in sexual arousal (Basson, McInnes, Smith, Hodgson, & Koppiker, 2002). It appears that nonspecific factors such as expecting to improve, having contact with a sexuality professional, and monitoring sexual response, can exert a powerful influence on women’s sexual arousal and satisfaction at large.

The EROS clitoral therapy device (Urometrics, St. Paul, Minnesota) is an FDA-approved treatment for women’s sexual arousal concerns. This small handheld device increases vasocongestion in the clitoral and labial region via a suction mechanism and has been reported to increase vaginal lubrication and sensation (Billups et al., 2001).

Psychological treatments for low desire include education about factors that affect sexual desire, couples exercises (e.g., scheduling times for physical and emotional intimacy), communication training (e.g., opening up about sexual issues and needs), cognitive restructuring of dysfunctional beliefs (e.g., a good sexual experience does not always end with an orgasm), sexual fantasy training (e.g., training people to develop and explore mental imagery), and sensate focus. Sensate focus, introduced by Masters and Johnson in the 1970s, is a behavioral technique in which couples learn to focus on the pleasurable sensations that are brought about by touching, while decreasing attention on goal-directed sex (e.g., orgasm). Recent research has also indicated that mindfulness-based approaches, which cultivate active awareness of the body and its sensations in a nonjudgmental and compassionate way, may be helpful for women with FSIAD (Brotto & Basson, 2014; Brotto & Luria, 2014). By focusing on the physical sensations of sexual activity instead of being preoccupied with sexual performance, or current level of desire or arousal, couples can learn to be present and respond to their partner during the sexual situation. In the beginning stages of sensate focus couples are encouraged to touch each other’s bodies and feel for sexual sensations but refrain from touching breasts or genitals, or engaging in intercourse. The exercises aim to build an organic desire for full intercourse. Over time the couples are encouraged to touch more and more areas and then finally to have intercourse.

For women in satisfying relationships, treatment may include identifying potential distracting, negative thoughts and helping them let go of these thoughts during sexual activity. Leiblum and Wiegel (2002) described four such types of distracting thoughts in women: myths and misconceptions (e.g., “Women are not supposed to enjoy sex”), negative emotions, performance anxiety, and body image concerns (e.g., focusing on unattractive aspects of one’s body). Behavioral techniques designed to help men and women explore their sexual likes and dislikes, alone or with their partners, can be used to help them associate sexual behaviors with positive

affect and experiences. For individuals who are distracted by feelings of shame or embarrassment about their bodies, cognitive restructuring might involve helping them to identify their fears (e.g., a fear of rejection) and dysfunctional beliefs (e.g., “My partner thinks my body is not sexy”) and then test the accuracy of these beliefs through a series of strategically designed behavioral experiments. The experiments aim to reduce avoidance behavior and provide corrective experiences to counteract dysfunctional beliefs. For example, a woman who keeps her clothing on during sex because she feels that her partner would reject her if he saw her naked would be encouraged to incrementally remove pieces of clothing, and test the reaction of her partner.

Assessment and Treatment of Female Orgasmic (FOD) Disorder

A doctor or psychologist familiar with the structure and function of orgasms should conduct the assessment of FOD. Depending on the etiology of the orgasm problem, a variety of both cognitive behavioral and physical therapy techniques can be effective for increasing orgasmic capacity.

Assessment

Assessment of FOD involves a comprehensive sexual, medical, and psychosocial history similar to that used for assessing FSIAD. It is important for the clinician to determine whether the woman is unable to attain orgasm in all situations or just with a certain partner or during certain intercourse positions or sexual activities because this information may help determine the most appropriate type of therapy.

Treatment

In general, sex therapy for FOD focuses on promoting healthy changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. Sensate focus and systematic desensitization are used to treat FOD when anxiety seems to play a role.

Sex education and communication skills training are often included as adjuncts to treatment. Kegel exercises (Kegel, 1952), which involve tightening and relaxing the pubococcygeous muscle, are also sometimes included as part of a treatment regime. Feasibly, they could help facilitate orgasm by increasing blood flow to the genitals, or by helping the woman become more aware and comfortable with her genitals.

To date, the most efficacious treatment for FOD is directed masturbation (DM). This treatment utilizes cognitive behavioral therapy techniques to educate a woman about her body and the sensations of manual self-stimulation. DM includes several stages that gradually build on one another. The first step of DM involves having the woman visually examine her nude body with the help of a mirror and diagrams of female genital anatomy. She is then instructed to explore her genitals using touch with an emphasis on locating sensitive areas that produce feelings of pleasure. Once pleasure-producing areas are located, the woman is instructed to concentrate on manual stimulation of these areas and to increase the intensity and duration until “something happens.” The use of topical lubricants, vibrators, and erotic videotapes are often incorporated into the exercises. Next, once the woman is able to attain orgasm alone, her partner is usually included in the sessions in order to desensitize her to displaying arousal and orgasm in his or her presence, and to educate the partner on how to provide her with effective stimulation.

Directed masturbation has been shown to effectively treat primary FOD when provided in a variety of formats, including individual, group, couples therapy, and bibliotherapy (for review, see Meston, 2006). A study of therapist-directed group therapy using DM reported a 100% success rate in treating primary FOD at 2-month follow-up (Heinrich, 1976). It has been proposed that DM is so effective because, in the early stages, it eliminates several factors that can impair orgasmic capacity, such as anxiety that may be associated with the presence of a partner. Since the exploration is focused on the woman’s manual sexual stimulation, she is not dependent on her partner’s sexual ability, or her ability to communicate her sexual needs to her partner until later in the treatment. Recent research has indicated that DM is particularly effective for women with primary FOD (Graham, 2014). It appears the DM can also be effective for women with secondary FOD who are uncomfortable touching their genitals, but studies have found DM to be less effective for secondary FOD, than primary FOD (Fichen, Libman, & Brender, 1983). This may be because many women with secondary FOD only have trouble attaining orgasm with their partner. Therefore, treatments for secondary FOD typically?? focus on couple’s issues of communication, sexual skills, comfort, and trust.

If the etiology of the FOD appears to be related to anxiety about sex, then anxiety reduction techniques such as systematic desensitization and sensate focus may be useful. These strategies are often combined with sexual techniques training, DM, sex education, communication training, bibliotherapy, and Kegel exercises. As described earlier, Kegel exercises strengthen the pubococcygeous muscle, and are believed to facilitate orgasm by increasing vascularity of the genitals (Kegel, 1952). Supporting this technique, one study found a difference in the size of the pubococcygeous muscle between orgasmic and nonorgasmic women (Graber & Kline-Graber, 1979). Yet if anxiety is not the presenting cause of the orgasm problem, these techniques, while effective for desire and arousal problems, do not appear to be effective for treating orgasm problems (Meston, Levin, Sipski, Hull, & Heiman, 2004).

For women who have orgasm difficulties resulting from hysterectomy and oophorectomy, combined estrogen and testosterone therapy has been shown to enhance orgasmic ability (Shifren et al., 2000). A number of psychotherapeutic drugs have been used to try to eliminate orgasm problems that are secondary to antidepressant drug treatments. Results from placebo-controlled studies, to date, have failed to identify any drugs that enhance orgasmic ability better than placebo. However, one study indicated that exercise increases genital arousal in women taking both SSRIs and SNRIs (Lorenz & Meston, 2012). As SSRIs are known to have greater SNS suppression compared to SNRIs, women talking SSRIs experienced significantly greater genital response post-exercise than women taking SNRIs (Lorenz & Meston, 2012).

Assessment and Treatment of Genito-Pelvic Pain/Penetration Disorder

The assessment of genito-pelvic pain should include an accurate description of the location, intensity, quality, duration, and time course of

the pain, the degree of interference it has with sexuality, a summary of what elicits the pain (both sexual and nonsexual behaviors), and the meaning attributed to the pain. Pain is considered subjective and therefore usually measured by a patient’s self-report. Additional assessment by a gynecologist can help identify the specific area(s) of the pain, as well as take into account other potential gynecological issues that may be contributing to the pain. Assessment by a physical therapist may also be useful to confirm a diagnosis of GPPPD.

Treatment

The main treatments for genito-pelvic pain are cognitive behavioral sex therapy/pain management, electromyographic feedback, and vestibulectomy. Topical anesthetics and other medications are also sometimes used to alleviate genital pain, but well controlled studies examining their long-term effectiveness are currently lacking. Physical therapy with a focus on strengthening the pelvic floor through exercises, and enhancing flexibility with massage and stretching techniques have been used to treat sexual pain. Antidepressants and anticonvulsants have been used for pain relief, yet there are a limited number of clinical trials to support their efficacy (Schultz et al., 2005).

The most current treatments for genito-pelvic pain combine cognitive behavioral therapy to address education and faulty cognitions and physical therapy to strengthen and relax the vaginal muscles (Bergeron, Morin, & Lord, 2010). Cognitive behavioral sex therapy for dyspareunia generally includes educating the woman about sexual pain, the effect it has on sexual desire, arousal, and orgasm, and the factors that maintain the pain. Often cognitive restructuring exercises are used to help the women identify faulty cognitions (e.g., “If I have sex my vagina may tear apart”) and to replace them with more accurate beliefs (e.g., “My vagina is made of stretchable muscles that stretch out during intercourse”). These exercises aim to reduce the anxiety associated with sexual activity and encourage women to engage in non-penetrative sexual activity, to enhance sexual pleasure. Short-term group cognitive behavioral therapy for PVD significantly reduced genital pain from pre- to post-treatment, with 39% of women endorsing great improvement or complete pain relief at the 6-month follow-up interval (Bergeron, Binik, Khalifé, Pagidas, & Glazer, 2001). Group cognitive behavioral therapy and pain management for women with PVD also showed substantial reductions in genito-pelvic pain (Bergeron, Khalifé, & Dupuis, 2008). Further, Masheb and colleagues (2009) compared CBT to supportive psychotherapy in women with PVD and found that CBT resulted in significantly greater reductions in pain compared to supportive psychotherapy.

Electromyographic biofeedback has been used to treat genito-pelvic pain in women. Electromyography is a physiological response technique that records the electrical activity of skeletal muscles. The woman is trained to use the electromyography sensor to assess the tension in her pelvic muscles as she learns pelvic floor relaxation exercises. The exercises are practiced at home to reduce hypertonicity and increase the strength and flexibility of her pelvic floor. This technique was developed by Glazer, Rodke, Swencionis, Hertz, and Young (1995), who observed a relationship between PVD and abnormal responding of the pelvic floor musculature. Evidence suggests that electromyography and the pelvic floor training significantly reduce sexual pain from PVD and may occasionally eliminate it altogether (Bergeron et al., 2001; Glazer et al., 1995; McKay et al.,
2001). Despite encouraging results from these trials of electromyography, success rates have varied considerably, calling for further study.

When physical therapy and psychological treatments have proven ineffective, there are also surgical treatment options. Vestibulectomy is an outpatient procedure that involves removal of vulvar vestibular tissue, and has been shown to significantly reduce or completely alleviate genital pain among the majority of recipients. If the genito-pelvic pain appears to have an etiology related to atrophy of the vaginal tissue, such as is common post- menopause, estrogen administration may help to rebuild vaginal tissue. The estrogens are usually administered via oral pharmacology or topical cream applied to the vagina. Studies on the efficacy of estrogen treatment for dyspareunia related to atrophy of vaginal tissue have shown encouraging results (for review, see Krychman, 2011).

Treatment for vaginismus or involuntary spasms of the pelvic floor muscle can include many of the same techniques used for treating dyspareunia, such as cognitive behavioral therapy, electromyographic feedback, and vestibulectomy. As mentioned previously, cognitive behavior sex therapy focuses on educating the woman about her disorder, its potential impact on sexual desire, arousal, and orgasm, and potential elements that can maintain pain. Cognitive restructuring exercises and relaxation exercises like diaphragmatic breathing and progressive muscle relaxation are used to help the woman reduce her anxiety and avoidance of sexual activity.

Systematic desensitization has also been used to treat women who experience these painful pelvic spasms. In the context of sex therapy, systematic desensitization exercises are assigned for homework and entail relaxation coupled with gradual habituation to vaginal touch and

penetration, usually beginning with the woman’s fingers or artificial devices specifically designed for this purpose. Partners may also be incorporated into these exercises if desired. Despite the widespread use of systematic desensitization to treat this disorder, there is no empirical evidence that it is an effective treatment (Heiman & Meston, 1997). In a recent randomized clinical trial of cognitive behavioral therapy for lifelong vaginismus that included systematic desensitization as a treatment component, women showed improvements in their ability to engage in penetrative intercourse (van Lankveld et al., 2006). However the efficacy of systematic desensitization alone is still unknown.