Female Sexual Interest/Arousal Disorders

Cindy Meston, Ph.D. & Amelia M. Stanton

Sexual Interest/Arousal Disorders

Sexual interest refers to the motivation to engage in sexual activity. Interest is commonly referred to as “desire,” “sex drive,” and “sexual appetite,” and describes the sexual feelings motivating a person to seek some type of sexual activity, whether partnered or alone.

Sexual arousal is conceptualized as the second phase of the sexual response cycle and defined by both physical and mental readiness for sexual activity. Physiological changes occur in the body to prepare for a sexual interaction (erection in males, vaginal swelling and lubrication in females).

Female Sexual Interest/Arousal Disorder

Definition, Diagnosis, and Prevalence

Female Sexual Interest/Arousal Disorder (FSIAD) is defined in the DSM-5 as lack of, or significantly reduced, sexual interest/arousal. A woman must have three of the following six symptoms in order to receive the diagnosis: absent or reduced interest in sexual activity; absent or reduced sexual thoughts or fantasies; no or reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate; absent or reduced sexual excitement or pleasure in almost all or all sexual encounters; absent or reduced sexual interest/arousal in response to any internal or external sexual cues; and absent or reduced genital or non-genital sensations during sexual activity in all or almost all sexual encounters. These symptoms must cause clinically significant distress and have persisted for a minimum of six months. The disorder is specified by severity level and subtyped into lifelong versus acquired, generalized versus situational.

In past editions of the DSM, sexual interest and sexual arousal have been considered to be separate, though related, constructs. Most recently, the DSM-IV-TR had separate diagnoses of hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD). HSDD was characterized by the absence of sexual fantasies, lack of desire for sexual activity, and FSAD was characterized by continuous or recurrent inability to retain, or maintain, sufficient lubrication or swelling. The DSM-5 Sexual Dysfunction Subworkgroup cited evidence that desire and arousal could not be reliably distinguished in women (Brotto, Heiman, & Tolman, 2009; Graham, Sanders, Milhausen, & Mcbride, 2004). Other experts in the field disagree with this conceptualization (e.g. Clayton, DeRogatis, & Rosen, 2012), and the categorization of desire and arousal disorders into one diagnostic category has led to substantial controversy in the field (Kamens, 2011).

As FSIAD is new to the DSM, prevalence studies have not yet been published. However, previous work has examined the prevalence of low sexual interest (HSDD) and low sexual arousal (FSAD) in women. One of the most frequently cited prevalence study found low sexual interest in 22% of women in the general U.S. population (Laumann, Paik, Rosen, & Page, 1999). In a survey of women from 29 countries, rates of self-reported low sexual interest ranged from 26 to 43% (Laumann et al., 2005). For a clinical diagnosis of HSDD, which takes levels of distress into account, rates range from 7.3% (Bancroft, Loftus, & Long, 2003) to 23% (Witting et al., 2008), depending on a woman’s age, cultural background, and reproductive status.

Prevalence studies of sexual arousal problems in women have focused primarily on self-reported lack of vaginal lubrication. These studies have not always included all the information necessary to diagnose FSAD, as many did not inquire about distress or level of stimulation. Bancroft and colleagues (2003) found that 31.2% of heterosexual women in the U.S. reported lubrication problems over the past month. For women living in the United Kingdom, the prevalence of persistent lubrication problems, lasting three months or more, ranged from 2.6% (Mercer et al., 2003) to 28% (Dunn, Croft, & Hackett, 1999). Research that does reference distress has found that many women reporting lubrication problems are not distressed by their lack of lubrication (e.g. Bancroft et al., 2003; Shifren, Monz, Russo, & Segreti, 2008). Lubrication problems have been found to increase with age and menopausal status.

Factors Associated With Female Sexual Interest/Arousal Disorder

Research has not yet examined factors associated with FSIAD. However, there are a number of causes and consequences of low sexual interest (HSDD) in women and low sexual arousal (FSAD). These elements are broken down into biological factors including medical health, hormones, and medications, and psychological factors including stress, relationships, comorbid mental illness, and history of sexual abuse.

Biological Factors

Endocrine levels are the most commonly discussed biological factor that may be related to low sexual interest in women. Lack of sexual desire has been associated with menopause, during which decreased ovarian function results in lower estrogen production. Epidemiological studies indicate that “surgical menopause” induced by oophorectomy (surgical removal of the ovaries), which causes a sharp drop in estradiol and testosterone, is a more prominent risk factor for HSDD than natural menopause, particularly among younger cohorts (Dennerstein, Koochaki, Barton, & Graziottin, 2006; Leiblum, Koochaki, Rodenberg, Barton, & Rosen, 2006). Increased sexual desire has been found in women near the time of ovulation (e.g., Diamond & Wallen, 2011; Pillsworth, Haselton, & Buss, 2004), and research has shown that decreased sexual desire occurs after chemical suppression of ovarian hormones (Schmidt & Rubinow, 2009).

Researchers have concluded that sex hormones, specifically androgens, estrogens, and progestins, affect female sexual interest and function, but there is still some uncertainty as to which hormones are most important (Sandhu, Melman, & Mikhail, 2011). Androgens and estrogens govern the structure and function of the cervix, vagina, labia, and clitoris. With respect to sexual interest, androgens may be most influential, as they represent the immediate precursor to estrogen synthesis and thus affect sexual desire, mood, and energy (Goldstein, Traish, & Kim, 2004). The concept of androgen insufficiency as a potential cause of low sexual desire in women is controversial. Researchers originally believed that androgen depletion occurred organically due to age-related decline in adrenal and ovarian androgen production; now, the field recognizes that the decline in androgen production begins in the early 20s, which means that it does not occur as a result of natural menopause (Sandhu et al., 2011). Though low androgen levels may contribute to hypoactive sexual desire in women, the lack of reference ranges for androgens in women have made it difficult to determine when a clinical insufficiency is present.

Evidence for the relationship between testosterone and women’s sexual desire indicates that the hormone is correlated with solitary desire. In contrast to dyadic desire, or the desire to be sexual with another person, solitary desire is thought to be a “true” measure of desire, one that is less influenced by social context and more responsive to endogenous physiology (Van Anders, 2012). Several studies have indicated that higher levels of testosterone are associated with increased solitary desire (Van Anders, Brotto, Farrell, & Yule, 2009; Van Anders & Gray, 2007). In these same studies, dyadic desire showed no or negative correlation with testosterone. Masturbation, which is considered to be a behavioral index of solitary desire, has been linked to testosterone, such that women with low testosterone and high masturbation reported higher solitary desire than women with low testosterone and low masturbation (Van Anders, 2012).

There has also been recent interest in whether the hormonal changes caused by oral contraception use can lead to low sexual interest in women. Oral contraceptives involve a combination of estrogens and progesterone, and produce substantial increases in sex hormone-binding globulin, which can lower testosterone levels. It is possible that this decrease in testosterone could contribute to the low sexual desire reported by some women taking oral contraceptives. Research on the relationship between oral contraceptives and sexual desire has produced mixed results with studies reporting that oral contraceptives increase, decrease, or do not change women’s sexual desire. Despite the fact that oral contraceptives have been shown to decrease androgen levels, they have not been consistently associated with decreases in sexual desire (Burrows, Basha, & Goldstein, 2012). When McCall and Meston (2006) assessed cues for sexual desire, they determined that contraceptive use did not influence sexual desire in women with and without HSDD. Other studies have shown that oral contraceptives do have a negative impact on libido. For instance, a recent study of pre and post-menopausal women revealed that women taking oral contraceptives had a significantly lower incidence of sexual thoughts and sexual interest compared to nonusers (Davison, Bell, LaChina, Holden, & Davis, 2008). In a study of over 1,000 German medical students, oral contraceptive users had significantly lower scores on the desire subscale of the FSFI than did nonusers (Wallwiener et al., 2010); however, the direction of the relationship could not be determined. It is important to note that, for some women, the benefits derived from the use of oral contraception, such as freedom from a fear of pregnancy and a reduction in menstrual symptoms, may serve to enhance, rather than inhibit, sexual desire.

It is well known that many psychoactive medications affect sexual desire. There are both intra-class and inter-class variations among antidepressants with respect to sexual dysfunction and particularly sexual desire. These variations are largely dependent on neurotransmitter receptor profiles and genetics (Clayton, El Haddad, Iluonakhamhe, Ponce Martinez, & Schuck, 2014). Selective serotonin reuptake inhibitors (SSRIs), used most commonly for treating depression and anxiety, increase serotonin levels and produce a variety of sexual side effects in both men and women including decreased desire. Sexual dysfunction secondary to SSRI use is believed to result, in part, from activation of the serotonin2 receptor. Newer generations of antidepressants that act as antagonists (blockers) at the serotonin2 receptor (e.g., agomelatine, bupropiron, moclobemide, and reboxetine) are associated with fewer sexual side effects (Keks, Hope, & Culhane, 2014). Clayton and colleagues (2014) suggest that future research should seek to validate genetic factors associated with antidepressant medications. Doing so would enable personal genotyping and the development of individualized treatment approaches.

Research has shown that endocrine levels play a role in female sexual arousal. Specifically, estrogens influence the physiologic function of tissues, including the lower genital tissues. That is, estrogens have vasodilatory and vasoprotective effects that govern blood flow into the vagina and the clitoris (Sarrel, 1998). Reductions in estradiol during menopause and lactation have been associated with reduced blood flow to the vaginal walls, resulting in reduced vaginal lubrication (e.g., Graziottin & Leiblum, 2005; Simon, 2011). One of the major biological changes that occurs during menopause is a decrease in circulating estrogen, that helps account for decreased lubrication and thus decreased genital arousal (Sandhu et al., 2011). Yet, there is no precise estrogen “cut off” value that indicates whether one’s level of estrogen is adequate for sexual arousal. In other words, it is hard to determine if estrogen deficiency can be deemed to be a specific cause of sexual arousal problems.

Both the sympathetic and the parasympathetic nervous systems (SNS and PNS) play a role in genital arousal in women. Norepinephrine (NE) is the primary neurotransmitter involved in SNS communication, and when measured after exposure to a sexually arousing film, blood levels of NE are higher than pre-film levels (Exton et al., 2000). The spinal cord literature provides strong support for the role of the SNS in female sexual arousal. Women with spinal cord injuries between areas T11 and L2 in the spinal cord show a lack of lubrication during psychological sexual arousal (Sipski, Alexander, & Rosen, 1997). According to Sipski and colleagues (2001), this region is associated with sympathetically mediated genital vasocongestion. That is, this is the area of the spinal cord where sympathetic nerves project to the genital region.

Laboratory studies have also provided evidence for the role of SNS involvement in women’s sexual arousal. Meston and colleagues reported that moderate activation of the SNS using either exercise (Meston & Gorzalka, 1995, 1996a, 1996b) or ephedrine (Meston & Heiman, 1998) facilitated genital sexual arousal, and suppression of the SNS using clonidine inhibited genital arousal (Meston, Gorzalka, & Wright, 1997). A recent study proposed there is an optimal level of SNS arousal that is necessary for adequate genital arousal in women (Lorenz, Harte, Hamilton, & Meston, 2012). Lorenz and colleagues found that moderate increases in SNS activity were associated with higher physiological sexual arousal responses, while both very low and very high SNS activation were associated with lower levels of physiological sexual arousal. Similarly, low resting state heart rate variability has been associated with a risk for sexual arousal problems (Stanton, Lorenz, Pulverman, & Meston, 2015). Heart rate variability is a non-invasive test of autonomic imbalance (Xhyheri, Manfrini, Mazzolini, Pizzi, & Bugiardini, 2012), and it has been used to examine the relative role of SNS activity in female sexual arousal (Lorenz et al., 2012). Mechanisms that interfere with normal SNS activity, such as stress, can negatively impact a woman’s ability to become sexually aroused.

Vascular and neurological problems may also lead to sexual arousal concerns. Researchers have shown reduced sexual arousal in patients with multiple sclerosis (Hulter, 1999; Lew-Starowicz & Rola, 2013), pelvic vascular disorder (Schover & Jensen, 1988), and diabetes (Spector, Leiblum, Carey, & Rosen, 1993). Prescription drugs, especially SSRIs and SNRIs, may also decrease sexual arousal and vaginal lubrication in women (Frohlich & Meston, 2000; Kennedy & Rizvi, 2009). Some hormonal forms of contraceptives have been shown to reduce arousal (Smith, Jozkowski, & Sanders, 2014).

Psychological Factors

Low sexual interest and/or arousal has also been linked with a number of psychosocial factors in both men and women. After controlling for age, relationship satisfaction, and sexual satisfaction, Murray and Milhausen (2012) found that relationship duration significantly predicted variance in sexual desire. Specifically, women’s sexual desire decreased as relationship duration increased. Similarly, Sims and Meana (2010) reported that, in married women, feelings of overfamiliarity and institutionalization of the relationship led to decreased desire. Daily hassles such as worrying about children and paying the bills, and high-stress jobs are offenders for suppressing sexual desire, as are a multitude of relationship or partner-related issues. In regard to the latter, couples reporting sexual difficulties have been characterized by sex therapists as having less overall satisfaction within their relationships, an increased number of disagreements, more communication and conflict resolution problems, and more sexual communication problems including discomfort discussing sexual activities compared to couples without sexual problems. Warmth, caring, and affection within the relationship are undoubtedly linked to feelings of sexual desire. Beliefs and attitudes about sexuality acquired over the course of sexual development can influence sexual desire and sexual response across the lifespan. Women who internalize passive gender roles or negative attitudes toward sexuality may be at greater risk of experiencing sexual problems (Nobre & Pinto-Gouveia, 2006).

Societal factors may also contribute to low sexual interest and arousal. Sexual norms differ greatly by region and by culture. Women who are socialized to believe that being interested in sex is shameful often experience guilt and shame during sex, which in turn have been associated with both low levels of sexual desire and low levels of arousal (Woo, Brotto, & Gorzalka, 2012).

McCall and Meston (2006) reported four distinct factors that describe triggers or cues for sexual desire in women. These include emotional bonding cues (e.g., “Feeling a sense of love with your partner,” “Feeling a sense of commitment from your partner”), erotic/explicit cues (e.g., “Watching an erotic movie,” “Asking for or anticipating sexual activity”), visual/proximity cues (e.g., “Seeing/talking with someone famous,” “Seeing a well-toned body”), and romantic/implicit cues (e.g., “Having a romantic dinner with your partner,” “Laughing with a romantic partner”). Not surprisingly, when compared to sexually healthy women, women diagnosed with HSDD reported significantly fewer cues ion each of these domains.

Psychological conditions most commonly associated with a lack of sexual interest include social phobia, obsessive-compulsive disorder, panic disorder, and mood disorders—depression in particular. It is feasible that sexuality becomes of secondary importance when an individual is experiencing substantial distress in other areas of his or her life. With regard to depression, it is feasible that rumination aboutof negative events, a common cognitive aspect of depression, may contribute to the decrease in desire noted in depressed persons by causing an exclusive focus on aspects of sexuality that are unpleasant. It is well known that people with depression are prone to interpret negative events as caused by stable, global causes (Hankin, Fraley, & Abela, 2005), and this cognitive style could certainly negatively affect one’s perception of sexuality.

A history of unwanted sexual experiences can also negatively affect sexual desire. Many, but not all, women with a history of childhood sexual abuse fear sexual intimacy, are likely to avoid sexual interactions with a partner, and are less receptive to sexual approaches from their partners (Rellini, 2008). Sexual self-schemas, cognitive generalizations about sexual aspects of the self that guide sexual behavior and influence the processing of sexually relevant information (Andersen & Cyranowski, 1994), have been shown to differ between women with and without a history of childhood sexual abuse (Meston, Rellini, & Heiman, 2006; Stanton, Boyd, Pulverman, & Meston, 2015). A high proportion of women with a history of childhood sexual abuse engage in risky sexual behaviors such as engaging in sex with strangers while intoxicated (e.g., Bensley, Van Eenwyk, & Simmons, 2000). It is unknown whether this behavior is a reflection of high levels of sexual desire, an inability to maintain or enforce physical boundaries, a compulsive act, emotional avoidance, or some combination of these reasons. Other studies have found that prior sexual abuse is associated with low sexual interest (Leonard & Follette, 2002).

Many of the factors affecting women’s sexual desire noted earlier also affect women’s sexual arousal. According to the Dual-Control Model proposed by Bancroft and colleagues (2000), sexual arousal is the combination of both excitatory and inhibitory forces. Five main themes have been described as potential inhibitors or enhancers of sexual arousal for women ages 18 to 84 years: feelings about one’s body; negative consequences of sexual activity (e.g., bad reputation, pregnancy); feeling desired and accepted by a sexual partner; feeling used by a sexual partner; and negative mood (Graham et al., 2004).

Assessment and Treatment of Female Sexual Interest/Arousal Disorder

Given that FSIAD is new to DSM-5, there are no assessment tools based on the new diagnostic criteria, and there are no published treatment studies that use the new criteria. Therefore, this section draws on the HSDD and FSAD literature.

Assessment

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 oophorectomy, 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.