Sexual Medicine

Introduction. Data concerning the physiology of female sexual functioning are still obtained from animal studies, but an increasing amount of novel evidence comes from human studies. Aim. To gain knowledge of psychological and biologic physiology of women's sexual functioning, mainly addressing sexual arousal and orgasm. Methods. A broad-based literature review of current knowledge of the psychological and biologic physiology aspects of women's sexual functioning. Results. A comprehensive understanding of the anatomical, neurobiological, and psychological mechanisms behind sexual function and responses is of paramount importance. A biopsychological paradigm was considered when reviewing currently available data, thus considering aspects of: (i) sexual differentiation of the brain, which is critical for sex differentiation in behavior; (ii) central neurobiology of sexual function, highlighting specific and innovative findings from neuroimaging methods that enable visualization of active brain areas during arousal and orgasm; and (iii) peripheral functional anatomy, mainly addressing genital arousal and orgasm. Translational science was also covered, providing data about the actual role of sexual arousal in women in both procreation/reproduction and recreation/pleasure. The interaction between physiological and psychological states of women's sexual response, nonspecific sexual response, interoceptive awareness, and flexibility of sexual interests have also been addressed. Conclusion. Further research on normal physiology of women's sexual function is needed in order to expand and "translate" current knowledge into the pathophysiological clinical setting. This manuscript encompasses data presented at the 3rd International Consultation on Sexual Medicine in Paris, France, July 10-13, 2009. Salonia A, Giraldi A, Chivers ML, Georgiadis JR, Levin R, Maravilla KR, and McCarthy MM. Physiology of women's sexual function: Basic knowledge and new findings. J Sex Med 2010;7:2637-2660.

Introduction. Research indicated that: (i) vaginal orgasm (induced by penile-vaginal intercourse [PVI] without concurrent clitoral masturbation) consistency (vaginal orgasm consistency [VOC]; percentage of PVI occasions resulting in vaginal orgasm) is associated with mental attention to vaginal sensations during PVI, preference for a longer penis, and indices of psychological and physiological functioning, and (ii) clitoral, distal vaginal, and deep vaginal/cervical stimulation project via different peripheral nerves to different brain regions. Aims. The aim of this study is to examine the association of VOC with: (i) sexual arousability perceived from deep vaginal stimulation (compared with middle and shallow vaginal stimulation and clitoral stimulation), and (ii) whether vaginal stimulation was present during the woman's first masturbation. Methods. A sample of 75 Czech women (aged 18-36), provided details of recent VOC, site of genital stimulation during first masturbation, and their recent sexual arousability from the four genital sites. Main Outcome Measures. The association of VOC with: (i) sexual arousability perceived from the four genital sites and (ii) involvement of vaginal stimulation in first-ever masturbation. Results. VOC was associated with greater sexual arousability from deep vaginal stimulation but not with sexual arousability from other genital sites. VOC was also associated with women's first masturbation incorporating (or being exclusively) vaginal stimulation. Conclusions. The findings suggest (i) stimulating the vagina during early life masturbation might indicate individual readiness for developing greater vaginal responsiveness, leading to adult greater VOC, and (ii) current sensitivity of deep vaginal and cervical regions is associated with VOC, which might be due to some combination of different neurophysiological projections of the deep regions and their greater responsiveness to penile stimulation. Brody S, Klapilova K, and Krejč ová L. More frequent vaginal orgasm is associated with experiencing greater excitement from deep vaginal stimulation. J Sex Med 2013;10:1730-1736.

Orgasm is a sensation of intense pleasure creating an altered consciousness state accompanied by pelvic striated circumvaginal musculature and uterine/anal contractions and myotonia that resolves sexually-induced vasocongestion and induces well-being/contentment. In 1,749 randomly-sampled U.S. women, 24% reported an orgasmic dysfunction.

Sexual arousal and desire are integral parts of the human sexual response that reflect physiological, emotional, and cognitive processes. Although subjective and physiological aspects of arousal and desire tend to be experienced concurrently, their differences become apparent in certain experimental and clinical populations in which one or more of these aspects are impaired. There are few subjective scales that assess sexual arousal and desire specifically in both men and women. Aims. (i) To develop a multidimensional, descriptor-based Sexual Arousal and Desire Inventory (SADI) to assess subjective sexual arousal and desire in men and women; (ii) to evaluate convergent and divergent validity of the SADI; and (iii) to assess whether scores on the SADI would be altered when erotic fantasy or exposure to an erotic film was used to increase subjective arousal. Methods. Adult men (N = 195) and women (N = 195) rated 54 descriptors as they applied to their normative experience of arousal and desire on a 5-point Likert scale. Another sample of men (N = 40) and women (N = 40) completed the SADI and other measures after viewing a 3-minute female-centered erotic film or engaging in a 3minute period of erotic fantasy. Main Outcome Measures. Principal components analyses derived factors that the scale descriptors loaded onto. These factors were categorized as subscales of the SADI, and gender differences in ratings and internal validity were analyzed statistically. Factors were considered subscales of the SADI, and mean ratings for each subscale were generated and related to the other scales used to assess convergent and divergent validity. These scales included the Feeling Scale, the Multiple Indicators of Subjective Sexual Arousal, the Sexual Desire Inventory, and the Attitudes Toward Erotica Questionnaire, the Beck Depression Inventory (BDI)-II, and the Beck Anxiety Inventory. Results. Descriptors loaded onto four factors that accounted for 41.3% of the variance. Analysis of descriptor loadings ≥ 0.30 revealed an Evaluative factor, a Physiological factor, a Motivational factor, and a Negative/Aversive factor based on the meaning of the descriptors. Men's and women's subjective experiences of sexual desire and arousal on the Physiological and Motivational factors were not significantly different, although on the Evaluative and Negative factors, statistically significant differences were found between the genders. Mean scores on the Evaluative factor were higher for men than for women, whereas mean scores on the Negative factor were higher for women than for men. Internal consistency estimates of the SADI and its subscales confirmed strong reliability. Mean scores on the Evaluative, Motivational, and Physiological subscales of the SADI were significantly higher in the fantasy condition than in the erotic clip condition. Women had significantly higher mean scores than men on the Physiological subscale in the fantasy condition. Cronbach's α coefficients demonstrated excellent reliability of the SADI subscales. Evidence of convergent validity between the SADI subscales and other scales that measured the same constructs was strong. Divergent validity was also confirmed between the SADI subscales and the other scales that did not measure levels of sexual arousal, desire, or affect, such as the BDI-II. Conclusion. The SADI is a valid and reliable research tool to evaluate both state and trait aspects of subjective sexual arousal and desire in men and women. Toledano R, and Pfaus J. The sexual arousal and desire inventory (SADI): A multidimensional scale to assess subjective sexual arousal and desire. J Sex Med 2006;3:853-877.

Factual presentations of sexual anatomy are required for educational purposes, for clinical and more general communication about sexual matters. To date, unambiguous, accurate and objective images with appropriate labeling to enhance specificity in communication have been lacking. Aim. The aim of this presentation is to provide a comprehensive overview of anatomy of the distal vagina. We aim to simplify the anatomy to reduce the confusion of historical descriptions. In doing so, we aim to avoid sacrificing any of the specific detail. This would aid communication between clinicians, researchers, and the nonclinician regarding this anatomy. Outcome Measures and Methods. This article reviews the historical and current anatomical literature. Systematic dissection and photography, histological study, and magnetic resonance imaging have been used as the basis for this presentation. Digital technology has been used to label, color, and highlight photography to provide clarity and permit diagramatization of photography. No distortion has otherwise been used in presenting images from cadavers or anatomical research. Results. The anatomy of the distal vagina and surrounding structures is shown and described in detailed. The distal vagina, clitoris, and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit though the responses are not uniform. Conclusions. Significant progress has been made in the field of female sexual anatomy and its pictorial representation. This may facilitate further progress in the related fields of female sexual health and education. O'Connell HE, Eizenberg N, Rahman M, and Cleeve J. The anatomy of the distal vagina: Towards unity. J Sex Med 2008;5:1883-1891.

At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims. The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods. This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 (SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures. The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt.

Introduction. Most pharmacological treatments that are currently being developed for women with sexual arousal disorder are aimed at remedying a vasculogenic deficit. Aim. This study investigated whether pre-and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre-and postmenopausal women without sexual problems. Method. Twenty-nine medically healthy women with sexual arousal disorder (15 premenopausal and 14 postmenopausal), diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, and 30 age-matched women without sexual problems (16 premenopausal and 14 postmenopausal) were shown sexual stimuli depicting cunnilingus and intercourse. Main Outcome Measure. Genital arousal was assessed as vaginal pulse amplitude (VPA) using vaginal photoplethysmography.

We read with great interest the article by Lombardi and colleagues exploring the correlation between hormonal status and sexual function in patients with multiple sclerosis (MS), a chronic autoimmune disorder in the central nervous system (CNS) [1]. Sexual dysfunction (SD) is associated with chronic diseases [2], and is more common in women suffering from MS than in the general she population [3]. Dysregulation of the hypothalamic-pituitarygonadal axis has also been reported in MS [4]. Therefore, studies aiming to address the correlation between hormonal status and SD in female patients with MS are justified.

The existence of the G-spot is controversial. Aim. To evaluate, by the use of three-dimensional (3-D) ultrasonography, the anatomic structures of the urethrovaginal space. Methods. Nineteen (Group I) eumenorrheic young women who experienced, and 20 (Group II) who did not experience a vaginal orgasm underwent two-dimensional (2-D) and 3-D ultrasonography and color Doppler analysis of the urethrovaginal space and of the clitoris during the early follicular phase of the menstrual cycle. Main Outcome Measures. 2-D ultrasonographic evaluation of the urethrovaginal space, and color Doppler evaluation of the urethrovaginal main feeding artery and dorsal clitoral arteries; 3-D volume calculation of the urethrovaginal space, and 3-D power Doppler analysis of vascular indices of the urethrovaginal space and clitoral body (vascularization index, flow index, vascularization flow index); hormonal evaluation. Results. The 3-D reconstruction of the urethrovaginal space demonstrated a gland-like aspect with small feeding vessels. The total length (19.1 Ϯ 2.7 mm vs. 17.5 Ϯ 2.1 mm; P = 0.047), measured with 2-D ultrasound, and the 3-D mean volume (0.59 Ϯ 0.13 mL vs. 0.26 Ϯ 0.07 mL; P < 0.001) of the structures contained in the urethrovaginal space were significantly higher in Group I than in Group II. The mean time since the last intercourse was 31 Ϯ 9 hours in Group I and 18 Ϯ 3 hours (P = 0.033) in Group II. The urethrovaginal space vascularization, the clitoral volume and vascularization, and the circulating hormonal values did not significantly differ among the two groups. The mean volume of the structures contained in the urethrovaginal space was correlated with time since intercourse (r = 0.685; P = 0.021) and with serum testosterone (r = 0.637; P = 0.032) and androstenedione (r = 0.744; P = 0.011). Conclusions. The structures we observed in the urethrovaginal space have a gland-like aspect and their volume is correlated with both serum androgen concentrations and time since intercourse. Battaglia C, Nappi RE, Mancini F, Alvisi S, Forno S, Battaglia B, and Venturoli S. 3-D volumetric and vascular analysis of the urethrovaginal space in young women with or without vaginal orgasm.

There are many methods to evaluate female sexual function and dysfunction (FSD) in clinical and research settings, including questionnaires, structured interviews, and detailed case histories. Of these, questionnaires have become an easy first choice to screen individuals into different categories of FSD. Aim. The aim of this study was to review the strengths and weaknesses of different questionnaires currently available to assess different dimensions of women's sexual function and dysfunction, and to suggest a simple screener for FSD. Methods. A literature search of relevant databases, books, and articles in journals was used to identify questionnaires that have been used in basic or epidemiological research, clinical trials, or in clinical settings. Main Outcome Measure. Measures were grouped in four levels based on their purposes and degree of development, and were reviewed for their psychometric properties and utility in clinical or research settings. A Sexual Complaints Screener for Women (SCS-W) was then proposed based on epidemiological methods. Results. Although many questionnaires are adequate for their own purposes, our review revealed a serious lack of standardized, internationally (culturally) acceptable questionnaires that are truly epidemiologically validated in general populations and that can be used to assess FSD in women with or without a partner and independent of the partner's gender. The SCS-W is proposed as a 10-item screener to aid clinicians in making a preliminary assessment of FSD. Conclusions. The definition of FSD continues to change and basic screening tools are essential to help advance clinical diagnosis and treatment, or to slate patients adequately into the right diagnostic categories for basic and epidemiological research or clinical trials. Giraldi A, Rellini A, Pfaus JG, Bitzer J, Laan E, Jannini EA, and Fugl-Meyer AR. Questionnaires for assessment of female sexual dysfunction: A review and proposal for a standardized screener. J Sex Med 2011;8:2681-2706.

Questo è uno studio osservazionale, multicentrico, a carattere nazionale, per la validazione culturale e linguistica, dall'inglese all'italiano, del questionario di valutazione dei disturbi della sessualità femminile FSFI (Female Sexual Function Index),

Prior studies have addressed sexual abuse and sexual function in adult women. No studies have focused on the effect of adolescence rape on sexual functioning. Aim. To investigate the effect of rape on sexual problems and on pelvic floor problems, as well as the mediating role of pelvic floor problems on sexual problems, in a homogenous group of victims of adolescence rape without a history of childhood sexual, physical, and/or emotional abuse. Main Outcome Measures. Sexual functioning and pelvic floor functioning were assessed using self-report questionnaires. Methods. In this cross-sectional study, a group of 89 young women aged 18-25 years who were victimized by rape in adolescence was compared with a group of 114 nonvictimized controls. The rape victims were treated for posttraumatic stress disorder (PTSD) 3 years prior to participation in the study. Results. Three years posttreatment, rape victims were 2.4 times more likely to have a sexual dysfunction (lubrication problems and pain) and 2.7 times more likely to have pelvic floor dysfunction (symptoms of provoked vulvodynia, general stress, lower urinary tract, and irritable bowel syndrome) than nonvictimized controls. The relationship between rape and sexual problems was partially mediated by the presence of pelvic floor problems. Rape victims and controls did not differ with regard to sexual activities. Conclusions. Rape victims suffer significantly more from sexual dysfunction and pelvic floor dysfunction when compared with nontraumatized controls, despite the provision of treatment for PTSD. Possibly, physical manifestations of PTSD have been left unaddressed in treatment. Future treatment protocols should consider incorporating (physical or psychological) treatment strategies for sexual dysfunction and/or pelvic floor dysfunction into trauma exposure treatments. Postma R, Bicanic I, van der Vaart H, and Laan E. Pelvic floor muscle problems mediate sexual problems in young adult rape victims.

Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim. To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods. Fifty transsexual women who had undergone SRS Ն6 months earlier were recruited. Main Outcome Measures. Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results. Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions. Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain. Weyers S, Elaut E, De Sutter P, Gerris J, T'Sjoen G, Heylens G, De Cuypere G, and Verstraelen H. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med 2009;6:752-760.

Hypoactive sexual desire disorder in menopausal w omen: a survey of w estern european w omen Abstract I ntroduction. The prevalence of hypoactive sexual desire disorder (HSDD) in menopausal women and the frequency of sexual activity, sexual behavior, and relationship or sexual satisfaction associated with HSDD have not been studied using validated instruments to identify women with HSDD. Aims. To determine: (i) the prevalence of HSDD among women who have undergone hysterectomy and bilateral oophorectomy (surgical menopause) with that of premenopausal or naturally menopausal women; (ii) the relationship between low sexual desire and sexual activity and behavior; and (iii) the relationship between low sexual desire and sexual or partner relationship satisfaction. Methods. Cross-sectional survey of 2,467 European women aged 20-70 years, resident in France, Germany, Italy, and the United Kingdom. Measures were the Profile of Female Sexual Function © (PFSF © ), Personal Distress Scale © (PDS © ), and a sexual activities measure. Outcome Measures. Clinically derived cutoff scores for the desire domain of the PFSF and the PDS were used, sequentially, to classify women as having low sexual desire and to further classify these women with low desire as distressed or nondistressed. Thus, women with HSDD had low sexual desire and were distressed by their low desire. The analysis population included 1,356 women who had current sexual partners and were surgically menopausal, regularly menstruating, or naturally postmenopausal. Results. A greater proportion of surgically menopausal women had low sexual desire compared with premenopausal or naturally menopausal women (odds ratio [OR] = 1.4; confidence interval [CI] = 1.1, 1.9; P = 0.02). Surgically menopausal women were more likely to have HSDD than premenopausal or naturally menopausal women (OR = 2.1; CI = 1.4, 3.4; P = 0.001). Sexual desire scores and sexual arousal, orgasm, and sexual pleasure were highly correlated (P<0.001), demonstrating that low sexual desire is frequently associated with decreased functioning in other aspects of sexual response. Women with low sexual desire were less likely to engage in sexual activity and more likely to be dissatisfied with their sex life and partner relationship than women with normal desire (P<0.001). Conclusions. Surgically menopausal women are at increased risk for HSDD. HSDD is associated with diminished sexual and partner relationship satisfaction and negative emotional states. Dennerstein L. Koochaki P.E. Barton I. Graziottin A. Hypoactive sexual desire disorder in menopausal w omen: a survey of w estern european w omen Hypoactive sexual desire disorder in menopausal w omen: a survey of w estern european w omen Hypoactive sexual desire disorder in menopausal w omen: a survey of w estern european w omen Hypoactive sexual desire disorder in menopausal w omen: a survey of w estern european w omen