Understanding Women's Subjective Sexual Arousal Within the Laboratory

16 Pages·2017·0.45 MB·English

Understanding Women’s Subjective Sexual Arousal Within the
Laboratory: Definition, Measurement, and Manipulation
Ariel B. Handy, BA, Amelia M. Stanton, BA, and Cindy M. Meston, PhD
ABSTRACT
Introduction: Subjective sexual arousal (SSA) is positive, cognitive engagement in sexual activity. SSA is
considered animportantaspectofthesexualexperience, as ithas beenfound tofacilitate sexual activity and,in
situationsofchronicallyloworabsentarousal,potentiallycausedistress.DespitetheclinicalimplicationsofSSA,
a thorough review of how to manipulate SSA has yet to be conducted.
Aim: To review the state of knowledge about SSA in women, including its definition, measurement, and the
outcomes of studies attempting to manipulate SSA within a laboratory setting.
Method: A comprehensive search of the electronic databases of PubMed and PsycINFO was conducted. The
generatedlistofarticleswasreviewedandduplicateswereremoved.Individualarticleswereassessedforinclusion
and, when appropriate, relevant content was extracted.
MainOutcomeMeasure:ThepotentialeffectsofvariousmanipulationsofSSAinalaboratorysettingwasthe
main outcome.
Results: 44 studies were included in this review. Manipulations were grouped into 3 primary categories:
pharmacological (n ¼ 16), cognitive (n ¼ 22), and those based on changes to the autonomic nervous system
(n¼6).ResultssuggestthatcognitivemanipulationisthemosteffectivemethodofincreasingSSA.Alteringthe
relative balance of the 2 branches of the autonomic nervous system (the sympathetic nervous system and the
parasympathetic nervous system) also appears to be a promising avenue for increasing SSA.
Conclusion:Thisreviewsupportstheuseofcognitivemanipulationforincreasingwomen’sSSAinalaboratory
setting.Avenuesforfutureresearchandrecommendationsforcliniciansarediscussed.HandyAB,StantonAM,
Meston CM. Understanding Women’s Subjective Sexual Arousal Within the Laboratory: Definition,
Measurement, and Manipulation. Sex Med Rev 2018;XX:XXXeXXX.
Copyright (cid:1) 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Subjective Sexual Arousal; Sexual Arousal; Female Sexual Function
DEFINING SUBJECTIVE SEXUAL AROUSAL Feelingaroused,bothinthebodyandthemind,isanintegral
Subjective sexual arousal (SSA) has been defined as positive component of the sexual experience. Sexual arousal decreases
cognitiveengagementinresponsetoasexualstimulus,1suggesting sexual self-restraint6 and motivates individuals to engage in sex-
ual activity.7 In fact, feeling sexually aroused is one of the most
thatonemustbeimplicitlyorexplicitlyawareofasexualstimulus,
common reasons why men and women have sex. In a study of
which could be internal (eg, sexual thoughts) or external (eg, a
partner),inordertoexperienceSSA.SSAhasalsobeendefinedas over1,500undergraduatestudents,MestonandBuss7identified
the “emotional”2,3 or “cognitive”4,5 state of sexual arousal. These 237 unique reasons why men and women engage in sexual ac-
terms, as well as “psychological” or “mental” arousal, are used tivity; experiencing SSA (“I was horny”) was one of the top-10
most frequently cited reasons. It is also thought that increased
interchangeably in the literature and are thought to represent a
feeling of being “turned on” in one’s mind. SSAmayenhancepleasureandsatisfactionduringsexualactivity,
both of which are linked with engagement in future sexual
activity.8e10Conversely,chronicallyloworabsentSSAmaylead
toclinicallymeaningfuldistress.Giventhatsexualarousalcanact
as both a motivation for sexual activity and a potential cause of
ReceivedSeptember1,2017.AcceptedNovember20,2017.
distress, understanding how SSA has been manipulated in a
DepartmentofPsychology,UniversityofTexasatAustin,Austin,TX,USA
laboratory settinghas important clinicalimplications. Thus, this
Copyrightª2017,InternationalSocietyforSexualMedicine.Publishedby
review aims to examine laboratory-based measurement, analysis,
ElsevierInc.Allrightsreserved.
https://doi.org/10.1016/j.sxmr.2017.11.001 and manipulation of SSA.
SexMedRev 2017;-:1e16 1
2 Handyetal
MODELS OF SEXUAL AROUSAL AND RESPONSE THE OVERLAP OF SSA AND SEXUAL DESIRE
Masters and Johnson11 proposed the first highly cited model Researchers have debated the distinction between SSA and
of sexual response in 1966. In their model, sexual response is sexualdesire.Thoughdesire(alsoreferredtoassexualinterestor
divided into 4 linear phases: excitement, plateau, orgasm, and libido)isprimarilyconceptualizedasthemotivationtoengagein
resolution. Recognizing that these stages only addressed physio- a sexual activity,1 as opposed to the act of being engaged itself,
logical sexual arousal, Kaplan12 expanded this framework to thereisevidencetosuggestthatdesireandSSAmaybe2names
includesexualdesireasapreludetoexcitement,maintainingthe forthesameconstruct.Afterconductingaseriesoffocusgroups
originalmodel’slinearstructure.Withtheexpansionofsexuality aimed at exploring women’s qualitative experience of sexual
research in the late 20th century, researchers began to theorize arousal,Grahametal16reportedthatwomenfrequentlyusedthe
that the female sexual response cycle may not be limited to the terms “arousal” and “desire” interchangeably; women were also
specific phases outlined in the Kaplan12 and Masters and John- foundtousetheterm“arousal”todescribebothSSAandgenital
son11 models. Basson8 deviated from the linear models to arousal.Furthermore,participantsdescribedarousalanddesireas
establish a circular model of sexual response, which incorporates being difficult to separate from one another, leading Graham
both physiological (eg, genital arousal) and subjective (eg, SSA, et al16 to suggest that women may not differentiate between
satisfaction) components, as well as several additional factors, desire and arousal in the same manner as do researchers. It is
suchastheneedforintimacy.Ithasbeensuggestedthatwomen unclear,however,whetherallwomeninthesampleweresexually
with different levels of sexual function identify with different healthy or had any diagnosed sexual dysfunction; it is possible
models of the sexual response cycle. In a study by Sand and that a distinction between desire and arousal may be better
Fisher,13womenwereprovidedwithdescriptionsof3modelsof recognized by women based on their level of sexual function.
sexual response (those of Masters and Johnson,11 Kaplan,12 and
Parsingapartthese2constructsisalsocomplicatedbythehigh
Basson8), and they were instructed to endorse the model that
ratesofcomorbidityofdesireandarousaldysfunctioninwomen.
theyfeltbestdescribedtheirownsexual experiences.Thoughall
In 1 study of women diagnosed with hypoactive sexual desire
3 models were endorsed with equal frequency, the women who
disorder(HSDD),41%ofwomeninthesamplealsometcriteria
endorsed the Basson8 model had significantly lower levels of
for either an arousal (female sexual arousal disorder [FSAD]) or
sexualfunctionthanthewomenwhoendorsedeithertheMasters orgasm dysfunction, and 18% met criteria for all three.17 Sarin
and Johnson11 or the Kaplan12 models. Therefore, it is possible and colleagues18 reported similarly high rates of comorbidity;
thatsexualfunctionplaysaroleinwomen’sconceptualizationsof
53% of women (25 out of 47) in the sample with HSDD also
the sexual response cycle.
met diagnostic criteria for FSAD. Twenty-two women met
Several additional models expanding the understanding of diagnosticcriteriaforHSDDaloneand18metcriteriaforFSAD
women’ssexualresponsehavebeenproposed.Onesuchmodelis alone. It is important to note that women in the studies noted
the Incentive Motivation Model (IMM),14 which outlines the above were not grouped into the theoretical subtypes of FSAD
interconnectedness of subjective, affective, and physiological (ie, genital, subjective, and combined genital and subjective
aspects of sexual arousal. The IMM also describes how the re- arousal dysfunction19). Previous research has indicated that
lationships among these components may lead to sexual desire. examining women with heterogeneous FSAD masks potential
OneaspectoftheIMMthatmaybeparticularlyimportanttothe differences in sexual responding that become detectable when
experience of SSA is the inclusion of perceived genital arousal; grouping women by sybtype.20,21 Thus, it is possible that the
recognizing that one is physiologically aroused may influence overlap between desire and arousal disorders may have been
SSA.15 drivenbyasinglesubtype ofarousaldysfunction.Also,thehigh
comorbidity of low desire with low arousal does not necessarily
A second theoretical model that has expanded our conceptu-
alization of sexual response and sexual arousal specifically is the mean that desire and arousal dysfunction are one and the same.
Information Processing Model (IPM).4 The IPM suggests that, Many disorders co-occur yet are distinct. For example, the esti-
matedcomorbidityofdepressionandanxietyis50%,22yetthere
in order to experience sexual arousal, one must attend to a
is little disagreement that depression and anxiety are different
stimulus and appraise it as sexual. Sexual information can be
constructs.
processed bothimplicitly andexplicitly. Theimplicitpathway is
thoughttobeanunconsciousdetectionofasexualstimulusthat Recently, Althof and colleagues1 proposed additional lines of
triggers physiological changes (eg, lubrication), whereas the evidence suggesting that SSA and desire are indeed distinct. In
explicit pathway represents a conscious application of a sexual thisreview,Althofetal1discussedcorrelationsbetweenthedesire
meaning to a stimulus that can trigger SSA. Within this frame- and arousal domains of the Female Sexual Function Index.23
work, individuals learn to associate a sexual meaning with a Specifically, the authors noted that, while the correlation be-
sexualornon-sexualexperience.TheIPMisparticularlyrelevant tweenthese2domainsishigh(.76),23only58%ofthevariance
tothepresentreview,asitemphasizescognitiveprocessesandthe is shared. This suggests that, though there is overlap between
experience of SSA. desire andarousal, theydonotrepresent thesame entity.Althof
SexMedRev2017;-:1e16
Women’sSexualArousalWithintheLab 3
etal1alsoprovidedananalysisofSSAinwomenwithlowdesire, ThereareanalyticadvantagestocontinuousassessmentofSSA.
reasoningthatifarousalanddesirewerethesame,womenshould Statistically,morereliablemeasurementstendtobeobtainedfrom
score similarly on both Female Sexual Function Index domains. incorporatingagreaternumberofdatapointsintothemodel.SSA
This was not found to be the case. No differences in SSA has traditionally been analyzed with statistics that evaluate differ-
emerged between women with and without low desire, which ences in mean (or maximum) SSA from baseline to stimulus
further supports the notion that SSA and desire are separate. exposure. This form of analysis examines SSA as a single datum,
which compromises the statistical advantage of continuous assess-
ment and masks potential patterns in women’s arousal over time.
MEASURING SSA IN THE LABORATORY
Psychometrics
Stimuli Content and Modality Effects
In the laboratory, SSA is frequently assessed directly before
When SSA is assessed in a laboratory setting, participants are
andafterthepresentationofasexuallyexplicitfilm,thoughitcan
typicallyexposedtoasexuallyexplicitstimulusandareinstructed
also be measured continuously throughout stimulus exposure.
to report their level of SSA. To induce arousal, researchers have
OneofthemostcommonlyusedinstrumentsistheFilmScale,24
employedavarietyofstimulisuchasaudiorecordingsofsexually
a7-pointLikertscalethathasbeenadaptedbymanyresearchers.
explicit narratives, fantasy, sexually explicit images, and sexually
TheFilmScalehasbeenusedinover200sexualitystudiessince
explicit video. A limited number of studies have compared the
itsintroductionin1983,anditisfrequentlyadaptedtomeetthe
effectiveness of varying types of stimuli in facilitating SSA. One
needsofagivenstudy.Thoughthesechangesprecludetheuseof
such study examined the additive effects of exposure to visual
reliabilityorvaliditystatistics,theFilmScaleisthemeasurement
video (ie, a visual video without the accompanying audio track),
of choice for many researchers. A concern regarding the use of
audiovisualvideo(ie,avisualvideowiththeaccompanyingaudio
retrospective, discrete measures of SSA is that this form of
track), and fantasy on SSA in a sample of undergraduate stu-
measurement may capture one’s current, post-stimulus state dents.27 When comparing the effects of visual video against au-
rather than one’s arousal throughout the course of the film.
diovisual video, no differences in SSA emerged. However, when
Similarly, discrete measurement does not allow for the contem-
women were instructed to fantasize prior to watching the video,
poraneous comparison with physiological genital arousal, which ratingsofSSAweresignificantlyhigher,regardlessofwhetherthe
is critical for measuring concordance (ie, the relative agreement
video was visual or audiovisual in nature. This is not to say that
between genital arousal and SSA).
fantasyisamorepotentstimulusthanvideo;rather,thecombined
Researchers have attempted to improve the measurement of effects of fantasy and video was better at facilitating SSA than
SSA by using levers and other apparatuses, and by employing either medium alone. In a separate study comparing the inde-
statistical techniques that utilize multiple data points. One such pendent ability of sexual fantasy vs a sexually explicit video at
apparatus, termed the “arousometer,” has been found to be a inducing sexual arousal, Laan and colleagues28 found that the
valid measure of SSA in sexually functional women.25 Using sexually explicit video elicited greater levels of SSA than did fan-
continuous measures, SSA can be assessed at the same time as tasy. Similar effects were later reported by Graham et al.29 To
genital arousal and thus compared contemporaneously. further examine the impact of stimulus type on SSA, Laan and
associates30 examined women’s response to male- vs female-
Retrospective, discrete measurement has also been found to be
negativelyimpactedbyfeelingsofsocialdesirability(ie,impression produced sexually explicit films. In the study, women exhibited
management). In a study conducted by Huberman et al,26 when a significantly larger increase in SSA to female-produced sexually
explicit films than to male-produced films. A more recent study
SSA was measured discretely, women who scored low on impres-
sion management reported greater SSA than those with high examining the influence of male- vs female-produced sexually
explicitfilmsfailedtoreplicatethesefindings.31Inthisstudy,men
impression management, suggesting that women may have
modifiedtheirresponsestoconformtosocietalnorms.Continuous and women were shown a female-oriented film followed by a
assessment, on the other hand, is thought to better capture male- and female-oriented film in a counterbalanced order. No
participants’ state during stimulus exposure, thus leading to more effect of film or sex of the participant was found.
accurate reporting. Indeed, Huberman et al26 failed to find a sig- Researchers have also examined the effects of sexual stimuli
nificant effect of impression management on SSA when SSA was content,suchasrelationshipcharacteristics,sexualactivities,and
measured continuously. However, both discrete and continuous sexualorientations,onSSA(forareview,seeChivers32).Chivers
measures of SSA have effectively differentiated between women andTimmers33assessedwhetherthetypeofrelationshipbetween
withandwithoutsexualarousalconcerns.21Onestudyfoundthat, the characters within the stimulus impacts SSA. In their study,
regardless of how SSA was measured, women with sexual arousal participants listened to 3 audio recordings of sexually explicit
concernsreportedsignificantlylowerlevelsofSSAthandidsexually narratives depicting sexual activity between strangers, friends, or
functional women. This suggests that, though continuous long-term partners. Though genital arousal was lower in narra-
measurement may be less susceptible to impression management, tives depicting sexual activity between friends than between
the type of measurement may not impact the results. strangersorlong-termpartners,nodifferencesinSSAemerged.33
SexMedRev2017;-:1e16
4 Handyetal
SSAdoesdifferbasedonthetypeofsexualactivitydepictedin photoplethysmography (for a review of measurement techniques,
the sexually explicit stimulus. For example, women report see Kukkonen38). However, a limited number of studies have
significantly lower levels of SSA to audio recordings depicting examinedcorrelationsbetweenSSAandphysiologicalsexualarousal
non-consensualand/orviolentsexualactivitythantoconsensual, using these techniques. Thermographic cameras, which measure
non-violent sexual activity.34 Additionally, SSA has been shown changes in genital temperature rather than changes in blood flow,
to vary based on women’s interest in masochism.35 Women arebecomingincreasinglypopularinlaboratoryresearch,astheydo
interested in masochism showed similar levels of SSA to maso- notcomeintodirectphysicalcontactwiththegenitals.Theaverage
chistic and non-masochistic sex, whereas women who were not correlation between SSA and genital arousal measured through
interested in masochism reported significantly higher SSA to thermographic cameras is .55,2 which is notably greater than the
non-masochistic sex than to masochistic sex.35 correlations that are associated with VPA. These studies suggest
that the form of genital arousal measurement may have a greater
There also appearsto be an effectof sexual orientation on SSA
influence on concordance than the form of SSA measurement.
measured in the laboratory. Women with same-sex attraction
reportgreaterlevelsofSSAtosame-sexcouplesengaginginsexual
activity than to opposite-sex couples. This does not appear to be
AN OVERVIEW OF LABORATORY-BASED STUDIES
the case for women with opposite-sex attraction; these women
MANIPULATING SSA
demonstrate similar levels of SSA to films depicting same-sex
couples and films depicting opposite-sex couples. A recent review Given the clinical importance of SSA, we sought to review
by Chivers32 explores this phenomenon, positing explanations for waysinwhichSSAhasbeenmanipulatedinalaboratorysetting.
these differences that range from sexual plasticity to protective A comprehensive search was conducted of the electronic data-
evolutionary mechanisms to in utero androgen exposure. bases of PubMed and PsycINFO for papers focusing specifically
on laboratory-based experiments aimed at altering SSA in
women. Combinations of the following terms were used to
THE RELATIONSHIP BETWEEN SSA AND search the databases: “subjective,” “mental,” “cognitive,” “psy-
PHYSIOLOGICAL SEXUAL AROUSAL chological,” “emotional,” “sexual,” and “arousal.” No date range
A considerable amount of research on sexual arousal has was specified to allow for the inclusion of as many studies as
examined the concordance between physiological arousal (eg, possible. Additional searches by hand were conducted. Results
vaginal pulse amplitude [VPA]) and SSA. Concordance is deter- from the searches were compiled (N ¼ 1,617) and duplicates
mined by correlating VPA with SSA; greater concordance is were removed (remaining n ¼ 1,235). The first 2 researchers
generally thought to be indicative of healthy sexual function.36 reviewed the titles and abstracts of the remaining articles and
Research has posited that concordance may vary greatly from removed articles that clearly did not pertain to laboratory-based
womantowoman,andthatconcordancemayalsodifferbasedon SSA manipulation (eg, correlational studies, non-laboratory-
the method of measuring SSA. Rellini and colleagues25 found based clinical trials, prevalence studies, psychometric evalua-
significant correlations between continuously measured SSA and tions). The full texts of the remaining articles (remaining
VPAin16outof22ofthewomenintheirsample,witharangeof n¼141)werereviewedandassessedforeligibility.Studieswere
r ¼ .08e.79. When examining the individual correlations of eligible for inclusion if they: (i) were published in peer-reviewed
discretelymeasuredSSAandVPAinthesamesampleofwomen, journals; (ii) were published in English; (iii) presented original
no significant correlations emerged. Others, however, have sug- findings; (iv) included women; and (v) measured and explicitly
gested that measurement may not play a large a role in concor- manipulated SSA in a laboratory setting. While there were
dance. A meta-analysis indicated that correlations between SSA numerous studies that measured SSA, several used the term
andVPAaregenerallylow,regardlessofwhetherSSAismeasured “subjective sexual arousal” to describe perceived genital arousal;
discretely (r ¼ .29) or continuously (r ¼ .30).2 Researchers have therefore, they were excluded. Ultimately, 44 studies remained
attemptedtoexplainthesediscrepanciesinconcordanceinseveral and were included in this review.
ways. For example, it has been hypothesized that women’s atti- Manipulationstudieswere groupedinto3primarycategories:
tudes toward sex and sexual stimuli, cultural messages women pharmacological, cognitive, and those based on changes to the
receive to inhibit sexuality, and an inability to perceive genital autonomic nervous system (ANS). Pharmacological studies
responses mayplay a role in concordance. However, research has (n ¼ 16) included studies examining the effects of drugs (eg,
largely failed to support these hypotheses.30,37 sildenafilcitrate),alcohol,orhormones(eg,testosterone)onSSA.
Alternatively,thevariabilityinconcordanceratescouldberelated Cognitive studies (n ¼ 22) examined the effects of mood
to the way in which genital arousal is measured. In addition to induction, conditioning, cognitive engagement, and other psy-
vaginal photoplethysmography, genital arousal can be measured chological manipulations. Finally, ANS-based studies (n ¼ 6)
through labial thermistors, thermographic cameras, ultrasound, frequently attempted to manipulate SSA through hyperventila-
magnetic resonance imaging, laser Doppler imaging, and clitoral tion or exercise.
SexMedRev2017;-:1e16
S Table 1. Asummaryofeachstudyinwhichthe primarymanipulation waspharmacologicalinnature W
e
x o
M Erotic FormofSSA TimeofSSA m
edR Year Authors Population Sample size Manipulation stimulus measurement measurement SSAanalysis Results ens’
ev2 2003 Bassonand Post-menopausal, 34Womenwith Sildenafilcitrate(50mg) Filmwithclitoral Questionnaire Pre-andpost- Unitcomparison* Noeffectofsildenafilcitrate Sex
017;- Brotto39 community FSAD ostrimplualcuesb;o1hpriorto stimulation stimulus onSSA ualA
:1e counterbalanced ro
16 2016 Brometal40 Pre-menopausal, 58Women Haloperidol(3mg)or Images Questionnaire Pre-andpost- Unitcomparison* Noeffectofhaloperidolon usa
l
community placebopill,withor stimulus SSA W
withoutgenital it
h
vibrostimulation; in
counterbalanced th
2017 Dolderetal41 Pre-menopausal, 12Women,12 MDMA(125mg), None Questionnaire Pre-andpost- Unitcomparison* Significant,positiveeffect eL
collegestudents men methylphenidate manipulation ofMDMAonSSA ab
(60mg),orplacebo comparedtoplacebo
2009 Georgeetal42 Pre-menopausal, E1:59women,56 E1:lowalcoholdose Film;vignette Questionnaire Post-stimulus; Unitcomparison* E1:SSAsignificantlygreater
communityand men;E2:165 (BAL¼0.04), pre-vignette inthemoderate-high
collegestudents men;E3:173 moderate-highdose doseconditioncompared
women (BAL¼0.08),or tocontrol;E2:SSA
control;E2andE3: significantlygreaterin
moderatedose thehigh-dosegroup
(BAL¼0.06), thaninanyothergroup;
moderate-highdose E3:significanteffectof
(BAL¼0.08),high alcoholonSSA,
dose(BAL¼0.10),or regardlessofcondition
control
2011 Georgeetal43 Pre-menopausal, E1:78women;E2: E1:alcohol(BAL¼0.08) Film Questionnaire Post-stimulus Differencescores† NoeffectofalcoholonSSA
community 74women orcontrol;E2:alcohol
(BAL¼0.10)or
control
2000 Grahametal29 Pre-menopausal, 28Women Female,male,orno Film;fantasy Questionnaire Pre-andpost- Unitcomparison* Noeffectoffragranceon
community fragrance,tested stimulus SSA
duringperiovularand
follicularphases;
counterbalanced
2002 Hackbertand Post-menopausal, 16Women DHEA(300mg)or Film Questionnaire Pre-andpost- Unitcomparison* Significant,positiveeffect
Heiman44 community placebo60minbefore stimulus ofDHEAonSSA
watchingfilm;
counterbalanced
2008 Harteand Pre-menopausal, 25Women Nicotine(6mg)or Film Lever Continuous Unitcomparison* NoeffectofnicotineonSSA
Meston45 communityand placebogum40min
collegestudents beforewatchingfilm;
counterbalanced
2007 Heard-Davison Post-menopausal, 10Women Methyltestosterone(5 Film Questionnaire Pre-andpost- Differencescores† Noeffectof
etal46 community mg)orplacebo; stimulus methyltestosteroneon
counterbalanced SSA
(continued)
5
Table1.Continued 6
Erotic FormofSSA TimeofSSA
Year Authors Population Sample size Manipulation stimulus measurement measurement SSAanalysis Results
2002 Laanetal47 Pre-menopausal, 12Women Sildenafilcitrate(50mg) Film Questionnaire Post-stimulus Unitcomparison* Noeffectofsildenafilcitrate
collegestudents orplacebo; onSSA
counterbalanced
1998 Mestonand Pre-menopausal, 20Women Ephedrine(50mg)or Film Questionnaire Post-stimulus Unitcomparison* Noeffectofephedrineon
Heiman48 communityand placebo40minbefore SSA
collegestudents watchingfilm;
counterbalanced
2002 Mestonand Post-menopausal, 23Womenwith L-arginineglutamate(6 Film Questionnaire Pre-andpost- Unitcomparison* Noeffectofanydrugon
Worcel49 community FSAD g)plusyohimbineHCl stimulus SSA
(6mg),L-arginine
glutamateplacebo(6
g)plusyohimbineHCl
(6mg),orplacebo;
counterbalanced
2015 Schmidetal50 Pre-menopausal, 15Women,15 MDMA(75mg), Images Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect
collegestudents men methylphenidate(40 ofmethylphenidateon
mg),orplacebo SSAcomparedtoMDMA
orplacebo
2000 Sipskietal51 Pre-menopausal 19Womenwith Sildenafil(50mg)or Film Verballyonascale Continuous Unitcomparison* Significant,positiveeffect
SCI placebo1hbefore from0e10 ofsildenafilonSSA,
stimulus,withor regardlessofclitoral
withoutclitoral stimulation
stimulation;
counterbalanced
2000 Tuitenetal53 Pre-menopausal, 8Women Testosterone(0.5mg)or Film Visualanalogscale Post-stimulus Unitcomparison* Noeffectoftestosteroneon
collegestudents placebo; SSA
counterbalanced
2002 Tuitenetal52 Pre-menopausal, 10Women Testosterone(0.5mg)or Film Visualanalogscale Post-stimulus Unitcomparison* Noeffectoftestosteroneon
collegestudents placebo; SSA
counterbalanced
BAL¼bloodalcohollevel;DHEA¼dehydroepiandrosterone;E¼experiment;FSAD¼femalesexualarousaldisorder;HCl¼hydrochloride;MDMA¼3,4-methylenedioxymethamphetamine;SCI¼spinal
cordinjury;SSA¼subjectivesexualarousal.
Allwomenweresexuallyfunctionalunlessotherwisespecified.
*Compared2timepointsofSSA.
†Post-stimulusSSAminuspre-stimulusSSA.
S
e
x
M
e
d
R
e
v
2 H
0 a
17;- ndy
:1e et
16 al
Table 2.Asummaryofeachstudythatemployedaprimarilycognitive manipulation
Se Erotic FormofSSA TimeofSSA W
x o
M Year Authors Population Samplesize Manipulation stimulus measurement measurement SSAanalysis Results m
ed en
R 2011 Bothetal56 Pre-menopausal, 32Women Classicalconditioningin Images Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect s’
ev communityand responsetoneutral ofCSþonSSA;no Se
2 x
0 collegestudents images(CS)paired extinctionofdifferential u
17;- withgenital responsetoCSþand alA
:1e vibrostimulation(þ) CSe ro
16 ornothing(e) us
a
2011 Bothetal57 Pre-menopausal, 47Women,37 Instructionalset:imagine Film Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect l
W
communityand men yourselfasoneofthe ofthe“hot”conditionon it
collegestudents actors(“hot”),focus SSA,regardlessof hin
onthesetting gender t
h
(“cold”),orno e
L
instructions a
b
2014 Brometal58 Pre-menopausal, 62Women,40 Classicalconditioningin Images Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect
communityand men responsetoneutral ofCSþonSSA,
college images(CS)paired regardlessofgender;
withgenital significantrevival
vibrostimulation(þ)
ornothing(e)
2015 Brometal59 Pre-menopausal, 34Women,38 Classicalconditioningin Images Questionnaire Post-stimulus Unitcomparison* Comparedtomen,women
communityand men responsetoimages reportedsignificantly
collegestudents (CS)followedby lessSSAfollowingCSþ
shock(þ)ornoshock thanCSe
(e)
2013 Carvalhoetal60 Community 28Women,29 Instructionalset: Film Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect
men fantasizeaboutyour offantasizingabout
partnerorfantasize one’spartneronSSA,
aboutsomeonewho regardlessofgender
isn’tyourpartner;
counterbalanced
1997 Elliottand Pre-menopausal 48Women Inducedanxietyor Audio Questionnaire Post-stimulus Unitcomparison* SSAwassignificantlyhigher
O’Donohue61 control,random inthenodistraction
assignment;no,low, conditioncomparedto
orhighdistraction, loworhigh,regardlessof
counterbalanced whetheranxietywas
induced
2007 Gillathetal62 Pre-menopausal, 23Women,17 Subliminalsexualimages Images Questionnaire Post-stimulus Unitcomparison* Significant,negativeeffect
collegestudents men followedbyneutral ofsubliminalsexual
images stimulionSSAfor
womenonly
2006 Kuffeland Pre-menopausal, 56Women Positiveornegative Film Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect
Heiman63 communityand sexualschema ofpositivecomparedto
collegestudents induction; negativeschemaonSSA
counterbalanced
(continued)
7
Table 2.Continued 8
Erotic FormofSSA TimeofSSA
Year Authors Population Samplesize Manipulation stimulus measurement measurement SSAanalysis Results
1993 Laanetal64 Collegestudents 49Women Instructionalset:become Film;fantasy Questionnaire;lever Pre-andpost- Unitcomparison* Significant,positiveeffect
asarousedaspossible stimulus; ofbeingtoldtobecome
orfocusonyour continuous arousedonSSA
pleasure;
counterbalanced
1995 Laanand Pre-menopausal, E1:32women;E2: E1:10trialsofthesame S1:images;S2: Lever Continuous Unitcomparison* E1:significant,positive
Everaerd65 collegestudents 42women imagefollowedby1 film effectofvariedimages
novelimageor11 onSSA;E2:marginal,
variedimages;E2:21 positiveeffectofvaried
uniformfilmsor21 filmsonSSA
variedfilms
1995 Laanetal28 Pre-menopausal 51Women Induced"positivemood Film,fantasy Questionnaire Pre-andpost- Unitcomparison* Noeffectofmoodinduction
forsex"orcontrol; stimulus onSSA
randomassignment
1997 Letourneauand Pre-menopausal, 25Women Classicalconditioningin Film Questionnaire Pre-andpost- Unitcomparison* Noeffectofconditioningon
O’Donohue66 collegestudents responsetoamber stimulus SSA
incandescentlight
pairedwithorwithout
eroticfilmclips
2007 McCalland Community 15FSAD,16 False-positiveorfalse- Film Questionnaire Pre-andpost- Differencescores† SSAwassignificantly
Meston67 control negativefeedback; stimulus greaterfollowingfalse-
counterbalanced positiveandlower
followingfalse-negative
feedback,regardlessof
sexualfunctioning
1985 Messéand Communityand 30Women Kegelexercisesorcontrol Fantasy Questionnaire Post-stimulus Unitcomparison* Fantasyplustensingelicited
Geer68 collegestudents significantlygreaterSSA
thantensingalone
2008 Middleton Pre-menopausal, 17FSAD,17 Positiveornegative Film Questionnaire Post-stimulus Unitcomparison* Significant,positiveeffect
etal69 community control sexualschema ofpositivecomparedto
induction; negativeschemaon
counterbalanced SSA,regardlessofsexual
function
1990 Palaceand Communityand 16withSexual Anxiety-provokingor Film Questionnaire Post-stimulus Unitcomparison* Significant,negativeeffect
Gorzalka70 collegestudents dysfunction,16 neutralfilm; oftheanxiety-eroticfilm
control counterbalanced onSSA,regardlessof
sexualfunction
S 2006 Saleminkand Pre-menopausal, 20Womenwith Low,medium,high Film Lever Continuous Differencescores† SSAwassignificantlylower
e
x Van communityand sexual distractionorcontrol; inhighdistraction
M
e Lankveld71 collegestudents dysfunction,21 counterbalanced comparedtocontrol;no
d
R control effectformoderate
ev distractions,regardless
20 ofsexualfunction Ha
17;- (continued) ndy
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16 al
Women’sSexualArousalWithintheLab 9
Pharmacological Studies
m A
Results fiSignicant,positiveeffectofbodyawarenessonSSAfiSignicant,positiveeffect’ofpicturingonesselffiwithapartnerinthelonSSA fiSignicant,negativeeffectoftheStrooptestonSSAfiSignicant,negativeeffectofacutedistressonSS fiSignicant,negativeeffectofsadcomparedtohappymoodonSSA usal. lsisefanettnuubcchOtdodlsuariinveedaoesstceorfidyantrhliyg3lei,-an0lbtdeatfetahfsmdheesescdigrsesteispgsroonehedffdviaofiirtedmechpwesaehhanacytindrondmroeldruotfoaifggceeciaacpocotptailesnoalps.ngemOSidtachSraranoanAltesit.tpao4edsp4urtepolubahAnrdtyeoideyodadcnrrifiohnootioeebvuopsfeunn,is2Ssadat9tnSil,g3Adaa9rsrte.euoisOnsp5esi3tgapgefrnorcottoirhhhnfitneelceynaf1enoofi65r-stt
SSAanalysis †Differencescores Unitcomparison* Unitcomparison* Unitcomparison* Unitcomparison* subjectivesexualaro amwMSpdSoaemeAsttitcht.hih5inyvy0ilienlespltgnyIhenereadencdisotoiehdrxxriays4eutmle0aasltelteytudwmhdeaayxgmsw,ppliit3ochhaf0iletstoaSfimcmSlomAelifltnoe,.h5eguy4Ientl(pdMwthshteaDuunstdsMoifdeonsaAuuttsens)pi,,gdpn(oo1tr7irhfi5t5paicntalawgnmcmotelmbgyethtoheisnyopinl)frprciehorws3ereuean,4tlrsitoee--.
¼
TimeofSSAmeasurement Pre-andpost-stimulus Post-stimulus Continuous Post-stimulus Pre-andpost-manipulation;post-stimulus session2;SSA doderefraafpttepeelci,lcthaacwawteedabadssaoi.lansiinlHgsakonoeliwadfifotceeuawvrnneisrdttth,uipfndoioynrascicatrloielavcnateoesdrheeudofscftletuSecodSdtnAyow,.nS4iMS1tShASDAi,nA4M2stchiAgtoehnm,osinfiaupmocagatrhenemdtlt,ahetbioftsoahcrMywialltpiaDotsharMteynin.no4Aig3-t
¼
2 Three studies assessed the impact of sildenafil on SSA with
S
FormofSSAmeasurement Questionnaire Questionnaire Verbalscale Questionnaire Questionnaire ¼S1session1; msmmtuigexdneoyodf.psraielIudsnsueanllttashwfi;ilaosomsricgeponnluaifincwecteibatrnohbtapselrapfinfoiencrcaettldoocwfosasrtitdulcddheiyinnn,jagufipralya)swretiaxrcseuicpafeolailnuyvetnesddxpei(ln1iitc9hiotenrfipllymr5e10-.
y; Duringthefilm,halfofthewomenreceivedclitoralstimulation.It
Eroticstimulus Film Film Clitoralstimulation Film Film pinalcordinjur wtswuilahddseeintnfhoaaelufi,rnlracdonlnittdohSoraSmatAliszsiieltndidmewcnuolailmnfiatilecionasinlgwtnrwiiitafihalcsfsaapneiilmtneldyaplltioconoycfierrddnea.di5sn1eajduHsriSygoS.n5wAi5fieTcvraeehnrgi,atsraesduflflgeeosgcnsetgsootis-ff
s
Manipulation Bodyawarenessorcontrol;counterbalancedInstructionalset:pictureyourselfwithapartnerfiinthelmorevaluatefithelm;randomassignmentDistractionviatheStrooptestorcontrol Acutepsychologicaldistressorcontrol;randomassignmentHappyorsadmoodinduction;counterbalanced ¼alarousaldisorder;SCI OtsmwhheoitanatrtTihtimen,naitngkpowaenoiafhnnoteielerallndetebwotvoiasgeoaritelllma4dtht6eheoe,ox5ennrpm2rya,,lw5fiaes3tneli)htwtahtmmetihinsoaaefipgynynn,innddpfwaooirrlnourotcgmgdbtos-hueeirncidnfssredtoircaunomgrocjneanueigdrncitlnyhlysup,esahrtisienheyolmesanissStooeteSuilrdsoeAedfgttifnohieeicsancaawtttlussoauctrmmhhaglleagaaenbesynsesgoa’tntsermtsoaiStnttph(SogealbAreg.tyes.,,
mplesize WomenwithFSAD Women WomenwithSCI,10control Women Women ¼femalesexuficied. iwatnhnecedrleusodtovuefeddraiaeilnvslaptrinhiheicytslysuircdeoaveflideahwgeienaswltahtehnr.eidsIthhreieastvdepireoovwagssr,eiynbiaenlneogduthlsetavhitneeltsnhlaaoectfukhsreeetox.efurPoaralgerepftnuilcineciipcatattyiinoootnnsf
Sa 21 62 10 59 32 ADspe studies (only 3 drugs were assessed in more than 1 study), could
Population Community Communityandcollegestudents Community Pre-menopausal Pre-menopausal,community ¼s;Eexperiment;FSonalunlessotherwiseofSSA.spre-stimulusSSA. ebfhtsohaneatravcibtseesfepaamotcsmtfyteaiScrpsohSklsneoAeu,dli,octmeihpgndiaaocyrtwfaaeolcnhhrvtitaeawcivrarhieoilsamtecbaifaclfesesesen,sctrtnswfosuoonoicrntgmhfh-edparShrsoSuiamnfAgrflms-omurooaeeanldcnano,tScileapeoSdtugAtoelic.acnnotaItintlioaociinnsenw,rta,neoloSsrsmovrS.eASracneneotlea’nimsotcTineeeoaasxinvbspmsualehebrraieli1pye--
Table2.Continued YearAuthors 2007Sealand76Meston 2009Sheenand72Koukounas 731996Sipskietal 742007terKuileetal 752010terKuileetal ¼CSconditionedstimuluAllwomensexuallyfuncti*Compared2timepoints†Post-stimulusSSAminu CmpfohOreaHmnrGtma,NlfaoacInfoToafllcIoyVotgshgiiEscne,ailatSsintmvTudeadUnrimeeDilpseaIuvEnilanaiSnpctitluourlndae.tseiudolntsi.n2o8f,t5he6iaesc7hr6esvtTiuehdweyetmhmaoptsletomycepodlmoysmoedmonea
SexMedRev2017;-:1e16
10
Table 3.Asummaryofeachstudyinwhichtheprimarymanipulation involvedchanges totheautonomicnervoussystem
Erotic FormofSSA TimeofSSA
Year Authors Population Samplesize Manipulation stimulus measurement measurement SSAanalysis Results
2002 Brottoand Community 25Youngpre- Hyperventilation Film Questionnaire Pre-andpost- Differencescores* Noeffectof
Gorzalka77 menopausal, (2-minrapid stimulus hyperventilation
21oldpre- breathing)or onSSA,
menopausal, control; regardlessofage
25post- counterbalanced
menopausal
women
2009 Brottoetal78 Community 16Womenwith Hyperventilation Film Questionnaire Pre-andpost- Differencescores* Noeffectof
genitalSAD,16 (2-minrapid stimulus hyperventilation
withsubjective breathing)or onSSA,
SAD,28with control; regardlessof
combined counterbalanced sexualfunction
SAD,42
control
2008 Hamiltonetal80 Pre-menopausal, 16Women 20minofExerciseor Film Questionnaire Pre-andpost- Differencescores* Noeffectofexercise
community 20minof stimulus onSSA
questionnaires;
counterbalanced
2012 Lorenzand Pre-menopausal, 32Womentaking 20-minExercise,wait Film Questionnaire Pre-andpost- Differencescores* Noeffectofexercise
Meston79 community SSRIs,15 5min;20-min stimulus ortimeuntil
takingSNRIs exercise,wait15 stimulus
min;20minof exposureon
questionnaires; SSA,regardless
counterbalanced ofantidepressant
use
2017 Stantonand Pre-menopausal, 33Women 14minofAutogenic Film Questionnaire; Post-stimulus; Unitcomparison†; Significant,positive
Meston82 collegestudents training lever continuous HLM effectof
autogenic
trainingonSSA
2018 Stantonetal87 Pre-menopausal, 25Women 22minofAutogenic Film Questionnaire; Post-stimulus; Unitcomparison†; Significant,positive
community training lever continuous HLM effectof
autogenic
trainingonSSA
HLM¼hierarchicallinearmodeling;SAD¼sexualarousaldisorder;SNRI¼serotonin-norepinephrinereuptakeinhibitor;SSA¼subjectivesexualarousal;SSRI¼selectiveserotoninreuptakeinhibitor.
Allwomenweresexuallyfunctionalunlessotherwisespecified.
*Post-stimulusSSAminuspre-stimulusSSA.
Se †Compared2timepointsofSSA.
x
M
e
d
R
e
v
2 H
0 a
17;- ndy
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16 al