Abstract
Despite more than a century of research on sexual dysfunction, there has been limited attention to ethical concerns. This is problematic because sex research involves complex ethical ...questions that generate confusion for ethics review and have not been addressed by ethical guidelines. We analyze two questions. First, does sexual content raise the risk profile of a research protocol? We argue that there is nothing inherent in sexual content that makes a study high risk and that many sexual dysfunction studies involve no more than minimal risk. Second, we ask whether research interventions that involve seeing participants undressed or having physical contact with a research subject are permissible? We argue that these interventions raise an important ethical challenge—they often involve sexual dysfunction researchers engaging in interventions that would not be conducted in their standard practice. To resolve this, we propose an expertise‐based account of the permissibility of sexual dysfunction research.
Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and ...the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders
as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered.
Vaginal spasm has been considered the defining diagnostic characteristic of vaginismus for approximately 150 years. This remarkable consensus, based primarily on expert clinical opinion, is preserved ...in the DSM-IV-TR. The available empirical research, however, does not support this definition nor does it support the validity of the DSM-IV-TR distinction between vaginismus and dyspareunia. The small body of research concerning other possible ways or methods of diagnosing vaginismus is critically reviewed. Based on this review, it is proposed that the diagnoses of vaginismus and dyspareunia be collapsed into a single diagnostic entity called “genito-pelvic pain/penetration disorder.” This diagnostic category is defined according to the following five dimensions: percentage success of vaginal penetration; pain with vaginal penetration; fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; pelvic floor muscle dysfunction; medical co-morbidity.
Research indicates that desire and arousal problems are highly interrelated in women. Therefore, hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD) were removed from ...the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and a new diagnostic category, female sexual interest/arousal disorder (FSIAD), was created to include both arousal and desire difficulties. However, no research has tried to distinguish these problems based on psychosocial-physiological patterns to identify whether unique profiles exist. This study compared psychosocial-physiological patterns in a community sample of 84 women meeting DSM-IV (American Psychiatric Association,
2000
) criteria for HSDD (n = 22), FSAD (n = 18), both disorders (FSAD/HSDD; n = 25), and healthy controls (n = 19). Women completed self-report measures and watched neutral and erotic films while genital arousal (GA) and subjective arousal (SA) were measured. Results indicated that GA increased equally for all groups during the erotic condition, whereas women with HSDD and FSAD/HSDD reported less SA than controls or FSAD women. Women in the clinical groups also showed lower concordance and greater impairment on psychosocial variables as compared to controls, with women with FSAD/HSDD showing lowest functioning. Results have important implications for the classification and treatment of these difficulties.
The DSM-IV-TR attempted to create a unitary category of dyspareunia based on the criterion of genital pain that interfered with sexual intercourse. This classificatory emphasis of interference with ...intercourse is reviewed and evaluated from both theoretical and empirical points of view. Neither of these points of view was found to support the notion of dyspareunia as a unitary disorder or its inclusion in the DSM-V as a sexual dysfunction. It seems highly likely that there are different syndromes of dyspareunia and that what is currently termed “superficial dyspareunia” cannot be differentiated reliably from vaginismus. It is proposed that the diagnoses of vaginismus and dyspareunia be collapsed into a single diagnostic entity called genito-pelvic pain/penetration disorder. This diagnostic category is defined according to five dimensions: percentage success of vaginal penetration; pain with vaginal penetration; fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; pelvic floor muscle dysfunction; medical co-morbidity.
Pelvic floor muscle (PFM) dysfunctions are reported to be involved in provoked vestibulodynia (PVD). Although heightened PFM tone has been suggested, the relative contribution of active and passive ...components of tone remains misunderstood. Likewise, alterations in PFM contractility have been scarcely studied.
To compare PFM tone, including the relative contribution of its active and passive components, and muscular contractility in women with PVD and asymptomatic controls.
Fifty-six asymptomatic women and 56 women with PVD participated in the study. The PVD diagnosis was confirmed by a gynecologist based on a standardized examination.
PFM function was evaluated using a dynamometric speculum combined with surface electromyography (EMG). PFM general tone was evaluated in static conditions at different vaginal apertures and during repeated dynamic cyclic stretching. The active contribution of tone was characterized using the ratio between EMG in a static position and during stretching and the proportion of women presenting PFM activation during stretching. Contribution of the passive component was evaluated using resting forces, stiffness, and hysteresis in women sustaining a negligible EMG signal during stretching. PFM contractility, such as strength, speed of contraction, coordination, and endurance, also was assessed during voluntary isometric efforts.
Greater PFM resting forces and stiffness were found in women with PVD compared with controls, indicating an increased general tone. An increased active component also was found in women with PVD because they presented a superior EMG ratio, and a larger proportion of them presented PFM activation during stretching. Higher passive properties also were found in women with PVD. Women with PVD also showed decreased strength, speed of contraction, coordination, and endurance compared with controls.
Findings provide further evidence of the contribution of PFM alterations in the etiology of PVD. These alterations should be assessed to provide patient-centered targeted treatment options.
The use of a validated tool investigating PFM alterations constitutes a strength of this study. However, the study design does not allow the determination of the sequence of events in which these muscle alterations occurred-before or after the onset of PVD.
Findings support the involvement of active and passive components of PFM tone and an altered PFM contractility in women with PVD. Morin M, Binik YM, Bourbonnais D, et al. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med 2017;14:592-600.
Women's Sexual Pain Disorders Van Lankveld, Jacques J.D.M.; Granot, Michal; Weijmar Schultz, Willibrord C.M. ...
Journal of sexual medicine,
January 2010, 2010-01, 2010-Jan, 2010-01-01, 20100101, 2010, Letnik:
7, Številka:
1pt2
Journal Article
Recenzirano
Women's sexual pain disorders include dyspareunia and vaginismus and there is need for state-of-the-art information in this area.
To update the scientific evidence published in 2004, from the 2nd ...International Consultation on Sexual Medicine pertaining to the diagnosis and treatment of women's sexual pain disorders.
An expert committee, invited from six countries by the 3rd International Consultation, was comprised of eight researchers and clinicians from biological and social science disciplines, for the purpose of reviewing and grading the scientific evidence on nosology, etiology, diagnosis, and treatment of women's sexual pain disorders.
Expert opinion was based on grading of evidence-based medical literature, extensive internal committee discussion, public presentation, and debate.
A comprehensive assessment of medical, sexual, and psychosocial history is recommended for diagnosis and management. Indications for general and focused pelvic genital examination are identified. Evidence-based recommendations for assessment of women's sexual pain disorders are reviewed. An evidence-based approach to management of these disorders is provided.
Continued efforts are warranted to conduct research and scientific reporting on the optimal assessment and management of women's sexual pain disorders, including multidisciplinary approaches. van Lankveld JJDM, Granot M, Weijmar Schultz WCM, Binik YM, Wesselmann U, Pukall CF, Bohm-Starke N, and Achtrari C. Women's sexual pain disorders.
Provoked vestibulodynia, the most common form of vulvodynia (unexplained pain of the vulva), is a prevalent, idiopathic pain disorder associated with a history of recurrent candidiasis (yeast ...infections). It is characterized by vulvar allodynia (painful hypersensitivity to touch) and hyperinnervation. We tested whether repeated, localized exposure of the vulva to a common fungal pathogen can lead to the development of chronic pain. A subset of female mice subjected to recurrent Candida albicans infection developed mechanical allodynia localized to the vulva. The mice with allodynia also exhibited hyperinnervation with peptidergic nociceptor and sympathetic fibers (as indicated by increased protein gene product 9.5, calcitonin gene-related peptide, and vesicular monoamine transporter 2 immunoreactivity in the vaginal epithelium). Long-lasting behavioral allodynia in a subset of mice was also observed after a single, extended Candida infection, as well as after repeated vulvar (but not hind paw) inflammation induced with zymosan, a mixture of fungal antigens. The hypersensitivity and hyperinnervation were both present at least 3 weeks after the resolution of infection and inflammation. Our data show that infection can cause persistent pain long after its resolution and that recurrent yeast infection replicates important features of human provoked vulvodynia in the mouse.
Despite much theorizing about the interchangeability of desire and arousal, research has yet to identify whether men with desire vs. arousal disorders can be differentiated based on their ...psychophysiological patterns of arousal. Additionally, little research has examined the relationship between subjective (SA) and genital arousal (GA) in sexually dysfunctional men.
To compare patterns of SA and GA in a community sample of men meeting DSM‐IV‐TR criteria for hypoactive sexual desire disorder (HSDD), erectile dysfunction (ED), both HSDD and ED (ED/HSDD), and healthy controls.
Seventy‐one men (19 controls, 13 HSDD, 19 ED, 20 ED/HSDD) completed self‐report measures and watched two 15‐minute film clips (neutral and erotic), while GA and SA were measured both continuously and discretely.
Groups were compared on genital temperature (as an indicator of GA), SA, and psychosocial variables (i.e., body image, emotion regulation, sexual attitudes, sexual inhibition/excitation, mood, and trauma).
Genital temperature increased for all groups during the erotic condition, yet men with ED and ED/HSDD showed less GA than men without erectile difficulties. All groups increased in SA during the erotic condition, yet ED/HSDD men reported less SA than controls or ED men. SA and GA were highly correlated for controls, and less strongly correlated for clinical groups; men with ED showed low agreement between SA and GA. Groups also differed on body image, sexual inhibition/excitation, sexual attitudes and alexithymia.
Low desire vs. arousal sufferers have unique patterns of response, with those with both difficulties showing greatest impairment. Results have important implications for the diagnosis and treatment of these disorders. Sarin S, Amsel R, and Binik YM. How hot is he? A psychophysiological and psychosocial examination of the arousal patterns of sexually functional and dysfunctional men. J Sex Med 2014;11:1725–1740.
It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by ...methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias.
The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain‐free methodology, transperineal four‐dimensional (4D) ultrasound.
Fifty‐one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction.
Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data.
Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control.
Using a reliable and pain‐free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength. Morin M, Bergeron S, Khalifé S, Mayrand M‐H, and Binik YM. Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using 4D ultrasound. J Sex Med 2014;11:776–785.
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