Our current understanding of the female sexual response emerges from a ongoing dialogue between mind and body. These conversations between mind and body play essential roles in both mediating and disrupting sexual function. The classical assumptions that guided sexual science for many years is the idea that changes in genital physiology should directly reflect a woman’s subjective sexual desire and arousal. The foundations of these assumptions have slowly eroded as female sexuality researchers have used stronger study designs and more precise technologies to measure proxies of mind and body.
The scientific and clinical fallout has been enormous. These findings have lead to multiple revisions diagnostic criteria for sexual dysfunction, clinical guidelines for the management of sexual dysfunction, and even the very definitions of these constructs, desire and arousal. For example, this lack of knowledge inspired controversial changes in the DSM-5 criteria for sexual dysfunction related to desire, arousal, and pain. In response, serious ideological chasms have divided the field of female sex research. This is not a theoretical exercise. These decisions determine the diagnostic coding of sexual dysfunctions used by insurance companies to cover treatment (or not). These decisions influence clinical phenotyping that is used to divide women into groups so that we can better understand the nature of these processes. These decisions impact how the FDA measures treatment efficacy as new pharmacological compounds are developed to treat female sexual dysfunction. These decisions influence how experts explain sexuality to women, and by extension, how women understand their own sexuality.
Our limited understanding of human sexual function has broad scientific consequences. The truth is that we lack sufficient knowledge of physiological changes that lead to and sustain desire, arousal, orgasm, and pain. Forty years of research has overwhelmingly focused on the early stages of sexual response: sexual desire (the subjective component of sexual response) and sexual arousal (the genital component of sexual response). The formal study of this subjective/genital relationship is female sexual psychophysiology. The goal of sexual psychophysiology research is to identify the emergent interactions between genital and subjective arousal, usually in response to visual, auditory, or olfactory stimuli that researchers have deemed sufficiently “erotic.” One of the biggest strengths of researchers in this subfield is that they have continually questioned their own theoretical and clinical assumptions along the way. Their interest lies in discovering what IS, not what SHOULD BE true about female sexuality. As a result, there as been an active resistance to the oversimplification of female sexuality. And to be fair, a large faction of clinicians and researchers argue that these studies have already reduced female sexuality to its biomechanical, socially prescribed parts. An upcoming blog post will tackle that conflict, so let’s move on.
Men know when they are aroused. They have highly reliable visual indicators that tell them about their arousal. Women’s genitals are hidden from view. Religio-cultural beliefs do not encourage girls or young women to acknowledge or attend to their genitals, and young women learn that their monthly “curse” must be sanitized, hidden, and even suffered through if they experience painful menstrual cramps. Perhaps it comes as no surprise that there is little concordance between subjective and physiological sexual arousal.* What does that mean? It means that female sexual arousal does not show predictable linear increases with progressively more intense sexual stimuli, as it does in men. It means that women report varying levels of awareness of physiological sexual arousal, and this awareness appears to be unrelated to sexual functioning and sexual behavior (1). This finding has been replicated using multiple technologies, study designs, analysis methods, across international laboratories. It means that women may approach sexual information in a very different way. As Ellen Laan so eloquently stated: “Thus a stimulus is not intrinsically sexual, it becomes sexual by its transformation…” (2)
So let’s break this process down.
Contemporary models of female sexual response describe an initial subjective shift from neutrality to sexual desire as a woman recognizes sexual stimuli in her environment (3). If a woman is aware of this perceptual shift, she may ask herself, “Is it appropriate to get aroused right now?” If a woman then decides it is safe and appropriate to focus on her sexual cues (note that safe and appropriate are absolutely relative!), a incremental increase in both arousal and desire will emerge (4). If a woman is unaware of this shift, her thoughts, emotions, and behaviors may be implicitly biased toward or against sexual cues, depending on her sexual history (5). Once desire and arousal begin to build to a perceivable level, they depend on attention to the sexual cue (“Sex…or laundry? Ugh I forgot to cancel my Amazon Prime membership…”) (6), positive appraisal of the sexual cue (“I wonder what those smiling lips could do…?”), the desire to approach this sexual cue (“Wheeeeere is my rabbit?”), degree of physiological arousal (7), and of course experiential engagement (8). Sexual desire encompasses the psychological and the behavioral aspects of this process, and sexual arousal consists of the body’s concurrent response and a woman’s subjective awareness of her body’s response to the sexual cue.
Yes, we are splitting hairs with this definition of sexual arousal. A woman may not be aware of increased vaginal lubrication, but she may perceive tingling or warm sensations. Consider Laan and Everaerd (2), who found that women’s cognitive appraisals of erotic stimuli predicted changes in subjective sexual arousal. In contrast, cognitive appraisal explain less variability in the degree of genital arousal. The implication is that a stimulus explicitly evaluated as “sexual” may evoke a genital response that doesn’t really influence a woman’s perception of her own sexual arousal. Given that clinical relevance and efficacy is determined by patient-reported outcomes, a woman’s perception of her sexual arousal is more important than the arousal itself (9).
This is assuming that our measure of genital arousal is valid. Sexual psychophysiology research has capitalized on the use of effective erotic stimuli to maximize physiological arousal in laboratory analog settings. Erotic stimuli are judged to be effective if they produce corresponding increases in both physiological sexual arousal and self-reports of subjective arousal. However, if physiological arousal does not imply the presence of subjective arousal, we are unable to progress to the next levels of scientific questioning.
A large subset of women whose genital arousal tracks closely with their subjective perception, but we have yet to identify physiological differences to explain this. My interpretation of the data is that a strong learned component mediates the mind/body synchrony in women with high concordance (“Practice makes perfect!”).