In 2017, I was the Scientific Program Committee Chair for the International Society for the Study of Women’s Sexual Health. This was my welcome message to attendees:
The field of female sexuality is approaching a critical turning point in its evolution. We are positioned to explore, question, and potentially redefine the traditional sexual constructs we have inherited, as these ideas do not capture the broad spectrum of sexuality we encounter in the streets, in the clinic, in the lab, or in our homes. This freedom is both exhilarating and terrifying. We are entering one of the most exciting periods of change in modern sexology. Every step forward is a small revolution.
Looking back, we have come a long way from Masters and Johnson’s groundbreaking work that both buoyed and to some degree restricted the field’s evolution. As Helen Singer Kaplan aptly summarized in 1974, “The human sexual response is a highly rational and orderly sequence of physiological events, the object of which is to prepare the bodies of two mates for reproductive union.” Masters and Johnson certainly constructed a rational and orderly sexual gestalt. Their biomechanical model of sexual response (excitement, arousal, plateau, orgasm, and satiety) was based on a narrow definition of the ultimate form of sexual expression: genital arousal with vaginal penetration leading to orgasm. This focus is precisely why the classic reductionist model has failed to account for the broad range of sexual variability we observe in women. In the words of the late philosopher Robert Solomon, “Orgasm is the ‘end’ of sexual activity, perhaps, but only in the sense that swallowing is the ‘end’ of tasting a Viennese torte.”
Ironically, the pivotal events that would challenge the Masters and Johnson monolith began with the vaginal insertion of phallic diodes designed to measure vasocongestion.
In a series of female sexual psychophysiology (mind-body) experiments conducted in the 1990s, pioneering researchers in the Netherlands and North America performed a series of laboratory experiments in which women viewed erotic film clips after self-inserting a vaginal photoplethysmograph, a term for a device that measures light-derived (photo) increases (plethysmos) of fluid with a recording (graph) used to measure genital vasocongestion. These researchers reported that women exhibited varying levels of awareness of their genital sexual arousal, yet this awareness appeared to be unrelated to their subjective experience of arousal and sexual functioning (Rosen and Beck noted this discordance as early as 1988). These controversial findings have since been replicated across numerous international laboratories, using multiple methods to measure sexual desire, subjective sexual arousal and genital sexual arousal. After more than two decades of experimentation, intensive debate, proposals of new models, and many discarded erotic films, deciphering the mind-body interaction remains at the crux of understanding female sexual health and dysfunction. Critically, Masters and Johnson’s terminology and early data have been used to parse these constructs and to validate their accuracy.
An Embodied Mind
At present, there is universal agreement that a woman’s perception of desire, subjective and genital arousal, orgasm, and distress are the gold standards for validating new measures of function/dysfunction. A woman’s subjective perception depends on her relationship with her body, and every woman has a different relationship with her body. The Embodied Mind will be the new standard against which the field’s success is judged. However, we acknowledge the need to refine the definitions of these constructs with empirically-based information that can, in turn, inform expert consensus-based terminology in the future.
Also inherent in the embodied mind is an understanding of how the body impacts consciousness and how information is iteratively shared between the peripheral and central nervous systems. This requires the identification and validation of more accurate and precise physiological indicators of sexual desire, arousal, orgasm, and the many states in between. Ultimately, a woman’s embodied mind is the product of her biology, psychology, and social relationships and must be approached from a biopsychosocial perspective.
The Adapting Brain
With each sexual experience, a woman learns about her capacity for sexual pleasure. This process has been conceptualized as a delicate balance of excitatory and inhibitory factors stemming from her cognitive-emotional state, her history of sexual interactions, appreciation of erogenous sensory input, and a gamut of contextual, interpersonal, and existential considerations. The culmination of this learning results in a personalized sexual script, represented in the brain as a network of memories that can be adapted over time, between partners, and according to new sexual experiences. The changes in brain activity and anatomy that accompany and facilitate these adaptations are collectively called neuroplasticity. The main principle underlying neuroplasticity is surprisingly simple: brain activity and anatomy are shaped by the memories you use most often.
Memories can reflect movement, habits, reward, beliefs, sensory experiences, even conditioned immune responses. Therefore, it is fair to say that every individual who attends this meeting—regardless of discipline—interacts with and treats memories. Although strong, maladaptive memories are difficult to change, the mere fact that we understand how they can be changed is nothing short of amazing. The power of these ideas is their immense potential to transform our research, science, and clinical practice, as we will understand why therapeutic change happens and what can be done to facilitate that change.
Defining Female Sexuality
A woman’s body is her instrument in the world: it supports her actions, helps her pursue her goals, unites her with loved ones, brings her pleasure, propels her away from danger, and helps her bear and nourish new life. Sexuality can subtly pervade (and be invaded by) the rest of her life. Therefore female sexuality cannot be defined as a distinct construct; female sexuality is being-in-the-world.