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nonpsychiatric physicians (one gynecologist, one genitourinary sexual medicine specialist, one general practitioner, and two urologists) are now contributors. This reflects the continuing influence and importance of sexual medicine. Among the mental health professionals contributing to this volume, the vast majority are clinical psychologists, whereas only two are psychiatrists. Perhaps this reflects a lessening of interest in sex therapy among psychiatrists. For some topics, it proved very difficult to find a lead author who was both a seasoned clinician and a researcher. In such cases, we played matchmaker and linked a nonclinical researcher with a clinician. The results were excellent. We are worried, however, about the growing divergence between clinicians and researchers. Our goal in this volume was to integrate up-to-date research with clinical practice. This goal is achievable only if training programs and professionals insist on both.

One continuing trend is the internationalization of sex therapy. In this edition, there are authors from Belgium, Canada, England, the Netherlands, Israel, and the United States. We expect this trend to continue and expect that future editions will include contributors from non-Western countries. It is interesting that the single largest group of authors is Canadian. It appears that Canada, a country with a population of approximately 35 million people, has become a major center for sex therapy and research.

In the concluding chapter, "Sex Therapy in Transition: Are We There Yet?, " Meana, Binik, and Hall have brought into focus some of the basic issues that are raised in many of the individual chapters and that concern the field as a whole. Perhaps the central question is whether the concept of sexual dysfunction is still valid or useful. The authors of DSM-5 have punted on this issue by declining to define the concept of sexual dysfunction. Many classification gurus believe that the ultimate basis of classification is mechanism; unfortunately, we are nowhere close to understanding the mechanisms of most sexual dysfunctions. Other gurus believe that sexual dysfunctions are social constructions not easily classifiable by traditional methods. It seems likely to us that neither mechanism nor construction can currently deal with the phenomena of sexual dysfunction and that a combined classificatory approach is the next stage.

Meana and colleagues also raise important issues concerning the future relationship between sex therapy and sexual medicine, about the influence of the DSM diagnostic manuals, and about the pressing need for treatment outcome evaluation. In the final chapter, as in this introduction, we exhort readers, novices and seasoned practitioners alike, to continue questioning and challenging assumptions about the nature of sexual problems and, most important, to continue to develop and refine treatments. Sex therapy began as a challenge to psychotherapy, which had woefully neglected sexuality.

We think the future of our field depends on the very attitude that ushered sex therapy into existence. We are pleased to offer this edition of Principles and Practice of Sex Therapy as a guidepost along the way of what has been, and what we hope will continue to be, an amazing journey.

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**REFERENCES**

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.).

Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Binik, Y. M. (2010a). The DSM diagnostic criteria for dyspareunia. Archives of Sexual Behavior, 39(2), 278–291.

Binik, Y. M. (2010b). The DSM diagnostic criteria for vaginismus. Archives of Sexual Behavior, 39(2), 292–303.

Binik, Y. M., & Meana, M. (2009). The future of sex therapy: Specialization or marginalization? Archives of Sexual Behavior, 38(6), 1016–1027.

Brotto, L. A. (2010). The DSM diagnostic criteria for sexual aversion disorder. Archives of Sexual Behavior, 39(2), 271–277.

Clayton, A. H., Derogatis, L. R., Rosen, R. C., & Pyke, R. (2012). Intended or unintended consequences? The likely implications of raising the bar for sexual dysfunction diagnosis in the proposed DSM-V revisions: I. For women with incomplete loss of desire or sexual receptivity. Journal of Sexual Medicine, 9(8), 2027–2039.

Davis, S. N., Binik, Y. M., & Carrier, S. (2009). Sexual dysfunction and pelvic pain in men: A male sexual pain disorder? Journal of Sex and Marital Therapy, 35(3), 182–205.

Heiman, J. R. (2002). Psychologic treatments for female sexual dysfunction: Are they effective and do we need them? Archives of Sexual Behavior, 31(5), 445–450.

Kaplan, H. S. (1987). Sexual aversion, sexual phobias, and panic disorder. New York: Brunner/Mazel.

Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago: University of Chicago Press.

Leiblum, S. R., & Rosen, R. C. (Eds.). (1980). Principles and practice of sex therapy (1st ed.). New York: Guilford Press.

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**PART I**

**SEX THERAPY FOR SEXUAL DYSFUNCTION**

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**Desire and Arousal**

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**CHAPTER 1**

Sexual Interest/Arousal Disorder in Women

Lori Brotto and Mijal Luria

**B** rotto and Luria say, "A lack of interest in sexual activity that creates personal distress and strains relationship satisfaction is the most common reason that women seek sex therapy." And yet as Brotto and Luria point out, this seemingly straightforward problem is actually complex and resistant to treatment. The search for the elusive "cure" ultimately led to a renewed interest in research regarding the nature of female sexual desire and has resulted in a major reformulation of the diagnosis. Sexual interest arousal disorder (SIAD) is a new DSM-5 sexual dysfunction that merges the DSM-IV dysfunctions of hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD). The DSM-5 committee (of which Brotto was a member) noted that women often present clinically with both low sexual desire and diminished capacity for sexual arousal. Citing long-standing concerns about the adequacy of Masters and Johnson's triphasic and gender-neutral model of sexual response, the DSM-5

committee turned instead to the empirically based incentive motivation model, in which biological, psychological, and contextual factors interact to elicit sexual interest, as well as sexual arousal. The fact that no such diagnostic change was proposed for male HSDD reflects the growing divergence in theoretical conceptualizations between male and female sexuality. An important therapeutic implication of the new diagnosis and underlying model is that effective treatment of SIAD will often involve medication, individual or conjoint sex, therapy or some combination thereof.

**Lori Brotto, PhD,** is Head of the Division of Gynaecologic Specialties at the University of British Columbia, Associate Professor of Gynaecology and Psychiatry, and a Registered Psychologist in the province of British Columbia. Her research focuses on developing and testing mindfulness-based interventions for women with sexual difficulties and genital pain. Dr. Brotto is Associate Editor for the Archives of Sexual Behavior and Sexual and Relationship Therapy. She was a member of the Sexual and Gender Identity Disorders work group for DSM-5.

**Mijal Luria, MD,** is the Director of the Center for Sexual Health at the Hadassah Mt. Scopus Medical Center in Jerusalem, Israel, where she is an attending obstetrician–gynecologist and sex therapist. She was a member of the committee on Women's Sexual Desire and Arousal Disorders during the Third International Consultation on Sexual Medicine held in Paris in 2009. She is a board member of the International Society for the Study of Women's Sexual Health.

A lack of interest in sexual activity that creates personal distress and strains relationship satisfaction is the most common reason that women seek sex therapy. Described frequently by patients as "I've lost my libido," or "It takes a long time for me to get sexually excited," or "I would be content if we never had sex again!" the presence of little or no desire for sex has received widespread attention from clinicians, researchers, and the lay public because of its complexity and relative resistance to treatment. A new disorder, sexual interest/arousal disorder (SIAD), has been included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) to replace hypoactive sexual desire disorder (HSDD) and female sexual arousal disorder (FSAD) from the DSM-IV-TR (American Psychiatric 26

Association, 2000) due to long-standing dissatisfaction with HSDD and FSAD. In particular, criticisms have included the following: (1) HSDD and FSAD rely on Masters and Johnson's (1966) linear sexual response cycle, which may not fit the experiences of all women; (2) the frequency and intensity of desire for sex is only one aspect of how women describe their experience of sexual desire (or lack thereof); (3) reliance on sexual fantasies as an indicator of sexual desire is problematic because many women with satisfactory levels of desire report not having sexual fantasies; (4) "persistent and recurrent" are ambiguously interpreted in the DSM-IV-TR criteria; and (5) the use of the term "hypoactive" in HSDD is misleading, as it implies an underlying biological etiology to low sexual desire (Brotto, 2010; Graham, 2010) that is usually impossible to conclude in the clinical scenario. The following vignette illustrates a typical case of female SIAD.

Miranda presented for sex therapy with the primary complaint of "I don't feel any sexual excitement any longer." Upon being asked by her therapist, she revealed that she rarely thought about sex with her partner, although she continued to have sexual intercourse on a weekly basis. She did not initiate sexual activity, and she only reluctantly accepted her partner's sexual solicitations for fear of losing the relationship.

Sexual touching elicited few, if any, positive sexual sensations, and she was minimally aware of vaginal lubrication. On most occasions of sexual activity, the encounter ended with her feeling physically and emotionally dissatisfied; however, on a few occasions she was able to become somewhat sexually aroused in her mind. These problems had existed for the past 5 years and had led Miranda to withdraw emotionally from her 15-year relationship.

The criteria for SIAD are polythetic and require that a woman experience a minimum of three symptoms for at least 6 months. Possible manifestations of SIAD

include: lack of interest in sexual activity; reduced or absent erotic thoughts; lack of initiation and receptivity to sexual activity; reduced pleasure during sex; reduced or absent desire emerging during a sexual encounter; and a reduction in genital and nongenital sexual sensations. The criteria hinge upon a conceptualization of sexual interest/arousal that emphasizes its responsive nature. In other words, because some women may not experience desire for sex at the outset of sexual activity but are able to become sexually responsive during the sexual encounter (Carvalheira, Brotto, & Leal, 2010), a diagnosis of "dysfunction" is inappropriate for those women with the sole complaint of low or absent sexual desire before or at the start of a sexual encounter. The latter group may present for treatment on the basis of a dissatisfied partner who mourns her loss of innate sexual desire or because a woman herself believes that desire should be felt often and independent of potential inhibitory or excitatory forces. For example, Sarah (age 32, married) in the past experienced spontaneous sexual desire and a very robust sexual arousal response until the birth of her third child, when she experienced a marked decline in the frequency of sexual urges. She continued, however, to become sexually aroused and orgasmic during sexual activity, particularly if she was well rested, and this triggered responsive desire during the encounter. Sarah would not, in our view, meet criteria for SIAD.

The use of "persistent and recurrent" in previous editions of the DSM has also been 27

criticized due to its lack of objectivity in defining a sexual dysfunction and for the potential to overpathologize normal variations in sexual experience or behavior. Not all individuals seeking sex therapy have a diagnosable sexual dysfunction, and some, perhaps even many, require education and information to challenge sex-related myths.

Thus the criteria for SIAD require symptoms to be present for a minimum duration of 6

months. Some of the symptoms must have been present in all or almost all (approximately 75%) sexual encounters to rule out common normative variations in sexual interest (which may be adaptive to the particular context). As in the case of Miranda, it is the repeated experience of sexual interest/arousal concerns over a prolonged period of time that signal the likely presence of SIAD.

The introduction of polythetic criteria means that two women with different symptom expressions may both meet criteria for SIAD. For example, Mary may lack interest in sexual activity, have no erotic or sexual thoughts, and reject her partner's sexual invitations. Barbara, on the other hand, may have great difficulty becoming mentally sexually excited, have a reduced sexual desire response during sexual activity, and lack signs of physical sexual arousal. Because they experience three of six symptoms for 6 months or longer, both Mary and Barbara would meet SIAD criteria. The advantages of a polythetic system (with SIAD) over DSM-IV-TR's monothetic criteria (with HSDD) are that (1) it addresses the finding that sexual behavior alone is an unreliable referent for sexual desire; (2) it acknowledges that sexual response difficulties may be expressed differently across different women; (3) it expands the narrow focus on lubrication as a sole indicator of sexual arousal; and (4) it seeks to depathologize normal variations (and reductions) in sexual response by requiring that symptoms occur on most sexual encounters for a minimum duration of 6 months.

**EPIDEMIOLOGY**

Given that SIAD is a new disorder in DSM-5, its prevalence is unknown (for a review of prevalence studies, see Brotto, 2010, and Graham, 2010). Focusing on the symptom of

"lack of interest in sex" for the preceding month, the second wave of the British National Survey of Sexual Attitudes and Lifestyles (NATSAL) found a prevalence of 40.6% among women ages 16–44 (Mercer, Fenton, Johnson, Wellings, Macdowall, et al. (2003).

However, when a more stringent 6-month duration of symptoms was used, this figure dropped to 10.2%. This figure was also found in the more recent Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking (PRESIDE) study (Shifren, Monz, Russo, Segreti, & Johannes, 2008). Because less than 28% of sexual difficulties with a 1-month duration persist for 6 months or more (Hayes, Bennett, Fairley, & Dennerstein, 2006), only persisting symptoms of low sexual interest should be considered to fulfill a diagnosis of SIAD. Multinational studies find higher rates of low sexual interest in Middle East and Southeast Asian countries (Laumann, Nicolosi, Glasser, Paik, Gingell, et al., 2005), emphasizing the importance of cultural sensitivity when assessing sexual interest and arousal.

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A diagnosis of SIAD requires the presence of clinically significant distress and it is usually distress that brings women in for treatment. There is evidence from the Women's International Study of Health and Sexuality (WISHeS) that low desire is more distressing for younger as compared with older, menopausal women, challenging the view that low desire becomes more prevalent with age.

Even considering the drop in prevalence when low desire and distress together are experienced over several months, loss of sexual interest continues to be the most frequent complaint seen in sex therapy clinics, and the majority of women with any sexual difficulty (i.e., desire, arousal, orgasm, or pain-related) believe that their low sexual desire is the cause of their sexual difficulties (Hayes et al., 2006).

Women with SIAD may also experience a reduction in or absence of genital and/or nongenital sensations during sexual activity; however, the prevalence of this symptom is unknown, because past studies assessing FSAD have tended to focus on lack of lubrication, which ranges in prevalence from 2.6% to 31.2% (Graham, 2010). When a composite measure of arousal that included feeling aroused during sex, having pleasant tingling in genitals, and enjoying genitals being touched was assessed, the prevalence over the past month was 12.2%.

In the clinical scenario, women often report difficulties with both sexual interest and capacity for sexual arousal. For example, Brynne had a long history of dry vulvar tissue, some pain with penetration, and great difficulty reaching orgasm. Despite these concerns, she continued to have interest in sex and would masturbate once per week.

However, as her health deteriorated over time and necessitated the use of a cocktail of medications, her sleep became disrupted, her mood dropped, and she and her partner began to have increasing relational discord. Brynne's motivation for sex precipitously declined, which further hampered her ability to become sexually aroused. Brynne's situation is not unique. In fact, several studies have found a high degree of comorbidity between HSDD and FSAD, and desire and arousal scores using validated instruments are usually highly correlated (see Brotto, Graham, Binik, Segraves, & Zucker, 2011, for a review). A central tenet of the incentive motivation model for sexual response is that sexual desire and sexual arousal emerge together, in response to effective sexual cues.

Sexual desire and sexual arousal may even represent different sides of the same sexual coin.

**ETIOLOGY AND MODELS**

The incentive motivation model of sexual response, which arose from a large number of elegant Dutch studies, provides an integrative model in which biological, psychological, and contextual factors interact to elicit sexual interest and arousal (see Laan & Both, 2008, for a review). It posits that sexual desire results from an interplay between a sexual response system and effective stimuli that activate this system (Toates, 2009). Early views (Kaplan, 1977, 1979; Lief, 1977) likened sexual desire to other drive states, such as hunger and thirst, which were based on the premise that these appetitive reactions 29

originated from within an individual and progressively increased with time and that, once satiated, an individual could continue on for a period of time before the desire started to build again. However, this conceptualization does not mirror what patients report clinically. They lament the loss of touch that once triggered an electrifying arousal response or the desire for sex that was cultivated during a close dance with an attractive partner. In comparison with former linear models of sexual response, the incentive motivation model fits the experiences of women with and without sexual concerns because it emphasizes the important role of real or imaginary stimuli that trigger motivation and response. Within such a framework, sexual desire and sexual arousal are seen as simultaneous responses to a sexually relevant stimulus (i.e., a stimulus that the individual perceives as being sufficiently sexual) and are, therefore, not distinct constructs. This model places a heavy emphasis on the role of stimuli. However, within incentive motivation theory, stimuli become effective only in the context of a system that allows for sexual responsiveness. Biological and psychological factors can influence the responsiveness of the sexual system, as well as the effectiveness of sexual stimuli to elicit sexual response; thus an evaluation of biological, psychological, and sociocultural influences must form a part of a thorough assessment of SIAD.

Basson (2002a, 2002b), took the empirical findings from incentive motivation theory and applied them clinically to formulate a circular model of sexual response that has gained widespread interest. The model notes that women begin sexual encounters for any variety of sexual or nonsexual reasons and that awareness of any innate feelings of desire may be absent for women (note that although Basson originally conceptualized her model as applying to both men and women, in recent years scholars have applied it mostly to understanding women). During a sexual encounter, if a woman experiences some sexual arousal and excitement, this then triggers "responsive sexual desire"—a desire for the sexual activity to continue for now more sexual reasons, in addition to whatever initial incentives were present. If the outcome is rewarding (emotionally and/or physically), she might have more motivation to initiate or respond to cues in the future. Women with and without sexual difficulties often relate to this experience of

"responsive desire" more than any initial awareness of sexual desire (Carvalheira et al., 2010; Goldhammer & McCabe, 2011), and they sometimes report relief when a clinician normalizes their lessening sexual desire that comes about with age and relationship duration. Interestingly, even among women who reported high levels of sexual arousal, the majority (85%) reported that they at least occasionally began a sexual encounter with no desire but then experienced responsive desire as sex progressed (Carvalheira et al., 2010).

**Hormones, Neurotransmitters, and Medical Factors Affecting Sexual**

**Response**

Hormones may affect the responsivity of the sexual system and therefore should be considered in the woman with SIAD, both at the time of assessment and as treatment unfolds. In the context of a mental health practice, it may be necessary for 30

multidisciplinary medical colleagues (e.g., primary care physician, gynecologist, endocrinologist) to play a role. Steroid hormones activate mechanisms of sexual excitation by directing the synthesis of enzymes and receptors for several neurochemical systems (Kruger, Hartmann, & Schedlowski, 2005; Pfaus, 2009). Those include dopamine, norepinephrine, melanocortin, and oxytocin systems.

The most abundant and potent hormone before menopause is 17ß-estradiol (known

as "estradiol"; E2), produced by the granulosa cells of the ovaries. After menopause, estrogen is produced in extragonadal intracellular sites in small amounts. In a number of studies using varying methodologies (assessment at diverse menopausal transition stages, different study designs and questionnaires), a weak correlation between lower levels of estradiol and decreased sexual desire has been found by some (Freeman et al., 2007; Guthrie, Dennerstein, Taffe, Lehert, & Burger, 2004) but not by others (Avis, Stellato, Crawford, Johannes, & Longcope, 2000; Tungphaisal, Chandeying, Sutthijumroon, Krisanapan, & Udomratn, 1991); thus measurement of serum estradiol is not helpful for diagnosing a woman with low sexual desire. Nevertheless, an adequate level of estradiol is important for maintaining vaginal lubrication and avoiding dyspareunia (Guthrie et al., 2004; Sarrel, 1990).

Androgen levels peak when women are in their 20s and drop gradually with age, so that women in their 40s have approximately half the level of circulating total testosterone as women in their 20s. Despite long-held popular beliefs, population-based studies have shown minimal or no correlation between testosterone levels and sexual desire in women (Davis, Davison, Donath, & Bell, 2005; Guthrie et al., 2004; Santoro et al., 2005). The lack of accuracy of current assays to measure testosterone is a well-known limitation because most clinically available assays are designed to measure testosterone in the male range or to identify hyperandrogenic states in women (Davis, Guay, Shifren,

& Mazer, 2004). Because of the intracrinology of sex hormones, measuring androgen metabolites might identify cases of true androgen deficiency and differentiate women who will benefit from therapy from those who will not, but to date even these approaches have not been useful clinically for identifying women with a sexual desire disorder (Basson, Brotto, Petkau, & Labrie, 2010). Another confounding factor is the great variability in the responsiveness of women to androgens. For example, there are contradictory findings on the effects of the oral contraceptive pill, which increases the concentration of sex-hormone-binding globulin (SHBG), thereby lessening the bioavailable testosterone, on sexual interest (Burrows, Basha, & Goldstein, 2012). It is possible that polymorphic variations in the androgen receptor gene may also influence women's responses to androgens.

Dopamine is considered to be the major neurotransmitter involved in sexual arousal, due to its actions in mesolimbic and hypothalamic circuits. Some women given dopaminergic drugs such as bupropion or apomorphine have reported increased sexual desire and response (Caruso et al., 2004), though these agents are usually not used clinically to boost sexual motivation. There was much promise for flibanserin, a 5-hydroxytryptophan 1A (5-HT1A) receptor agonist, 5-HT2A receptor antagonist, and dopamine D4 receptor partial agonist in the treatment of loss of sexual desire (Goldfischer et al., 2011); however, it was not approved by the Food and Drug 31

Administration (FDA) and therefore remains unavailable clinically. Much is unknown about the role of neurosteroids (i.e., steroids synthesized de novo within the brain) in mediating sexual interest in women, but they are speculated to play a role in sexual motivation. Clinically, it is, at present, impossible to directly measure neurosteroid levels.

Although progesterone receptors are found in many of the same brain areas as estrogen receptors, including the hypothalamus and the limbic system, there are few data on its effects on human sexual behavior. There is some evidence in humans that synthetic progestins may have negative effects on sexual desire (Sherwin, 1999).

Medical conditions affecting the circulatory, endocrine, musculoskeletal, and central nervous systems are important to take into account in the presence of sexual interest and arousal complaints. However, their impact on sexual response may be indirect and illustrate the biopsychosocial complexity of SIAD. For example, whereas cancer treatment may stop ovarian function and contribute to vaginal stenosis, dryness, and pain, the impact of cancer on sexual self-esteem and body image may exert even greater negative effects on sexual motivation.

Taken together, it is important that the clinician be mindful of the myriad medical and organic contributors to SIAD, yet not become blindsided by their presence to the exclusion of other important relational and psychological factors.

**Relational Aspects**

The link between sexual function and relationship well-being has been repeatedly confirmed. Sexual problems might be both the cause and the result of unsatisfactory relationships. The woman who lacks motivation for sexual contact as a result of her low emotional intimacy, trust, or respect toward her partner is unfortunately a very common finding in the clinical scenario. A woman's feelings for her partner are a major determinant of her sexual desire, above and beyond any hormonal contributors (Dennerstein, Dudley, & Burger, 2001; Guthrie et al., 2004).

Formalization of the relationship can also influence sexual desire: feelings of love, security, partner support, commitment, and emotional closeness are less likely to lead to sexual desire by married women than by single women (McCall & Meston, 2006). In married women, feelings of institutionalization of the relationship, overfamiliarity, and desexualization of roles can dampen sexual desire (Sims & Meana, 2010). Relationship experts, such as Perel (2006), argue that in cultivating security, stability, love, and commitment, a couple is at risk of losing the very ingredients that fuel their eroticism (e.g., passion, danger, the unknown). In the clinical scenario, a therapist must therefore balance concerns about a woman's complaints of loss of motivation for once highly passionate and erotic sex in the context of her now 10-year relationship. Specific partner-related attributes can also affect her sexual desire, including a partner with a high sexual interest who asks for (or even demands) sex with minimal efforts to elicit her sexual response; a partner with poor sexual technique or particularly rigid sexual beliefs about sexual technique; a partner with sexual needs that the woman believes she 32

cannot satisfy; and a partner to whom the woman is not attracted (Witting et al., 2008).

His sexual dysfunction can also adversely affect her interest in sex, and improvement in his sexual function can simultaneously increase hers. Within an incentive motivation model, partner factors that influence the range and intensity of stimuli used and the woman's response to those cues become an important focus in the clinical scenario.

**Mood**

Along with relationship factors, mood is a major correlate of women's sexual health.

Mood instability, low self-esteem, and having an introverted personality style have been associated with decreased sexual interest and may all influence the responsivity of the sexual system. Having depression significantly increases the odds of having low sexual interest by at least twofold among women ages 40–80 (Laumann et al., 2005), and loss of sexual desire is common in major depressive disorder (MDD), which is defined by a

"loss of interest or pleasure." Sexual dysfunction secondary to antidepressant therapy is also well documented though such complaints tend to focus more on orgasmic functioning and not sexual desire. In the case of Leslie, a 24-year-old single female student who became severely depressed following the unexpected death of her mother, her lack of motivation to masturbate would not warrant a diagnosis of SIAD, even though this represents a marked reduction from her previous frequency of two to three times a week. If the low sexual interest/arousal is attributable to a nonsexual psychiatric disorder (such as MDD in Leslie's case), then the clinician would not apply a diagnosis of SIAD.

**Sociocultural Influences**

Sexuality has always been subject to the influence of social constructs. Negative messages about masturbation in girls and the view of women as passive recipients of men's sexual desires and actions may encourage a passive attitude to sexual activity and inhibit their sexual interest (Boul, Hallam-Jones, & Wylie, 2009). In the last 10 years a different theoretical framework, the "new view of women's sexual problems" (Tiefer, 2001; Tiefer, Hall, & Tavris, 2002), has emerged in response to the medicalization of sexual difficulties that may have been perpetuated by previous DSMs and by pharmaceutical interests. The new view stresses the importance of social factors as a cause of women's sexual avoidance or distress and deemphasizes the focus on hormonal and/or biological factors. Inadequate sex education, failure to meet cultural norms concerning sexual attractiveness or sexual response, fatigue due to family and work obligations, or conflict between the sexual norms of culture of origin and those of the dominant culture may be at the heart of many sexual problems (Tiefer et al., 2002) and therefore deserve attention clinically.

Another important sociocultural influence on women's sexual desire concerns ethnicity. Cross-cultural studies find markedly disparate rates of low desire depending 33

on a woman's ethnic background (Cain et al., 2003; Laumann et al., 2005), and certain variables, such as sex guilt and religiosity, mediate the association between a woman's culture and her level of sexual desire (Woo, Brotto, & Gorzalka, 2011; Woo, Morshedian, Brotto, & Gorzalka, 2012). In the absence of qualitative data on how women from various ethnocultural groups experience sexual motivation, however, one must be cautious in assuming that a lack of motivation for sex is a necessary sign of a sexual dysfunction among ethnic minority women. There is much we do not know about the triggers of desire and arousal across cultures and whether a loss of sexual response is experienced as distressing. If ethnocultural factors do have an impact on sexual response, their mechanism of influence may include a biological propensity of the sexual system, as well as responses to sexual cues that are influenced by nonbiological factors.

**Assessment/Treatment Algorithm**

We have devised an assessment/treatment algorithm useful in guiding the clinician (Figure 1.1). In evaluating the criteria for SIAD, the clinician must inquire about both frequency and intensity of sexual interest, fantasies/erotic thoughts, pleasure during sex, and physical sensations. The rationale stems from the finding that some women may identify more with how often they do (or do not) experience sexual interest/arousal, whereas other women may recognize changes in the intensity of their response. The range of sexual stimuli that might elicit a woman's sexual interest and arousal should also be explored, along with her current and past responses to such stimuli given that women with low desire have a more restricted range of effective stimuli that elicit their desire (McCall & Meston, 2006). The clinician should also assess typical patterns of initiation between the couple, given that a woman's lack of initiating sexual activity may not necessarily point to a problem with her sexual motivation as men, in general, are more likely to initiate sex (Baumeister, Catanese, & Vohs, 2001).

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**FIGURE 1.1** **.** Assessment and treatment algorithm. After initial assessment, if medical problems are found, further medical examination and treatment are warranted. If psychological or couple issues are first detected, the client may benefit from treatment focusing on cognitive processing, mindfulness skills, and behavioral changes. In some cases, couple therapy is needed. Psychoeducation is imperative to overcome unfavorable beliefs and to define and adjust expectations. If there are few or no motivations to be sexual, sexual stimuli are not satisfactory, thought content is distracting or disturbing, mindfulness-integrated CBT is recommended. Address sexual scripts and develop alternatives as needed. Address pleasure. Off-label medications are indicated only if previous steps were unsuccessful, after the client received full explanation on the limitations and possible risks of medical treatment.

**ASSESSMENT AND DIAGNOSTIC ISSUES**

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The assessment of women with sexual interest and arousal problems is based on three main elements: a structured interview, a physical examination, and, to a smaller extent, laboratory investigation. In keeping with incentive motivation theory and Basson's (2002a, 2002b) circular model of sexual response, the clinician must inquire about both frequency and intensity of sexual interest, fantasies/erotic thoughts, pleasure during sex, and physical (including genital and nongenital) sensations. As reviewed, hormonal factors may influence the responsiveness of the sexual system but may also have an impact on reasons to engage in sex. Similarly, psychological and sociocultural processes may affect one's sexual propensity, his or her reasons for engaging in sex, and responses to sexual cues. A complete assessment of SIAD requires that the clinician be attentive to the myriad psychosocial and biological contributors and how they may interact to influence a woman's motivation for sex and her subsequent response.

**Structured Interview**

A thorough biopsychosocial assessment should comprise a complete medical history (including hormonal status and mood), a demographic overview (along with sociocultural and family-of-origin issues that may have affected views on sexuality), and a physical and emotional developmental history (including past sexual experiences—

wanted and unwanted). If the woman is currently in a relationship, assessment of nonsexual aspects of the relationship, level of commitment, partner's perspective on symptoms, and partner's sexual function should be assessed. An interview with the partner (together and alone) can be invaluable. Specific to evaluating the diagnostic criteria for SIAD, the clinician should assess the woman's motivations (or lack of motivation) for sexual activity, as well as disincentives to engage sexually. The range of stimuli and current and past response to such stimuli, her ability to stay focused and experience responsive desire, and the sexual outcome—whether the sexual experience is emotionally and/or physically satisfying or pleasurable—should also be assessed. Even if a woman describes only few effective cues that elicit her sexual desire/arousal, it is still crucial to evaluate her partner's sexual technique and other partner-related factors that may be explaining her symptoms (Laan & Both, 2011). In the case of Laura, a 50-year-old woman in a committed 3-year lesbian relationship, her self-definition was "I never was much of a sexual person," and she only minimally enjoyed sex throughout each of her long-term relationships. In the context of her structured interview, Laura revealed that foreplay was always minimal, that she was highly distractible during sexual activity and would worry about upsetting her partners, and that she experienced great discomfort in communicating to her partners about what was pleasurable to her.

Moreover, Laura felt that each of her partners, except her current one, was more interested in her own orgasms than in learning how to please Laura sexually. In Laura's case, the role of partner-related factors and insufficient stimulation may be especially pertinent to assess and subsequently address in treatment.

There are a large number of self-report and clinician-administered scales and interviews that assess sexual desire in women (for a review, see Brotto, Bitzer, Laan, 36

Leiblum, & Luria, 2010). Although these can be useful for screening sexual symptoms in a busy medical setting, they are of unknown reliability in making a diagnosis of SIAD. It is noteworthy that when a self-report validated measure of sexual functioning is used, the prevalence of low desire is considerably higher than when computerized or face-to-face interviews are employed (Witting et al., 2008)

**Physical Examination**

The physical examination, when a woman presents with symptoms of low sexual interest/arousal, is a good setting to explore her perceptions, beliefs, and attitudes in response to her own anatomy and to educate and encourage a positive approach to her genitals and body. In the case in which a mental health professional is providing care, a referral to a primary care physician or specialist may be warranted. A gynecological examination should include an evaluation of the level of voluntary control of the pelvic floor muscles, pelvic floor muscle tone, presence of vaginal atrophy, size of introitus, presence of discharge or evidence of infection, epithelial disorders, and/or pain, as well as an evaluation of the pelvic organs. Vulvovaginal hypotrophy or atrophy is common after menopause, in breastfeeding women, in women treated with low-estrogen or progesterone-only contraceptives, and in hypothalamic or pituitary disease. Ruling out these contributors to low desire/arousal is essential.

**Laboratory Investigations**

Laboratory evaluation is seldom of use in the identification of female sexual desire and arousal problems. Estrogen deficiency is best detected by history and a physical examination. If the menopausal status in a hysterectomized woman is unclear, measurements of estradiol and follicle-stimulating hormone (FSH) are indicated. If irregular menstrual patterns, unexplained amenorrhea, or fertility problems are present, prolactin and thyroid-stimulating hormone (TSH) levels should be tested as well.

Androgen serum levels do not correlate with sexual function and are currently not recommended.

Assessment

of

genital

sexual

response

with

vaginal

photoplethysmography similarly is not used clinically, as it is found to correlate poorly with women's subjective experiences (Chivers, Seto, Lalumière, Laan, & Grimbos, 2010).

**Specialized Examinations**

A number of specialized tests, which are available to evaluate vascular and neurological parameters of women's sexual function, are usually available only in research settings.

Their use in identifying women with SIAD is currently unknown, and they are not used clinically.

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**APPROACHES TO TREATMENT**

Figure 1.1 outlines our treatment algorithm, which is based on the principles of incentive motivation (i.e., that sexual desire/arousal emerge in response to effective cues and that each individual has a predisposition to sexual responsiveness that is influenced by both biology and psychology) and on the circular model of sexual response that highlights the importance of incentives for sex, stimuli, and context. Each of these aspects is addressed in treatment, and identification of "breaks" in the cycle is used to guide treatment. For example, treatment of Jane, who states that her only motivation for sex is to avoid her husband's outbursts of anger and that she derives no personal benefit from sex, may include couple therapy focused on nonsexual dynamics, possibly including couple communication and emotional regulation skills for Jane's husband. On the other hand, Michelle reports having a variety of positive reasons to engage in sex but derives little to no pleasure from sexual touch and therefore limits foreplay with her boyfriend to just a few brief moments prior to intercourse. Michelle and her partner may benefit from couple exercises in sensate focus and exploration of stimuli through skills in sexual technique. This may include psychoeducation on the nature of the sexual response, including the role of age, relationship duration, and sexual myths. Next we review the brief literature exploring nonpharmacological and pharmacological treatments that may be useful for SIAD.

**Nonpharmacological Treatments for SIAD**

The literature on nonpharmacological treatments for low desire/arousal is sparse, and there is insufficient evidence for a single "evidence-based" treatment. However, there is considerable interest in evaluating psychological treatments, in particular, cognitive-behavioral therapy (CBT) and mindfulness-based interventions (MBIs). At present, we can conclude that there is promising evidence for these methods in improving women's low desire and arousal, but future research should focus on more carefully evaluating these methods in large samples of women with SIAD compared with a control group.

**Cognitive-Behavioral Therapy**

Early sex researchers identified anxiety surrounding sexual performance as one of the most important precipitants of sexual dysfunction (Masters & Johnson, 1970).

Spectating was thought to lead one to evaluate and monitor his or her own performance instead of focusing on the pleasurable sensory aspects of the sexual encounter. The resulting preoccupation with performance and critical thoughts then disrupted the processes of sexual functioning and hindered sexual response. Such cognitive interference, which distracts the person from focusing on the erotic encounter, can also activate the autonomic nervous system, triggering negative affect that is not 38

synonymous with sexual arousal or pleasure. This anxiety creates further cognitive interference, perhaps giving rise to thoughts such as "I'm a failure" or "I'll never be able to experience desire," which in turn hinder the sexual response. Behavioral avoidance is a natural consequence, which further exacerbates the anxiety about performance (Barlow, 1986). Such cognitive catastrophizing and behavioral avoidance are common among women seeking treatment for sexual response concerns.

Although much of the early research focused on men, there is evidence that cognitive distraction during sexual activity negatively affects women's sexual esteem, sexual satisfaction, and sexual response. Compared with women without sexual difficulties, those with sexual dysfunction hold stronger negative beliefs about the influence of age and body image on sexuality, and this makes them more vulnerable to activation of negative self-schemas (specifically those of incompetence) when confronted with a negative sexual situation (Nobre & Pinto-Gouveia, 2006). These self-critical schemas then trigger negative automatic thoughts, which prevent the woman from focusing on sexual stimuli and elicit negative affect, which further impairs sexual response.

These findings provide a strong justification for the use of CBT skills such as challenging problematic thoughts and shifting attention allocation through performance-based exercises. Unfortunately, only few studies have evaluated CBT for women's low sexual desire or arousal (see Brotto et al., 2010, for a review).

There is evidence that 8 weeks of individual CBT (including sensate focus, directed masturbation, and the coital alignment technique) significantly increases sexual desire and leads to lasting improvements 6 months later. There is also evidence that CBT

administered in group format over 12 weeks to women with HSDD significantly reduces HSDD severity, with sustained gains even a year after treatment. The finding that CBT

for low desire, administered with minimal intervention and using a self-help manual, led to only marginal improvements suggests that this approach may be inadequate to address the complexity of loss of sexual interest within a relationship.

In two studies that evaluated CBT for women with complaints of lack of sexual arousal, treatment significantly improved self-reported subjective arousal to the level of that of women in the nonclinical group or in comparison with a placebo control condition. In one study, CBT also resulted in a trend toward increased concordance between self-reported and physiologically measured sexual arousal, suggesting that one mechanism by which CBT is effective is in assisting women to appreciate their genital arousal response, which, in turn, may influence their subjective experience.

Neither study found an effect of CBT on physiological sexual arousal measured with a vaginal photoplethysmograph. This concurs with evidence that women's genital arousal response is usually robust even if a woman is reporting a complete lack of subjective sexual arousal and suggests that treatments focused on strengthening the physiological sexual response may do nothing to alter a woman's reported sexual difficulties. It is perhaps not surprising, therefore, that all proposals to the FDA for pharmaceutical agents to treat women's sexual dysfunction have been rejected on the grounds of inadequate efficacy (as well as questionable long-term safety data).

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**Mindfulness-Based Interventions**

Mindfulness is an ancient Eastern practice that embodies present-moment, nonjudgmental awareness. It made its debut into western healthcare in the 1970s through treatment of chronic pain and the work of Kabat-Zinn, who developed mindfulness-based stress reduction (Kabat-Zinn, 1990). Since then, it has been adapted for a variety of populations and uses, including the prevention of depressive relapse, and found to be effective for a large range of psychological and health-related conditions.


Input: Write about the pharmacological treatments for Sexual Interest/Arousal Disorder (SIAD) in women, including hormonal treatments such as estrogen and testosterone, as well as non-hormonal treatments like melanocortin-stimulating hormones and α-adrenergic antagonists. Discuss the effectiveness and potential side effects of these treatments, as well as the ongoing search for a safe and effective pharmacological solution for women's low desire.

Response:
Clinically, women with SIAD may describe their symptoms as "a disconnect between my mind and my body" and may declare an absence of pleasure despite the genital arousal response remaining robust. MBIs, which aim to cultivate active awareness of the body in an accepting, nonjudgmental, and compassionate manner, might be ideally suited to help with the complaints of low sexual desire (Brotto & Heiman, 2007). A three-session mindfulness-based CBT group treatment for women with low sexual desire has been found to significantly improve sexual desire, sex-related distress, and perceptions of genital tingling. The treatment included in-session mindfulness practices followed by daily at-home mindfulness practice, and exercises included an eating meditation, followed by body-scan, mindfulness-of-breath, and finally mindfulness-of-thoughts exercises. When women became more accustomed to practicing mindfulness in their day-to-day lives, exercises that bridged mindful awareness with sexual activity were then introduced. When applied to women with primarily sexual arousal complaints, this four-session mindfulness-based CBT treatment significantly improved women's perception of their genital arousal during an erotic film. Moreover, their self-reported sexual arousal during sexual activity, desire, orgasm, and sexual satisfaction all improved. Although the absence of a control group makes it difficult to delineate the precise mechanisms by which this MBI was effective, the finding that these effects were replicated in four studies to date suggests that skills in mindful awareness may be useful in the treatment of SIAD.

**Pharmacological Treatments for SIAD**

The search for a pharmacological means to cure women's low desire has been fierce. The main paths under investigation include hormonal treatment, dopaminergic agonists, melanocortin-stimulating hormones, α-adrenergic antagonists, nitric oxide delivery systems, and prostaglandins. Because most of these agents have been tested in women meeting criteria for HSDD or FSAD, their efficacy in treating SIAD is largely unknown.

**Hormonal Treatment: Estrogen**

Desire disorders emerging from vulvovaginal atrophy can benefit from estrogen treatment. Given the direct causal relationship between low estrogen levels and atrophy, estrogen therapy, unless contraindicated, is the current standard of care for treating this 40

condition (Tan, Bradshaw, & Carr, 2012). Local delivery is the preferred method of treatment. Systemic estrogen is indicated in the presence of other climacteric symptoms, specifically hot flashes.

Local estrogen therapy can be given as tablets, pessaries/vagitories, cream, or a vaginal ring. Therapy is available as conjugated equine estrogens, estradiol, estriol, or estrone. Concurrent progestogen therapy is not indicated, nor is annual endometrial surveillance, in asymptomatic women using vaginal estrogen. For women with a history of hormone-dependent cancer, management is decided in consultation with the oncologist balancing quality-of-life concerns and risk of recurrence.

**Hormonal Treatment: Testosterone**

The controversy surrounding the use of testosterone for the treatment of low sexual desire has a long history and continues to be hotly debated today. Despite the fact that testosterone therapy did not meet regulatory approval for the treatment of HSDD, estimates suggest that 4.1 million prescriptions for off-label testosterone are made annually in the United States alone (Davis & Braunstein, 2012). Studies in naturally and surgically menopausal estrogenreplete and nonreplete women who reported a decline in their desire for sex have found a benefit of a 300 µg/day testosterone patch. Concerns about the high rate of androgenic side effects (30% of the sample) and the finding of more new cases of breast cancer not found in the placebo group remain, however.

Findings for a testosterone spray in premenopausal women with HSDD are significant, though the actual increase amounted to only one sexually satisfying event per month.

Most recently, there was much excitement about a topical gel formulation of testosterone (Libigel) as providing "a clear path to FDA approval"; however, a lack of significant benefit over placebo in all study endpoints, and the finding that the placebo effect was more beneficial than drug on some endpoints (BioSante Pharmaceuticals, 2012), suggests that sex researchers would do well to capitalize on these findings and attempt to understand what the mechanisms are by which the placebo response is so effective (Bradford & Meston, 2009). In all of these trials, only women with a baseline frequency of two to three sexually satisfying episodes per month were enrolled, as opposed to what is commonly seen in clinical practice, in which women consistently report few or no sexually satisfying encounters.

Currently the use of transdermal testosterone for reduced sexual desire in surgically postmenopausal women has been approved by the European Medicines Agency (since 2010) but not by the FDA or Health Canada. The main concerns are the inconsistent evidence of the androgen effects on breast tissue proliferation and the unknown effects on insulin resistance, metabolic syndrome, and cardiovascular disease. The 2009

International Consultation on Sexual Medicine supported the investigational use of testosterone in postmenopausal estrogen-replete women in specific cases and with clear guidelines (see Basson, Wierman, van Lankveld, & Brotto, 2010, for more information).

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**Selective Tissue Estrogenic Activity Regulator: Tibolone**

Available in 90 countries (but not in North America), tibolone is a 19-nor testosterone derivative and a selective tissue estrogenic activity regulator (STEAR) that is metabolized into metabolites with estrogenic, progestagenic, and androgenic properties.

Tibolone therapy has shown increases in sexual desire, frequency of arousability, sexual fantasies, and vaginal lubrication versus placebo (Laan, van Lunsen, & Everaerd, 2001).

In two studies without a placebo control group, women receiving either tibolone or two different estrogen–progesterone preparations (Nijland et al., 2008; Uygur, Yeşildaglar, & Erkaya, 2005) showed an overall improvement in sexual function. Tibolone has been found to increase the risk of recurrence of breast cancer (Kenemans et al., 2009) and the risk of stroke in older women (60–85 years; Cummings et al., 2008). Its efficacy and safety in women with SIAD is unknown.

**Hormone Precursor Replacement Therapy: DHEA**

A recent comprehensive review on the use of systemic dehydroepiandrosterone (DHEA) has found no convincing data to support its use to improve sexual function, with contradictory findings regarding its safety. However, vaginal application of DHEA for postmenopausal vaginal atrophy significantly improves sexual desire/interest, sexual arousal, orgasm, and pain (Labrie et al., 2009a, 2009b). This effect is attributed to the tissue local conversion of DHEA into androgens as well as estrogens, possibly exerting benefits on all the three layers of the vaginal wall, and does not significantly increase serum levels of these hormones. This may be especially beneficial for women in whom the use of estrogen is contraindicated. More information on the use of vaginal DHEA is warranted, particularly in women with SIAD.

**Centrally Acting Investigational Medications for Low Desire/Arousal**

Centrally acting medications to improve sexual desire remain strictly off-label, and their efficacy and safety in women with SIAD is unknown. However, there is limited evidence for the beneficial effects of buproprion (a norepinephrine and dopamine reuptake inhibitor); intranasal bremelanotide (an alpha-melanocyte-stimulating hormone analogue), though there have been concerns about cardiovascular side effects; apomorphine (a dopaminergic agent), though it had a high incidence of side effects; and flibanserin (a 5-HT1A receptor agonist, 5-HT2A receptor antagonist, and dopamine D4

receptor partial agonist).

**Peripherally Acting Investigational Medications for Low Desire/Arousal**

Pharmacological agents that target genital congestion may not be clinically relevant 42

given that most women who present for treatment because of sexual interest or arousal concerns have normal genital congestion when measured in the laboratory. If difficulties with genital sexual sensations predominate the clinical picture and/or if the genital arousal response is related to spinal cord injury or diabetes, sildenafil may be considered (see Brotto et al., 2010, for review). Although a number of other peripherally acting agents have been tested in controlled trials, findings have not been conclusive, and, as such, they are not considered frontline treatments for sexual interest/arousal concerns.

Taken together, the literature reviewed suggests there is much work to be done in terms of evaluating treatments for women with SIAD. The algorithm in Figure 1.1

suggests that if medically indicated, pharmaceutical treatment may be useful, though the clinician must bear in mind that their use remains off-label. Although nonpharmacological treatments such as sensate focus, CBT, and mindfulness skills have a long history, evidence of their efficacy in the scientific literature is minimal.

Nonetheless, we advocate a stepwise treatment plan that includes psychoeducation and clarification of myths early on, followed by more concentrated couple and/or individual therapy at subsequent stages. If lack of motivation/incentives for sex, difficulties with effective stimuli, or a problematic context are contributing to the SIAD symptoms, we advocate strongly for involvement of the partner in therapy.

Although a multidisciplinary treatment team may be warranted in some cases (particularly if there are biomedical contributors such as significant endocrine disorder, genital pain affecting desire/arousal, or medical disease affecting response, such as spinal cord disease or multiple sclerosis), our experience is that this is not necessary for the successful treatment of SIAD. We do, however, believe that sex therapy plays an important role in treatment, and this may be delivered by a skilled practitioner in any of the fields known to interact with women with sexual concerns (e.g., psychology, psychiatry, family medicine, gynecology, social work, nursing).

**CASE DISCUSSION: MINDFULNESS-BASED COGNITIVE**

**THERAPY IN THE TREATMENT OF SIAD**

Patricia was a 48-year-old full-time teacher, married to Edward, a hospital administrator, and they had one child together. Patricia had been married previously and had one adult child from that relationship. They presented for treatment after struggling with discrepant desire in their relationship for the full duration of their 15-year marriage. She reported having had a very low interest in sexual activity for her entire life and rarely experienced any erotic thoughts. She did not initiate sexual activity with Edward but responded to his attempts to initiate approximately 50% of the time. In the past 5 years, however, Edward initiated sex less and less frequently, as he perceived Patricia's lack of receptivity as a personal rejection. She had difficulty identifying any triggers for her sexual desire or response, though she did describe sexual activity with him as enjoyable once she was able to relax and focus on the present moment, which occurred only very rarely. Sex was occasionally painful due to lack of lubrication, and 43

she could not identify nongenital signs of arousal within her body. She struggled with a lifelong history of anxiety—particularly centered around a fear of negative evaluation—

and she experienced physical symptoms of anxiety during stressful situations daily. She also had a more generalized difficulty in identifying positive emotions and struggled when trying to label her mood during positive events. Patricia was otherwise healthy, perimenopausal, and not taking any medications. During her individual interview Patricia noted that she occasionally masturbates, mostly as a method of stress reduction.

However, Edward was unaware of this, as she worried that he might perceive her interest in masturbation as indicating that she specifically was not interested in sex with him. She and Edward were in a loving and mutually respectful relationship and were clearly very committed to one another. In his individual assessment, however, Edward declared that he could not envision himself remaining in this relationship if Patricia's sexual difficulties did not improve.

Because Patricia had reduced interest in sex and an absence of erotic thoughts/fantasies, rejected Edward's sexual invitations, and displayed a lack of sexual response to cues that would normally elicit desire and a lack of physical signs of excitement, she met diagnostic criteria for SIAD. A physical examination revealed signs of vulvar-vaginal atrophy, and Patricia was prescribed a topical estrogen, which, over a period of weeks, restored some positive genital sensation.

The entire first treatment session was spent providing psychoeducation and describing the circular model of sexual response, as well as principles of incentive motivation theory. Patricia acknowledged that she was not completely aware of what

"turned her on," and she expressed discomfort about communicating to Edward the particular touches and stimuli that she found arousing. As a result, her motivations for sex stemmed primarily from a need to keep Edward happy, even though she derived no personal satisfaction out of sex. Early sessions focused on exploring possible positive incentives to engage in sex. Although Patricia would accept that sex was probably good for her relationship, she also maintained that because the rest of their nonsexual relationship was very rewarding, she was not as motivated as Edward to work on improving her desire. Moreover, because she had never experienced a pronounced sexual response or sexual pleasure in the past, Patricia felt as if she was in pursuit of something she had no personal experience with. Indeed, the lifelong nature of her symptoms posed a challenge to our treatment. Some cognitive challenging of fixed beliefs, such as "It is inappropriate to share with Edward my sexual wants" and "Every time Edward touches me, he is communicating to me that he only wants sex" was useful early in the therapy process.

Patricia was introduced to mindfulness skills, initially for up to 10 minutes in session and subsequently 30 minutes' daily practice of the body scan at home. She was encouraged to suspend any attachment toward needing to "be fixed" but, rather, to be with her moment-to-moment sensations. After a period of weeks, this allowed Patricia to begin to identify body sensations that were experienced as positive, and her practice also allowed her to explore her anxiety more fully in a compassionate and nonjudgmental manner. She learned that from her earliest interactions, sex had been quite stressful for her, due to having partners who blamed her for not reaching orgasm.

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Her more general restricted range of emotions stemmed from an emotionally invalidating environment as a child, combined with extreme pressure placed on her to excel in competitive swimming throughout her childhood and adolescence. Patricia was then introduced to mindfulness-of-thoughts skills, in which she was able to view her worries as "mental events," and she began to identify bodily sensations that accompanied these mental events. After a few months of daily mindfulness practice, Patricia began to explore the use of mindfulness during solo sexual activity. She would place her hand on different parts of her body and then fully attend to any resulting sensations without judgment. The exercises became gradually more sexual. She started to experience some pleasure during the exercises and could guide her mind fully to the present. Distractions could fade into the background landscape and were no longer seen as an impediment to being sexual. The exercises were then generalized to partnered sexual activity with Edward, during which Patricia learned to accept her state of sexual neutrality at the beginning of sexual interactions but then welcomed her responses as the encounter ensued. Edward responded positively to Patricia's newfound response and therefore began to initiate nonintercourse sexual encounters more often. The introduction of sensate-focus exercises then encouraged Patricia to verbalize what she experienced as pleasurable to Edward. By the end of 1 year of treatment, Patricia felt that she had gained some interest in sexual activity, was fully aware of the responsive nature of her sexual desire, and found their sexual interactions to be pleasurable. There was ongoing work to do in terms of her own generalized anxiety and fear of negative evaluation, though Patricia felt that the mindfulness skills learned in sex therapy had a positive effect on her mental well-being and self-esteem more generally. During the next stage of therapy, the couple and therapist focused on exploring varied forms of sexual stimuli that might effectively elicit Patricia's sexual interest and arousal. Patricia's more generalized anxiety was an obstacle at times to exploring new triggers, and this was addressed through a combination of mindful self-compassion, as well as gentle probing of her articulated thought biases.

**CONCLUSIONS**

Because SIAD is a new disorder in DSM-5, empirical research testing the reliability and validity of this condition has not yet been carried out. However, on the basis of long-standing concerns about the reliance on Masters and Johnson's sex response cycle to categorize and define sexual desire and arousal complaints, this new diagnosis offers an alternative conceptualization that is based on an incentive motivation model and the concept of responsive sexual desire. Insufficient evidence exists to suggest that SIAD

applies as well to men as it does to women. Compared with research on men's sexual difficulties, there is still much that is unknown about effective treatments for women's sexual interest/arousal difficulties, and psychological treatment outcome studies are rare. As the race continues to identify an effective and safe pharmaceutical treatment for women's sexual difficulties, the diagnosis of SIAD offers researchers and clinicians an 45