Psychophysiological and subjective sexual arousal - Transsexual ...

240 L. A. Brotto et al.subjective reactions to the film given that the sixdomains of this scale might be theoretically related. Ap level of 0.05 / 6 = 0.008 was thus set for thesecomparisons. For analysis of all other variables, a plevel of 0.05 was deemed significant.ResultsDemographic informationAll 15 MTF individuals completed the studyprocedures in their entirety. Participants were anaverage of 43.2 years old (range 33–55) and receivedSRS approximately 24 months earlier (range 12–60months). All participants received penile skin inversionsurgery and were receiving follow-up care at thesame clinic. At the time of participation in this study,the average vaginal length was 8.9 cm (range 5.5–11.6 cm). Vaginal length was unrelated to time sincesurgery (p 4 0.05). Four participants were involvedin a sexual relationship at the time of physiologicaltesting. Eleven women identified as having a largelyor entirely heterosexual orientation (i.e., attracted tomen), one woman as equally homosexual andheterosexual, and three women as largely or entirelyhomosexual (i.e., attracted to women). Fourteenwomen were Caucasian and one was First NationsCanadian. Ten participants were currently employed,four women were either retired orunemployed, and one did not provide employmentinformation.Questionnaire dataBISF-W subscale totals (means and SEM) are listedin Table I. On all subscales, scores were found to bein the lower half of the normative range for thisquestionnaire despite the finding that scores on theTable I. Responses to items on the Brief Index of SexualFunctioning for Women (BISF-W) in post-surgical MTF women.The number of women the data are based upon are listed. Datarepresent means (+ standard error of the mean).BISF-WsubscalenMean(+ SEM)Maximumpossible scoreThoughts/15 5.93 (1.34) 12desireArousal 15 3.00 (0.63) 8Frequency of15 2.10 (0.48) 6sexual activityReceptivity/6 8.67 (1.02) 15initiationPleasure/orgasm 11 2.66 (0.54) 8Relationship15 5.20 (1.02) 12satisfactionProblemsaffecting sexualfunction15 2.29 (0.44) 16For all scales except the ‘‘Problems affecting sexual function’’,higher scores denote better sexual function. For the final subscale,higher scores indicate more problems affecting sexual function.‘‘Problems affecting sexual function’’ subscale werevery low, indicating no sexual problems. Responseson the Detailed Assessment of Sexual Arousal with amaximum score of 7, revealed the average level ofmental sexual arousal to various types of sexualstimuli to be 5.00 (SEM = 0.28). Awareness of nongenitalphysical arousal was 4.7 (SEM = 0.37),awareness of genital arousal was 4.57(SEM = 0.41), and self-reported pleasure from directgenital stimulation was 4.67 (SEM = 0.48). Sixwomen (40%) reported an ability to attain orgasmby at least one means (e.g., clitoral stimulation,intercourse, vibrator use, fantasy). Ten women(67%) reported being satisfied with their orgasmicfunction, three women (20%) reported being dissatisfiedor distressed, and two women (13%) did notcomplete this item.Effects of erotic stimuli on physiological sexual arousalAs suggested by Table II, the effect of the erotic filmon physiological sexual arousal was not significant,t (14) = 0.147, p 4 .05 (mean VPA increase duringneutral condition = 4.94 mV and mean VPA increaseduring erotic condition = 4.83 mV). Closer examinationof individual VPA profiles indicates that therewere numerous movement artefacts throughout theVPA signals, which rendered data reduction andanalysis difficult, even with software artefact removaland smoothing. We chose a random sample of fourVPA outputs to illustrate the magnitude of movementartefacts (see Figure 1).Effects of erotic stimuli on self-report measures of arousaland affectAs shown in Table II, the erotic film significantlyincreased self-reported autonomic arousal, t(14) =75.00, p 5 0.001; perceptions of genital arousal,t(14) = 74.84, p 5 0.001; subjective sexual arousal,t(14) = 74.71, p 5 0.001, and positive affect, t(14) =74.32, p 5 0.001. Neither anxiety, t(14) = 1.38,Table II. Effects of visual sexual stimuli (neutral and erotic) onVaginal Pulse Amplitude (VPA) and self-report measures ofarousal and affect. Data represent means (+ standard error ofthe mean).Measure Neutral EroticVPA (millivolts) 4.94 (2.14) 4.83 (1.41)Autonomic arousal* 9.60 (1.10) 16.93 (1.03)Perception of8.80 (1.18) 17.73 (1.69)physical arousal*Subjective sexual 7.40 (0.52) 10.8 (0.53)arousal*Positive affect* 12.53 (1.32) 20.67 (1.66)Negative affect 13.00 (0.70) 14.27 (1.16)Anxiety 2.73 (0.54) 2.07 (1.66)*p 5 0.001, significant difference between neutral and eroticconditions.

Sexual arousal in new women 241Figure 1. Effects of visual sexual stimuli (neutral and erotic) on Vaginal Pulse Amplitude (VPA) for a random sample of four data outputs.Output to the left of the dotted line indicate responses to the neutral stimulus and output to the right of the dotted line represent responses tothe erotic film.p 4 0.05, nor negative affect, t(14) = 71.33, p 4 0.05,were significantly affected by the erotic film.Responses to vaginal probe insertionThe mean level of awareness of the probe was 3.9(SEM = 0.68) where 1 = completely unaware and10 = completely aware of the probe. The averagelevel of pain from inserting the probe was 1.0(SEM = 0.00) where 1 = no pain and 10 = verypainful. Vaginal length was not significantly relatedto awareness of the probe during testing (r = 0.08),nor to pain with insertion of the vaginal probe(r = 0.00), p 4 0.05.DiscussionOverall the findings suggest satisfactory levels of selfreportedsexual arousal in the real-life setting forMTF individuals who are at least 12 months post-SRS. Compared to responses from a similarly-agedgroup of natal women experiencing sexual arousaldifficulties [31], levels of self-reported mental arousal,awareness of genital arousal, and pleasure fromdirect genital stimulation were higher in the currentgroup of MTF participants. However, scores on theBISF-W Desire, and Pleasure subscales were in thelower half of the normative range for this questionnaire.This may partially be explained by the low

242 L. A. Brotto et al.number of new women currently in a relationship orcurrently engaging in partnered sexual activity.Despite the lower Desire and Pleasure scores, thisgroup did not report sexual problems overall. Therefore,it appears that this group of MTF individualsexperience satisfactory levels of subjective andperceived physiological sexual arousal in their naturalenvironments.With respect to orgasmic function, 40% reportedability to reach orgasm by at least one means, and67% reported overall satisfaction with orgasm. Thissuggests that satisfaction with orgasmic function isnot necessarily dependent on the physiological abilityto attain orgasm, at least in this particular group.Given the marked variability of rates of orgasmicability in prior research, and the current finding thatsatisfaction is not correlated with ability, one mightconclude that a focus on orgasmic capacity may notbe the optimal endpoint measure of sexual functionin this group. Rather, assessment of satisfaction maybe a more accurate measure. Moreover, whichfactors predict orgasmic satisfaction, given that actualorgasmic capacity per se is not a predictor, would bean interesting question to explore.In response to visual sexual stimuli presentation,self-reported sexual arousal, perception of genitalarousal, and perception of autonomic arousal increased.This suggests that this particular group ofMTF participants was able to become subjectivelyaroused in a highly artificial testing situation. Moreover,their positive affect towards the erotic filmincreased, whereas anxiety and negative affect wereunaffected. Thus, despite the exclusive heterosexualcontent of the film, all participants experiencedsubjective pleasure while viewing the film. Thesefindings suggest that future research should continueto explore assessment of sexual arousal in alaboratory setting using other forms of genital arousalassessment.With regards to the main outcome variable in thestudy, we were unable to measure VPA responsesduring the erotic condition due to significant movementartefacts. We present a random sample of fourVPA outputs in Figure 1; however, the VPAresponses of all 15 participants contained movementartefacts during the erotic segment that rendereddata analysis impossible. In approximately half of thedata outputs we could calculate VPA mean valuesduring the neutral stimulus condition. Thus, thesefindings are not inconsistent with those of Schroderand Carroll [16] who detected a VPA signal during aresting baseline condition, but who did not subsequentlypresent their participants with erotic stimuli.Given the dependence on within-subject comparisonsinherent to using the vaginal photoplethysmograph,one cannot make inferences with respectto genital arousal during the erotic condition onthe basis of exposure to a baseline condition or toa neutral film alone. We were able to locate onearticle, published in Dutch, which used vaginalphotoplethysmography in a group of MTF women.In their small sample of five individuals, Balsma et al.[32] detected a VPA signal during the erotic filmexposure in only two women, but movementartefacts prevented VPA analysis in the remainingindividuals. The problem of movement artefactstherefore seems characteristic of the study sampleas opposed to the methodological techniques employedat our site alone.A number of explanations might account for thenumerous movement artefacts during the eroticstimulus condition. It is possible that discomfortfrom the inserted probe resulting in movement mightbe responsible. However, when asked about theirlevel of awareness of the probe and the amount of painevoked from its insertion, responses were relativelylow (3.9 and 1.0, respectively, on a scale from 1 to10). Moreover, awareness of the probe was notrelated to vaginal length. Another explanation forthe numerous artefacts relates to the tissue used toconstruct the neovagina. Balsma and colleagues [32]speculated that the movement artefacts may beattributable to muscle contractions because of remainingmale muscle tissue which is stronger in themale pelvic muscles. In natal women the pelvic floormuscles surround the vaginal opening while in MTFwomen the neovagina is created behind the malepelvic floor muscles. Only the levator ani muscles(which are much deeper in the perineum) have asimilar position in both men and women. Theseresearchers also suggest that movement artefacts maybe due to the influence of the prostate, which ispreserved in MTF women. In the current study allnew women had undergone penile inversion surgerywhere scrotal tissue is used to line the vaginal vault.Another explanation is that MTF women, as do natalmen, use voluntary pelvic floor contractions as ameans of enhancing vasocongestion.In conclusion, the findings from this studysuggest that the vaginal photoplethysmograph cannotbe considered a viable technique to study theblood flow patterns in the neovagina duringconditions of sexual arousal. However, the findingthat this group was able to become subjectivelysexually aroused suggests that the laboratoryassessment of sexual arousal may be acceptable ifalternative forms of objective genital arousal measurementare considered. Recently neural activityin response to non-erotic stimuli was measured in agroup of MTF individuals using the P300 wave,and was found to significantly differ from a natalcontrol group [33]. It is possible that suchtechniques may be helpful in the psychophysiologicalassessment to sexual stimuli in the future. Itmight also be fruitful to re-examine the use ofearlier genital psychophysiological techniques (e.g.,the heated electrode) [22] which, despite theirobtrusiveness, are less susceptible to movementartefacts. With growing sophistication in theassessment of women’s sexual arousal, we expect

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244 L. A. Brotto et al.Current knowledge on this subject. Although subjective aspects of the sexual response inpostoperative male-to-female (MTF) women withGender Identity Disorder has been studied extensively,almost no data exist on physiological patterns of sexualarousal in this group of new women.. The study has implications for the use of vaginalphotoplethysmography, a technique used widely in themeasurement of sexual arousal in natal women, forMTF women.What this study adds. This study suggests that the vaginal photoplethysmographcannot be considered a viable technique to studythe blood flow patterns in the neovagina duringconditions of sexual arousal in MTF women due tomovement artefacts.. Given that this group of women became subjectivelysexually aroused to erotic stimuli in the laboratorysetting, researchers might explore other methods ofphysiological sexual arousal assessment less susceptibleto movement artifacts for furthering our understandingof the sexual response in new women.