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Volume 22 / Number 1 / 2017

Volume 22 / Number 1 / 2017

European Psychologist

European Psychologist

Editor-in-Chief Peter Frensch Managing Editor Kristen Lavallee Associate Editors Rainer Banse Ulrike Ehlert Katariina Salmela-Aro

Official Organ of the European Federation of Psychologists’ Associations (EFPA)

Special Issue Controversial Issues in Human Sexuality Research: The State of the Science


Clear and compact guidance on integrating mindfulness into practice “Offering conceptual clarity, depth, and analysis, this book skillfully and clearly guides the reader through the practice and implementation of effective mindfulness-based interventions.” Zindel V. Segal, PhD, Distinguished Professor of Psychology in Mood Disorders, Department of Psychology, University of Toronto, ON, Canada; Author of The Mindful Way Workbook

Katie Witkiewitz / Corey R. Roos / Dana Dharmakaya Colgan / Sarah Bowen

Mindfulness (Series: Advances in Psychotherapy – Evidence-Based Practice – Volume 37) 2017, viii + 80 pp. US $ 29.80 / € 24.95 ISBN 978-0-88937-414-0 Also available as eBook This clear and concise book provides practical, evidence-based guidance on the use of mindfulness in treatment: its mechanism of action, the disorders for which there is empirical evidence of efficacy, mindfulness practices and techniques, and how to integrate them into clinical practice. Leading experts describe the concepts and roots of mindfulness, and examine the science that has led to this extraordinarily rich and ancient practice becoming a foundation to many contemporary, evidenced-based approaches in psychotherapy.

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The efficacy of mindfulness-based interventions in conditions as diverse as borderline personality disorder, post-traumatic stress disorder, depression, alcohol and substance use, emotional dysregulation, attentiondeficit hyperactivity disorder, chronic stress, eating disorders, and other medical conditions including type 2 diabetes and rheumatoid arthritis is also described. The book is invaluable reading for all those curious about the current science around mindfulness and about how and when to incorporate it effectively into clinical practice.


European Psychologist

Volume 22, No. 1, 2017 OfďŹ cial Organ of the European Federation of Psychologists Associations (EFPA)


Editor-in-Chief

Peter A. Frensch, Institute of Psychology, Humboldt-University of Berlin, Rudower Chaussee 18, 12489 Berlin, Germany, Tel. +49 30 2093 4922, Fax +49 30 2093 4910, peter.frensch@psychologie.hu-berlin.de

Managing Editor

Kristen Lavallee, editorep-psych@hu-berlin.de

Founding Editor / Past Editor-in-Chief

Kurt Pawlik, Hamburg, Germany (Founding Editor) / Alexander Grob, Basel, Switzerland (Past Editor-in-Chief)

Associate Editors

Rainer Banse, Institute for Psychology, Social and Legal Psychology, University of Bonn, Karl-Kaiser-Ring 9, 53111 Bonn, Germany, Tel. +49 228 73 4439, Fax +49 228 73 4229, banse@uni-bonn.de Ulrike Ehlert, Institute of Psychology, University of Zurich, Binzmu¨hlestrasse 14 / Box 26, 8050 Zurich, Switzerland, Tel. +41 44 635 7350, u.ehlert@psychologie.uzh.ch Katariina Salmela-Aro, University of Helsinki, P.O. Box 4, 00014 University of Helsinki, Finland, Tel. +358 50 415-5283, katariina.salmela-aro@helsinki.fi

EFPA News and Views Editor

Eleni Karayianni, Department of Psychology, University of Cyprus, P.O. Box 20537, Nicosia, Cyprus, Tel. +357 2289 2022, Fax +357 2289 5075, eleni.karayianni@efpa.eu

Editorial Board

Louise Arseneault, UK Dermot Barnes-Holmes, Belgium Claudi Bockting, The Netherlands Gisela Bo¨hm, Norway Mark G. Borg, Malta Serge Bre´dart, Belgium Catherine Bungener, France Torkil Clemmensen, Denmark Cesare Cornoldi, Italy Istva´n Czigler, Hungary Ge´ry d’Ydewalle, Belgium Michael Eysenck, UK Rocio Fernandez-Ballesteros, Spain Dieter Ferring, Luxembourg Magne Arve Flaten, Norway Alexandra M. Freund, Switzerland Marta Fulop, Hungary

Danute Gailiene, Lithuania Alexander Grob, Switzerland John Gruzelier, UK Sami Gu¨lgo¨z, Turkey Vera Hoorens, Belgium Paul Jimenez, Austria Remo Job, Italy Katja Kokko, Finland Gu¨nter Krampen, Germany Anton Ku¨hberger, Austria Todd Lubart, France Ingrid Lunt, UK Petr Macek, Czech Republic Mike Martin, Switzerland Teresa McIntyre, USA Judi Mesman, The Netherlands Susana Padeliadu, Greece

Ståle Pallesen, Norway Georgia Panayiotou, Cyprus Sabina Pauen, Germany Marco Perugini, Italy Martin Pinquart, Germany Jose´ M. Prieto, Spain Jo¨rg Rieskamp, Switzerland Sandro Rubichi, Italy Ingrid Schoon, UK Rainer Silbereisen, Germany Katya Stoycheva, Bulgaria Jan Strelau, Poland Tiia Tulviste, Estonia Jacques Vauclair, France Dieter Wolke, UK Rita Zukauskiene, Lithuania

The Editorial Board of the European Psychologist comprises scientists chosen by the Editor-in-Chief from recommendations sent by the member association of EFPA and other related professional associations, as well as individual experts from particular fields. The associations contributing to the current editorial board are: Berufsverband O¨sterreichischer Psychologen/innen; Belgian Psychological Society; Cyprus Psychologists’ Association; Unie Psychologickych Asociaci, Czech Republic; Dansk Psykologforening; Union of Estonian Psychologists; Finnish Psychological Association; Fe´de´ration Française des Psychologues et de Psychologie; Socie´te Française de Psychologie; Berufsverband Deutscher Psychologinnen und Psychologen; Magyar Pszicholo´giai Ta´rsasa´g; Psychological Society of Ireland; Associazione Italiana di Pscicologia; Lithuanian Psychological Association; Socie´te´ Luxembourgeoise de Psychologie; Malta Union of Professional Psychologists; Norsk Psykologforening; O¨sterreichische Gesellschaft fu¨r Psychologie; Colegio Oficial de Psicologos; Swiss Psychological Society; Turkish Psychological Association; European Association for Research on Learning and Instruction; European Association of Experimental Social Psychology; European Association of Personality Psychology; European Association of Psychological Assessment; European Health Psychology Society. Publisher

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European Psychologist (2017), 22(1)

Ó 2017 Hogrefe Publishing


Contents Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science (Coordinator: Justin Lehmiller, Guest Editor: Katariina Salmela-Aro) Editorial

Controversial Issues in Human Sexuality Research: The State of the Science Justin J. Lehmiller

1

Original Articles and Reviews

Controversies of Women’s Sexual Arousal and Desire Meredith L. Chivers and Lori A. Brotto

5

EFPA News and Views

Ó 2017 Hogrefe Publishing

Women’s Sexual Desire: Challenging Narratives of ‘‘Dysfunction’’ Cynthia A. Graham, Petra M. Boynton, and Kate Gould

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Autogynephilia and the Typology of Male-to-Female Transsexualism: Concepts and Controversies Anne A. Lawrence

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Unique and Shared Relationship Benefits of Consensually Non-Monogamous and Monogamous Relationships: A Review and Insights for Moving Forward Amy C. Moors, Jes L. Matsick, and Heath A. Schechinger

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Meeting Calendar

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European Psychologist (2017), 22(1)


Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science

Editorial Controversial Issues in Human Sexuality Research The State of the Science Justin J. Lehmiller1,2 1

Department of Counseling Psychology, Social Psychology, and Counseling, Ball State University, Muncie, IN, USA

2

The Kinsey Institute, Indiana University, Bloomington, IN, USA

When Alfred Kinsey published his pioneering research on human sexuality in the middle of the twentieth century, it immediately became the subject of great controversy, with many of his findings provoking significant resistance and backlash. Kinsey’s work made a lot of people uncomfortable because it challenged their preconceived notions about sex and sexual desire. This was especially true with respect to the release of his 1953 volume, Sexual Behavior in the Human Female. It was the first book of its kind to investigate women’s sexual attitudes and behaviors from a scientific perspective. Over time, it helped to fundamentally reshape the way female sexuality was understood. In the decades since, the field of sex research has grown significantly; however, little has changed with respect to public reaction to sex research that challenges widely held beliefs. The unfortunate reality is that when research on sex and gender conflicts with people’s assumptions – and especially when it reveals inconvenient truths – the findings have a tendency to be ignored, misconstrued, or attacked, and the researchers who uncovered them are sometimes smeared in the process (see Dreger, 2016). This is true today more than ever. Indeed, this era of identity politics and social media echo chambers has fueled a growing divide between public opinion and scientific consensus on numerous sexuality issues – a divide that has implications not just for the advancement of science, but also for our health and happiness. It is this disconnect between popular belief and science that the current special issue is devoted to exploring. I invited contributions from an international team of experts to highlight the state of the science behind some of the most controversial and widely misunderstood aspects of human sexuality with the goal of challenging researchers, educators, and therapists to revisit some of their own Ó 2017 Hogrefe Publishing

assumptions. These articles offer insight into (1) the nature of sexual desire and arousal in women, (2) treatment of sexual difficulties in women, (3) typologies and subtypes of transsexualism, and (4) the outcomes associated with consensually non-monogamous relationships. Certainly, these topics do not represent the only controversial areas in modern sexuality research; however, they are among the most significant for psychologists to attend because, as you will see below, they have implications for both research and practice.

The Nature of Female Sexual Desire and the Treatment of Women’s Sexual Desire Difficulties Numerous scientific studies have explored the nature of female sexual desire in the last two decades; however, this work is frequently mischaracterized in the popular media and it remains poorly understood by many researchers and therapists. As such, I thought it was important to to invite not one, but two manuscripts on this topic. Part of the reason women’s sexual desire is so poorly understood is because the research on it that tends to get the most notice is that which appears to support long-held stereotypes of women’s sexuality. For instance, studies finding that women report lower levels of subjective sexual arousal in response to pornography than men (e.g., Koukounas & McCabe, 1997) are typically taken as support for the popular stereotype that women are inherently less visually aroused. Likewise, studies showing that heterosexual women (but not heterosexual men) tend to demonstrate European Psychologist (2017), 22(1), 1–4 DOI: 10.1027/1016-9040/a000286


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significant genital arousal in response to both male and female sexual stimuli (e.g., Chivers, Rieger, Latty, & Bailey, 2004) have been viewed as confirmation of the pervasive stereotype that all women are inherently bisexual. However, as Chivers and Brotto (2017) eloquently explain in this issue, these and other popular beliefs and stereotypes about the nature of female sexual desire do not stand up upon a closer examination of the research. They introduce four common assumptions about women’s sexual desire and arousal (including the idea that desire necessarily precedes arousal) and meticulously review the accumulated empirical evidence that challenges them. In addition, they highlight the importance of correcting these misperceptions. Most notably, they address how a failure to do so perpetuates ineffective treatment approaches for sexual difficulties among women. As Chivers and Brotto’s review points out, there is still much we do not know about women’s sexual desire and arousal. However, they lay out an ambitious agenda for future research and call for scientists to fundamentally change the way they study women’s sexual desire by taking a gendered approach. Graham, Boynton, and Gould (2017) extend the contributions of Chivers and Brotto by further exploring popular misconceptions of female sexual desire. They devote particular attention to misconceptions perpetuated by both the pharmaceutical industry and the popular media in the run-up to US Food and Drug Administration’s (FDA) approval of the new drug treatment for low libido in women, flibanserin (Addyi). However, they also address misconceptions that many women themselves hold with respect to female sexual desire (e.g., the belief that desire has a purely physiological basis). They do so by examining narratives from women who took part in a patient-focused drug development meeting sponsored by the FDA. Graham and colleagues go well beyond debunking myths and misconceptions about sexual desire, though, and also offer several important recommendations. Specifically, they highlight areas in which future research on this topic could be improved (e.g., taking into account variability in how women define “desire” and including women of diverse backgrounds in clinical trials for new treatments targeting sexual desire difficulties). They also offer suggestions for generating media reports about female sexual desire – and sex science more broadly – that will ultimately help produce a more informed public.

Typologies of Transsexualism In the last few years, transgender issues have become a major topic of discussion around the world, in part, due to extensive news coverage of a few high profile figures who European Psychologist (2017), 22(1), 1–4

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have transitioned, including Chaz Bono and Caitlin Jenner. Popular media reports on these cases suggest that transsexuals are a homogeneous group consisting of gender dysphoric individuals who simply feel as though they are “trapped in the body of the wrong sex.” However, some psychologists have argued that this explanation is incomplete and that there may be other variants of transsexualism. One example of this would be autogynephilia (Bailey 2003; Blanchard, 1989), a term that refers to natal males who derive sexual arousal from the prospect of being or physically becoming a woman. In the case of autogynephilia, there is thus a sexual component that contributes to the desire to transition to the other sex. This concept has attracted significant attention because it suggests that some (but not all) variants of transsexualism may be characterized as paraphilic in nature. Autogynephilia is controversial within the trans community, as well as in the scientific literature (Dreger, 2016), and it is rarely (if ever) discussed in the popular media In this issue, Lawrence (2017) reviews the history of research on autogynephilia, as well as the major concerns that have been raised by critics of the theory (e.g., that it emphasizes sexual motivations over matters of gender identity and perpetuates damaging stereotypes about transsexual persons). In addition to evaluating each of these concerns, Lawrence addresses implications of the controversy surrounding autogynephilia for clinical care. Most notable is the complete removal of autogynephilia from the section on gender dyphoria in the DSM-5 (APA, 2013), as well as its removal from guidelines for transgender care published by other organizations around the world.

Consensually Non-Monogamous Relationships The final paper in this issue addresses the topic of consensually non-monogamous relationships (CNMRs), or relationships in which the partners agree that it is acceptable to have more than one sexual and/or romantic relationship simultaneously. While research suggests that CNMRs are common (Haupert, Gesselman, Moors, Fisher, & Garcia, 2016) and that public interest in them is increasing (Moors, 2016), these relationships remain controversial. Studies have found that monogamous relationships tend to be viewed in a far more favorable light than CNMRs. For instance, relative to those practicing monogamy, persons in CNMRs are perceived as being both less committed and less healthy (Conley, Moors, Matsick, & Ziegler, 2013). These biases exist not only among the general public, but also among many researchers and clinicians. As some evidence of this, many psychological theories of romantic Ó 2017 Hogrefe Publishing


Editorial

relationship commitment, such as Rusbult’s (1980) Investment Model, suggest that perceiving alternative relationship partners as attractive or desirable is necessarily detrimental to relationship commitment. However, as Moors, Matsick, and Schechinger (2017) explain, these assumptions are not empirically supported. They review research that challenges the idea that persons in CNMRs are inherently less committed (Rubel & Bogaert, 2015). Indeed, it appears that persons in CNMRs experience similar relationship outcomes relative to those who are monogamous and, further, that there are some unique benefits yielded by consensual non-monogamy (e.g., variety in activities, personal growth). In addition, persons in CNMRs do not necessarily report worse sexual health outcomes either. For instance, self-reported rates of sexually transmitted infections are similar for persons who have and have not made monogamy agreements, a finding that may stem from high rates of infidelity and low rates of condom use among those who have agreed to be monogamous (Lehmiller, 2015). In addition to reviewing the literature in this area, Moors and colleagues offer a number of helpful recommendations for scientists that are aimed at advancing research on this topic, such as by moving past a focus on which type of relationship is “better” or “superior” than another and instead exploring the uniqueness of diverse relationship structures. Just as Chivers and Brotto (2017) argue elsewhere in this issue that research on female sexual desire should no longer be approached by considering men as the “baseline,” Moors and colleagues argue that research on CNMRs must move past using monogamous relationships as the “control group” or standard of comparison. Beyond implications for research, Moors and colleagues challenge relationship therapists and counselors to reconsider the idea that there is one “ideal” relationship structure all clients should strive for and to instead explore the unique benefits and drawbacks of different relationship styles.

Concluding Remarks This special issue offers an overview of the current state of the science on some of the most controversial aspects of human sexuality that have relevance to psychological practice, education, and research. As you read the papers that follow, I encourage you to do so with an open mind. These papers will surely challenge the way that many think about the nature of female sexual desire and arousal, the treatment of sexual desire difficulties, the origins of transsexualism, and what makes for a “healthy” romantic relationship; however, it is vital that we do not allow our own assumptions, worldviews, or personal values to trump what Ó 2017 Hogrefe Publishing

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we have learned from scientific research. We must be willing to consider alternative perspectives and adjust our views in response to data. A failure to do so not only has the potential to hamper scientific progress, but also to call into question the integrity of our field and negatively impact health and well-being.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Bailey, J. M. (2003). The man who would be queen: The science of gender-bending and transsexualism. Washington, DC: Joseph Henry Press. Blanchard, R. (1989). The concept of autogynephilia and the typology of male gender dysphoria. Journal of Nervous and Mental Disease, 177, 616–623. doi: 10.1097/00005053198910000-00004 Chivers, M. L., & Brotto, L. A. (2017). Controversies of women’s sexual arousal and desire. European Psychologist, 22, 5–26. doi: 10.1027/1016-9040/a000275 Chivers, M. L., Rieger, G., Latty, E., & Bailey, J. M. (2004). A sex difference in the specificity of sexual arousal. Psychological Science, 15, 736–744. doi: 10.1111/j.0956-7976. 2004.00750.x Conley, T. D., Moors, A. C., Matsick, J. L., & Ziegler, A. (2013). The fewer the merrier? Assessing stigma surrounding nonnormative romantic relationships. Analyses of Social Issues and Public Policy, 13, 1–30. doi: 10.1111/j.1530-2415. 2012.01286.x Dreger, A. (2016). Galileo’s middle finger: Heretics, activists, and one scholar’s search for justice. New York, NY: Penguin Books. Graham, C. A., Boynton, P. M., & Gould, K. (2017). Women’s sexual desire: Challenging narratives of “dysfunction”. European Psychologist, 22, 27–38. doi: 10.1027/1016-9040/a000282 Haupert, M., Gesselman, A., Moors, A., Fisher, H., & Garcia, J. (2016). Prevalence of experiences with consensual non-monogamous relationships: Findings from two nationally representative samples of single Americans. Journal of Sex & Marital Therapy. doi: 10.1080/0092623X.2016.1178675 Koukounas, E., & McCabe, M. (1997). Sexual and emotional variables influencing sexual response to erotica. Behaviour Research and Therapy, 35, 221–230. doi: 10.1016/S0005-7967 (96)00097-6 Lawrence, A. A. (2017). Autogynephilia and the typology of male-tofemale transsexualism: Concepts and controversies. European Psychologist, 22, 39–54. doi: 10.1027/1016-9040/a000276 Lehmiller, J. J. (2015). A comparison of sexual health history and outcomes among monogamous and consensually nonmonogamous sexual partners. The Journal of Sexual Medicine, 12, 2022–2028. doi: 10.1111/jsm.12987 Moors, A. C. (2016). Has the American public’s interest in information related to relationships beyond “the couple” increased over time? The Journal of Sex Research. doi: 10.1080/00224499.2016.1178208 Moors, A. C., Matsick, J. L., & Schechinger, H. A. (2017). Unique and shared relationship benefits of consensually nonmonogamous and open relationships. European Psychologist, 22, 55–71. doi: 10.1027/1016-9040/a000278 Rubel, A. N., & Bogaert, A. F. (2015). Consensual nonmonogamy: Psychological well-being and relationship quality correlates. The Journal of Sex Research, 52, 961–982. doi: 10.1080/ 00224499.2014.942722

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Rusbult, C. E. (1980). Commitment and satisfaction in romantic associations: A test of the investment model. Journal of Experimental Social Psychology, 16, 172–186. doi: 10.1016/ 0022-1031(80)90007-4 Published online March 23, 2017

Justin J. Lehmiller Department of Counseling Psychology, Social Psychology, and Counseling Ball State University 2000 W. University Ave. Muncie, IN 47306 USA justin.lehmiller@gmail.com

European Psychologist (2017), 22(1), 1–4

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Justin J. Lehmiller, PhD, is the Director of the Social Psychology Program at Ball State University, Muncie, IN and a Faculty Affiliate of The Kinsey Institute. His research focuses on sexual fantasy, casual sex, and consensually non-monogamous relationships. He is the author of a textbook entitled The Psychology of Human Sexuality.

Ó 2017 Hogrefe Publishing


Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science Original Articles and Reviews

Controversies of Women’s Sexual Arousal and Desire Meredith L. Chivers1 and Lori A. Brotto2 1

Department of Psychology, Queen’s University, Kingston, ON, Canada Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada

2

Abstract: The past three decades have seen an unprecedented increase in empirical research on women’s sexual response. In this review, we critically examine current controversies and assumptions associated with the nature of women’s sexual arousal and desire. We focus specifically on four assumptions: (1) the assumption that women should be aroused by stimuli that align with their stated preferences, (2) the assumption that women’s physiological and self-reported arousal should perfectly align, (3) the assumption that sexual desire precedes sexual arousal, and (4) the assumption that a single pharmaceutical compound will adequately restore women’s sexual response to her level of satisfaction. Engaging a gendered psychological framework for conceptualizing women’s sexuality, we emphasize the need for models of women’s sexual response to be sensitive to the sexed biological processes and gendered psychosocial factors that contribute to a woman’s unique sexual experience. Keywords: women, sexual desire, sexual arousal, sexual psychophysiology, sexual functioning

The past three decades have seen an unprecedented increase in empirical research on women’s sexual response. Researchers and clinicians have made significant inroads in terms of understanding the physiological, psychological, and experiential components of women’s sexuality. These changes are in recent revisions to the DSM-5 (American Psychiatric Association, 2013). Prior to the mid to late 1990s, women’s and men’s sexual response were mostly viewed as complementary, as two sides of the same coin (Chivers, 2005). As such, multiple perspectives on women’s sexuality, including models of sexual response, the nature of sexual desire, and expressions and treatment of women’s sexual concerns, were thought to be identical to those of men, albeit embodied within differently sexed forms. More recently, however, this genderless perspective on sexuality has been challenged as inadequately capturing women’s unique experiences (Brotto, 2010; Chivers, 2005, 2010, 2016). In this review, we will focus on current controversies associated with women’s sexual arousal and desire, which we will also refer to collectively as “sexual response.” Specifically, we review a number of misconceptions regarding women’s sexual response in the context of conceptualizing and assessing typical function, concerns about sexual response, and approaches to treatment. First, we will consider the assumption that women should be

Ó 2017 Hogrefe Publishing

sexually aroused only by stimuli that align with their stated sexual desires. Second, we will consider the assumption that physiological and psychological components of sexual response should correspond perfectly. Third, we will review assumptions regarding the relationships between desire and arousal and their temporal association. Fourth, we will briefly discuss current evidence-based treatments of women’s sexual difficulties. Before we engage in these controversies, however, we first provide an overview of models of sexual response and assessment of sexual response in laboratory and clinical settings.

Models of Sexual Response Original conceptualizations framed sexual desire as spontaneous, preceding arousal and emerging from internal drive states, much like hunger or thirst. Stemming from the foundational psychophysiological research of Masters and Johnson (1966, 1970) and expanded upon by Kaplan (1977) and Lief (1977), this view posited that sexual response unfolded in a linear, tri-phasic manner for women and men: sexual desire was the instigator of a sequence of events leading to arousal and eventual orgasm. Manifestations of sexual desire, such as number of sex acts or orgasms, were considered bona fide behavioral

European Psychologist (2017), 22(1), 5–26 DOI: 10.1027/1016-9040/a000274


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M. L. Chivers & L. A. Brotto, Controversies of Women’s Sexual Arousal and Desire

indicators, reflecting the “sum of the forces that incline us toward and away from sexual behavior” (Levine, 2002, pp. 47). Sexual desire and arousal were, therefore, viewed as distinct and sequential phases of sexual response. The relationship between sexual arousal and sexual desire, and their temporal associations, has since been hotly debated (Brotto, Graham, Binik, Segraves, & Zucker, 2011; DeRogatis, Clayton, Rosen, Sand, & Pyke, 2011; Everaerd, Laan, Both, & van der Velde, 2000; Meana, 2010). The linear model sharply delineated sexual desire and arousal as distinct aspects of sexual response, paving the way for a diagnostic system where disorders of sexual desire were distinct from disorders of sexual arousal (American Psychiatric Association, 2000). This approach did not, however, adequately characterize women’s experiences of sexual arousal and desire. For many women, distinction between sexual desire and arousal is artificial (Beck, Bozman, & Qualtrough, 1991; Brotto, Heiman, & Tolman, 2009; Graham, Sanders, Milhausen, & McBride, 2004). Validated measures of sexual functioning are often unable to separate desire from arousal items (Dennerstein, Lehert, & Burger, 2005; Rosen et al., 2000), and there is considerable comorbidity between disorders of sexual desire and sexual arousal (Bancroft, Graham, & McCord, 2001; Fugl-Meyer & Fugl-Meyer, 2002; Laumann, Paik, & Rosen, 1999; Rosen, Taylor, Leiblum, & Bachmann, 1993; Segraves & Segraves, 1991). A newer model of sexual response, the Incentive Motivation Model (IMM; Singer & Toates, 1987; Toates, 2009), proposes, instead, that sexual desire and arousal are reciprocally-reinforcing, such that sexual desire emerges from experiencing sexual arousal, and that arousal reinforces sexual motivations. Processing of a sexual stimulus automatically engages cognitive and physiological systems preparing the body for sexual activity, producing sexual arousal and triggering responsive sexual desire. Stemming from Emotion Theory (Lang, 1987; as summarized in Everaerd et al., 2000), the IMM posits that sexual motivation is not located “within” the individual, as a traitlike phenomenon, but, rather, is contextually-dependent (Singer & Toates, 1987). The IMM also posits that sexual response arises from the interplay between a sensitive sexual response system, determined by biological factors (hormones and neurotransmitters) as well as (conditioned) expectations based on past experiences, and an effective sexual stimulus. Individual differences in “arousability” also impact the strength and direction of the emerging sexual response, influenced by neurophysiological, personal, psychological, and cultural factors (Laan & Both, 2008). The IMM identifies sexual response, like other emotions, as responsive, and it challenges previous conceptualizations European Psychologist (2017), 22(1), 5–26

that situate sexual desire within an individual. It may be that sexual desire and arousal, while still framed within an incentive framework, may be phenomenologically distinguished for the individual. For example, feelings of sexual arousal may represent an awareness of genital changes resulting from sexual stimulation, perhaps combined with a conscious evaluation that the situation is indeed sexual. Sexual desire, on the other hand, may represent the experience of a willingness to behave in a sexual way, and takes place when feedback from physical changes goes beyond the threshold of perception (Laan & Both, 2008; Prause, Janssen, & Hetrick, 2008). In what follows, we distinguish between arousal and desire as a means of organizing existing research on sexual response.

Laboratory and Clinical Assessment of Sexual Response Sexual Arousal Sexual arousal is a term used to describe the physiological and psychological phenomena occurring in parallel with the emotional experience of sexual response (Chivers, Suschinsky, Timmers, & Bossio, 2013). Sexual psychophysiology is the measurement of this response, and involves the assessment of central and peripheral physiological changes reflecting activation of the autonomic nervous system by sexual stimuli. Nonspecific increases in sympathetic nervous system tone (e.g., cardiovascular and respiratory responses) are accompanied by increases in pelvic muscle tone (Zuckerman, 1971). Increases in heart rate and blood pressure lead to increased blood flow to the genitals, resulting in genital vasocongestion (Levin & Riley, 2007), the most reliable and valid physiological change associated with sexual response, in terms of specificity to processing sexual stimuli (Laan, Everaerd, & Evers, 1995; Suschinsky, Lalumière, & Chivers, 2009). Genital vasocongestion in women manifests as vulvar, clitoral, and vaginal vasoengorgement, genital lubrication, and increased tactile sensitivity (Paterson, Amsel, & Binik, 2013; Paterson, Jin, Amsel, & Binik, 2014). Most sexual psychophysiology methods assess the initial phases of genital vasocongestion, autonomic activity, and affective responses, though measurement of somatic, cognitive, and experiential aspects of orgasm are becoming more available (e.g., Patterson et al., 2013). The hormonal complement to sexual response is also becoming more routinely assessed as researchers recognize the dynamic and responsive nature of androgens, such as testosterone, to sexual stimuli (Goldey & van Anders, 2011). Ó 2017 Hogrefe Publishing


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Genital Measures of Women’s Sexual Response Vaginal Photoplethysmography (VPP) The most commonly used method of assessing genital vasocongestion in the vaginal capillary bed is the vaginal photoplethysmograph (VPP). The vaginal photoplethysograph (VPP; Palti & Bercovici, 1967) is a clear tamponshaped plastic probe containing a light source (e.g., infrared light-emitting diode, LED) and a light detector (photoresistor), and is the most commonly used means of assessing genital vasocongestion in women (see Chivers et al., 2013 for detailed explanation). VPP output is filtered to extract the AC coupled signal component, vaginal pulse amplitude (VPA), which is thought to reflect the dynamic changes in vasocongestion with each heartbeat, with higher amplitudes indicating higher levels of arousal (Prause & Janssen, 2005). Though some debate exists as to the actual physiological process assessed by VPP (e.g., vasomotion vs. vasocongestion; Levin & Wylie, 2008), the device shows good measurement properties in terms of discriminant, predictive, and construct validity (see Chivers, Seto, Lalumière, Laan, & Grimbos, 2010, for a review and discussion). Its relative ease of use and low cost makes it an attractive choice, however, most researchers recognize that vaginal hemodynamics do not represent the totality of changes to the female genitals during sexual response. Thermography Genital vasocongestion increases genital skin temperature (Henson, Rubin, Henson, & Williams, 1977; Webster & Hammer, 1983), a response that can be validly measured using surface thermistors (Henson & Rubin, 1978; Payne & Binik, 2006; Prause & Heiman, 2009; Webster & Hammer, 1983) and thermographic cameras (Kukkonen, Binik, Amsel, & Carrier, 2007, 2010). Labial temperature change is generally correlated with changes in vaginal vasocongestion assessed using VPP (Henson & Rubin, 1978; Henson, Rubin, & Henson, 1979; but see Prause & Heiman, 2009), as is thermal imaging (Huberman, Dawson, & Chivers, 2016). Discriminant validity of thermal imaging, for example, distinguishing between women with and without sexual difficulties, has not been demonstrated, however, this is not atypical for sexual arousal concerns among women (see Sarin, Amsel, & Binik, 2015); many investigators have reported similar patterns of genital vasocongestion among women with and without sexual arousal difficulties (see Brotto, Chivers, Millman, & Albert, 2016 for a discussion). Other Methods Less commonly used measures of women’s genital sexual response include laser Doppler imaging (LDI), which measures cutaneous blood flow to the vulvar skin through laser imaging (Waxman & Pukall, 2009), Doppler Ó 2017 Hogrefe Publishing

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ultrasound (Kukkonen et al., 2006), which is useful for targeted assessment of circulation to genital tissues, and clitoral photoplethysmography (CP), which is used for measuring clitoral blood volume changes during sexual response (Gerritsen et al., 2009; Suschinsky, Shelley, Gerritsen, Tuiten, & Chivers, 2016). Direct measures of vaginal/vulvar lubrication have been developed (see Dawson, Sawatsky, & Lalumière, 2015, for a discussion), but few have been implemented in clinical and experimental research. A novel and easy-to-use measure was recently developed by Dawson et al. (2015) who demonstrated response specificity with a litmus measure of introital moisture associated with sexual response. Pelvic floor surface electromyography has also been used to assess muscle tone associated with sexual response (Both & Laan, 2007), with preliminary data suggesting that intravaginal electromyography (EMG) is specific to processing sexual stimuli (Both, van Lunsen, Weijenborg, & Laan, 2012). Subjective Sexual Arousal The subjective component of sexual response reflects a person’s psychological experiences (e.g., memories, cognitions) along with their appraisals and integration of physical sensations (genital responses and general physiological responses) in response to a sexual stimulus (Laan & Both, 2008; Prause & Heiman, 2010). Self-report measures are most often used to assess individuals’ subjective experiences and can take a number of forms. The most routinely used involve reporting feelings of sexual arousal following stimulus presentation using discrete items with Likert-type scales (e.g., How sexually aroused do you feel? How strong were your genital sensations?) or contiguously reported feelings of sexual response during stimulus presentation using a lever, mouse, or keypad (Rellini, McCall, Randall, & Meston, 2005). Both methods are reliable, valid, and typically strongly correlated, but contiguous reporting is less prone to impression management bias (Huberman, Suschinsky, Lalumière, & Chivers, 2013). Cognitive Measures of Sexual Response Sexual response is accompanied by a host of cognitive and emotional processes that are not specific to processing sexual stimuli, but can be broadly defined as occurring along the sequence of cognitive and neural events involved in stimulus detection, processing, appraisal, and response generation (see Chivers et al., 2013). A number of researchers have employed cognitive/affective paradigms to objectively assess sexual attractions in the context of forensically-significant sexual interests, such as pedophilia, where self-report may not be reliable, and where genital measurement may not be feasible; Chivers (2016) provides a detailed discussion of cognitive/affective methods to assess sexual interest throughout early stages of cognitive

European Psychologist (2017), 22(1), 5–26


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and affective processing components of women’s sexual response. For example, eyetracking can be used to detect capture of attention by specific categories of sexual stimuli, a behavioral correlate of sexual interest and motivation. These paradigms may also be helpful for understanding how sexual stimuli activate different components of the sexual response system in the context of women’s sexual functioning.

Sexual Desire Reconceptualizing sexual desire as a motivational state that is evoked by sexual stimuli, and responsive to contextual factors, significantly influences how and when desire is assessed. By far, the most common methods of assessing sexual desire use self-report, with the majority of measures based on the assumption that sexual desire is a stable, traitlike, and tonic phenomenon. First we review common selfreport methods, then we discuss how the presence of sexual cues leads to sexual arousal and motivated sexual behaviors, and last we consider how arousal and desire shift depending on the sexual cues that are present. Because of the largely state-like nature of sexual desire, we argue that most of the conventionally used measures of desire provide an imprecise estimation of women’s experiences. Self-Report Measures The 14-item Sexual Desire Inventory-2 (SDI; Spector, Carey, & Steinberg, 1996) is one of the most widely used measures of trait-based sexual desire, with good discriminant and convergent validity. It is considered by some to be a more comprehensive measure of sexual desire because it assesses both individual and relational desire by assessing desired frequency of sexual activity through masturbation and with a partner. In clinical contexts, the 19-item Female Sexual Function Index (FSFI; Rosen et al., 2000), popularized in clinical trials throughout the 2000s, is the most widely used measure of sexual functioning due to its brevity and availability of cut-scores validated in clinical samples (Gerstenberger et al., 2010). Desire is assessed with two items about frequency (from never to always) and intensity (from none at all to very high) of sexual desire over the past 4 weeks. Criticisms of the FSFI are that desire is limited to frequency and intensity, it is not valid in women who are not engaging in sexual behavior, and that women may have difficulty rating their own sexual desire retrospectively and without reference to a particular sexual encounter (Forbes, 2014; Forbes, Baillie, & Schniering, 2014; Meyer-Bahlburg & Dolezal, 2007). Moreover, changes in a woman’s responsive sexual desire will not be captured by existing trait-based measures. Both the 14-item Changes in Sexual Functioning Questionnaire (Clayton, McGarvey, & Clavet, 1997) and the 22-item Brief Index of Sexual Functioning European Psychologist (2017), 22(1), 5–26

for Women (Taylor, Rosen, & Leiblum, 1994) assess desire across two subscales: desire/frequency and desire/interest, and are sensitive to changes following treatment (e.g., Shifren et al., 2000). The 13-item Sexual Interest/Desire Inventory (SIDI; Clayton et al., 2006) takes a more multidimensional view of sexual desire, and assesses the frequency of sexual activity, fantasy, degree of enjoyment with erotic material, and pleasure when thinking about sex. In addition to these correlates of desire, the SIDI also assesses a woman’s frequency of initiating sex, her receptivity to sex, and her satisfaction with desire (Clayton et al., 2006). A notable criticism of these measures of sexual desire is that they tap into sexual desire as conceptualized as a trait phenomenon (e.g., Forbes, 2014; Forbes et al., 2014). Because sexual desire is understood to be responsive to adequate cues or triggers within an incentive motivation framework, this suggests that current measures may offer only an imprecise picture of a woman’s experience. As a result, some have assessed state sexual desire by asking about desire to masturbate (one item) and desire for sex with a partner (one item) immediately following an arousal-inducing stimulus (Dawson & Chivers, 2014a, 2014b). One question from the “Arousal Continuation” domain of the SIDI that may be relevant to the concept of responsive sexual desire asks participants to rate the strength of their sexual desire “once you started to become sexually aroused.” Future research should seek to validate new measures of state sexual desire that could be amenable to the at-home situation. Qualitative and Clinical Interviews Open-ended interviews (Brotto et al., 2009) and focus groups (Graham et al., 2004) aimed at exploring how women experience sexual response shed light on the ways women experience and express sexual arousal and desire (Meana, 2010) that may not be captured by self-report questionnaires. Tolman and Szalacha (1999) used both qualitative and quantitative methods to examine sexual desire in adolescent girls, and differences in how it was experienced between urban and suburban girls. Although approximately two-thirds of the girls reported experiencing sexual desire using quantitative measure, urban girls discussed how they sacrificed sexual pleasure to protect themselves from negative consequences (e.g., pregnancy, AIDS), and suburban girls described more sexual curiosity coupled with conflict given negative cultural messages regarding expression of women’s sexuality. In the clinical setting, experts recommend a comprehensive clinical interview with recall of recent and more distant situations in which sexual desire was and was not experienced. The context of those situations, details about the partner, and a thorough consideration of the woman’s thoughts, emotions, and behaviors leading up to and during Ó 2017 Hogrefe Publishing


M. L. Chivers & L. A. Brotto, Controversies of Women’s Sexual Arousal and Desire

the sexual encounter, are often probed (Brotto & Laan, 2015). It is also generally accepted that questions about the kind of sexual activity that she desires may reveal that her sexual desire is stimulus- and context-dependent (and responsive). Recommendations from an international consensus panel argue that none of the validated measures of sexual desire or arousal substitute for a thorough and thoughtful clinical interview (Brotto, Bitzer, Laan, Leiblum, & Luria, 2010). In the absence of a stimulus- and contextdependent assessment of desire, it may not be possible to decipher whether a woman’s reportedly low level of sexual response is adaptive to her particular context, or if it reflects a true sexual dysfunction. Behavioral Measures The IMM proposes that sexual arousal and desire emerge in the presence of sexual incentives. The strength of sexual motivation is influenced by the reward value of incentives, and, after arbitration, may or may not be expressed as sexual behavior. Using behavioral measures, sexual desire could be assessed by assessing frequencies of sexual activity. Although desire may lead to sexual behavior, this does not necessarily mean that behavior is a valid and reliable index of sexual desire. In terms of the validity of this approach, several gendered factors need to be considered. Gender norms (Alexander & Fisher, 2003), reporting biases (Fisher, Moore, & Pittenger, 2012), and practical restrictions (Dawson & Chivers, 2014a) on expressions of sexual motivation are all factors that might influence whether desire manifests as overt behavior; indeed, desire in the absence of sexual action or behavior is more frequently observed among women than men (Baumeister, Catanese, & Vohs, 2001; Graham et al., 2004; Hill, 1997; Regan & Berscheid, 1995). Women have traditionally been socialized to espouse more conservative sexual attitudes and suffer more severe social consequences for being sexually expressive and assertive than men, called the sexual double standard (Jonason & Fisher, 2009). As such, using only behavioral assessments of sexual desire may significantly underestimate a woman’s sexual motivation. Alexander and Fisher (2003) examined the influence of gender stereotypes on the reporting of sexual behaviors using a bogus pipeline paradigm. In this experiment, participants were told that the veracity of their responses could be detected while they responded to questions about their sexuality. Under the bogus pipeline, women reported more sexual partners, consistent with the prediction from the sexual double standard hypothesis. Gender stereotypes may have a similar impact on the reporting on the frequency of sexual thoughts. In an ingenious study where women and men recorded the frequency of sexual and nonsexual thoughts throughout the day using a golf tally counter, Fisher et al. (2012) Ó 2017 Hogrefe Publishing

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demonstrated that observed gender differences in frequency of sexual thoughts may relate to a broader gender difference in frequency of needs-based cognitions; overall, men reported more frequent needs-based cognitions, for sleep and for food, as well as sex. Women’s reported frequency of behaviors may also be influenced by gendered physiological and cultural factors relating to menses, pregnancy, lactation, childbirth, periand post-menopause transitions, all normal and expected developmental fluctuations throughout a woman’s sexual career. Framing these fluctuations in behavioral expressions of sexual desire as deficits overlooks the gendered environmental conditions, within the woman, in her sexual relationships, and her broader social context, that might impact her sexual expression. Sensitivity to sexual cues, and attractions to sexual partners, also fluctuate with a woman’s hormonal cycles. Marked increases in sexual desire related behaviors have been reported during ovulation (e.g., Beck et al., 1991; Dawson, Suschinsky, & Lalumière, 2012; Hill, 1997; Hill & Preston, 1996; Impett & Peplau, 2002, 2003; Meston & Buss, 2007), suggesting a greater sensitivity and proceptivity (Diamond & Wallen, 2011; Diamond et al., 2016) to sexual cues at midcycle. Sexual behavior can occur for many reasons, some of which are not directly related to sexual desire per se, such as stress reduction, to attain resources or status, or to boost self-esteem (Beck et al., 1991; Hill, 1997; Hill & Preston, 1996; Impett & Peplau, 2002, 2003; Meston & Buss, 2007). Similarly, the goals of sexual behavior may not simply be sexual activity or pleasure, and therefore may not reflect sexual desire. Some women with and without sexual difficulties have reported desiring enhanced intimacy rather than sexual activity (Brotto et al., 2009; Mark, Fortenberry, Herbenick, Sanders, & Reece, 2012); other scholars suggest that the sexual reward of being desired (Meana, 2010) may be particularly potent among women, and that enhancing women’s self-consciousness of herself as an object of desire may be one means of cultivating sexual desire (Bogaert & Brotto, 2014). The relationship context of sexual desire must also be considered. The IMM proposes that level of sexual motivation is influenced by the hedonic quality of sexual cues that may change over time, likely owing to habituation to sexual cues (Dawson & Chivers, 2014c); sexual desire declines throughout a relationship and can be reinvigorated with a novel sexual partner (Dennerstein et al., 2005; Klusmann, 2002). Objective assessment of sexual motivation may circumvent these concerns by, instead, assessing the action tendencies or automatic physiological responses that are associated with sexual desire. For example, Both and colleagues have examined Achilles tendon reflex (T-reflex) modulation – a reliable indicator of motor preparation (Both, Everaerd, & Laan, 2003; Both, Spiering, European Psychologist (2017), 22(1), 5–26


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Everaerd, & Laan, 2004; Both, van Boxtel, Stekelenburg, Everaerd, & Laan, 2005) and showed sensitivity to cues of sexual stimulus intensity. Moreover, T-reflexes show predictive validity, being positively associated with selfreported sexual behaviors in the 24 hr post-testing (Both et al., 2004). Reconceptualizing sexual desire as a motivational state, emerging from sexual arousal, several investigators have examined the contextual and stimulus factors influencing responsive desire. These studies have shown that women’s desire for sex with a partner, and to masturbate, assessed using self-report measures, can fluctuate within a short time frame in response to sexual stimuli (and at levels that are similar between women and men; Both et al., 2004; Dawson & Chivers, 2014a; Goldey & van Anders, 2012). Dawson and Chivers (2014a, 2014b) and Schmidt (1975) have also reported that both preferred and nonpreferred sexual stimuli (relative to participants’ sexual orientation) can activate responsive sexual desire in women, reflecting a larger body of research showing significant variation in the relationships among sexual attractions and sexual response in women (see later in this review). Application of cognitive and affective methods of assessing sexual response may also prove useful in providing a quantitative measure of sexual motivation (Chivers, 2016).

Assumption #1: Women Should Only Respond Sexually to Stimuli That Align With Stated Sexual Desires and Attractions A growing body of research has focused on the relationships among women’s sexual attractions (e.g., sexual orientation, a directed form of sexual desire) and sexual response. The relationship between subjective and genital measures of sexual arousal shows systematic variation within women, providing an opportunity to explore the unique features that elicit a sexual response among women. The first of these variations is the category-specificity of sexual arousal. In this context, specificity refers to the degree to which self-reported sexual attractions and sexual desires correspond with patterns of self-reported and genital sexual response to categories of sexual stimuli depicting or describing individuals or activities associated with sexual attractions. In the standard specificity paradigm, responses to preferred and nonpreferred sexual stimuli are compared, with a nonspecific pattern emerging when the individual shows significant activation to both categories of stimuli that are significantly greater than to neutral European Psychologist (2017), 22(1), 5–26

stimuli. The most commonly investigated dimension of specificity of sexual response is sexual orientation, most often interpreted as directions of gendered sexual attractions to adult women (gynephilia hereafter), to men (androphilia), or both (ambiphilia). Sexual orientation can, however, be an umbrella term comprised of multiple dimensions, such as age/sexual maturity (as in the case of the chronophilias, see Seto, 2016), sexual activity preferences (see Chivers, 2016), subjective/nonsubjective sense of sexual identity (as in the case of asexuallyidentifying individuals, see Brotto & Yule, 2016), and a host of other dimensions including partner number orientation and nurturance (van Anders, 2015). With respect to gender attractions, sexual responses are more variably associated in women than typically observed in men. Androphilic women (typically heterosexuallyidentified) exhibit a gender-nonspecific pattern of genital response, that is, similar levels of genital response to sexual stimuli depicting their preferred gender or their nonpreferred gender (Bossio, Suschinsky, Puts, & Chivers, 2014; Chivers & Timmers, 2012; Peterson, Janssen, & Laan, 2010; Steinman, Wincze, Sakheim, Barlow, & Mavissakalian, 1981; Suschinsky et al., 2009; Wilson & Lawson, 1978). Self-reported sexual arousal is more variably gender-specific among androphilic women, with some studies reporting greater sexual arousal to sexual stimuli depicting men compared to women (e.g., Chivers, Rieger, Latty, & Bailey, 2004; Chivers, Roy, Grimbos, Cantor, & Seto, 2014; Chivers & Timmers, 2012; Schmidt, 1975; Suschinsky et al., 2009), while others have reported gender-nonspecific self-reported sexual arousal (Bossio et al., 2014; Chivers & Bailey, 2005; Chivers, Seto, & Blanchard, 2007; but see also Pulverman, Hixon, & Meston, 2015, who reported category-specific genital and self-reported response in androphilic but not gynephilic women). Gynephilic women (typically lesbian-identified) show gender-specific patterns of genital response in studies employing stimuli that depict or describe solitary women and men (Chivers, Bouchard, & Timmers, 2015; Chivers et al., 2007), and gender-nonspecific genital responses when stimuli depict couples engaging in sexual activity (Chivers et al., 2004; Peterson et al., 2010; Wincze & Qualls, 1984). More consistently than androphilic women, however, gynephilic women report gender-specific sexual arousal, though exceptions have been reported (e.g., Pulverman et al., 2015). Ambiphilic women’s sexual response has received relatively less attention. Two recent studies suggested that ambiphilic women’s sexual responses, both genital and self-reported, are significantly greater to female than male sexual stimuli across two modalities of stimuli: audiovisual (Timmers, Bouchard, & Chivers, 2015) and narrative (Bouchard, Timmers, Ó 2017 Hogrefe Publishing


M. L. Chivers & L. A. Brotto, Controversies of Women’s Sexual Arousal and Desire

& Chivers, 2015). Another study examining self-reported responses only found a gender-nonspecific pattern, consistently with what might be expected for a bisexual woman (Blackford, Doty, & Pollack, 1996). Gender-nonspecific response among androphilic women is not an artifact of the sexual stimuli typically employed in a specificity paradigm (i.e., usually audiovisual films of coupled sex; e.g., Bossio et al., 2014; Chivers et al., 2004, 2007; Peterson et al., 2010). Studies experimentally varying the intensity of sexual activity (Chivers et al., 2007), stimulus modality (e.g., recorded narratives; Chivers & Timmers, 2012), types of sexual activities (Chivers et al., 2014), and relationship contexts (Chivers & Timmers, 2012) depicted in sexual stimuli all report gender-nonspecific genital responses among androphilic women, ruling out the conclusion that the gender-specific responding is attributable to the type of stimulus used. This pattern of responding is also not moderated by menstrual cycle phase because androphilic women show gender-nonspecific responses in both fertile and nonfertile phases of their cycle (Bossio et al., 2014). The complexity of the relationships between gendered sexual attractions and women’s sexual response in women was recently underscored by Chivers et al. (2015) who demonstrated, across two studies using different stimulus modalities, that only exclusively androphilic women show gender-nonspecific genital responses. Women reporting any degree of gynephilia, even among those who selfidentify as heterosexual (and are predominantly androphilic), showed significantly greater response to female versus male sexual stimuli. Self-reported arousal was more variable but generally associated with women’s stated sexual attractions. This finding is particularly noteworthy given the implications of understanding how preferred and nonpreferred sexual cues become sexually salient and capable of activating the sexual response among women with no history of sexual attractions or behaviors with women. For example, exclusively androphilic women, that is, women reporting no sexual attraction or prior sexual history with women, showed significant sexual response to both female stimuli and male sexual stimuli, a pattern that is counter to their self-reported sexual attractions. This suggests that direct sexual experience with a sexual stimulus, or self-declared preference for a particular category of sexual stimuli, is not necessary to evoke a significant physical sexual response in women. Concerns regarding the reliability of nonspecific sexual response center on methods of assessing genital response. All the studies that have detected gender-nonspecific genital response use VPP; therefore, it is natural to wonder if the device cannot provide discriminant data. We can rule out this explanation since gender-specific response patterns have been reported for gynephilic cisgender women, Ó 2017 Hogrefe Publishing

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gynephilic transgender women, and androphilic transgender women (Chivers et al., 2004), and, as will be later discussed, for other sexual orientations. Additionally, we (Huberman & Chivers, 2015) recently demonstrated gender-nonspecific VPA and genital temperature response to solitary masturbation stimuli using concurrent thermography and vaginal photoplethysmography (VPP). Gendernonspecific sexual response is also not limited to genital responses assessment only (for a review, see Chivers, 2016). Patterns of gender-nonspecific activation of sexual response in androphilic women have been demonstrated at most if not all levels of sexual response, including early visual attention to sexual stimuli measured using eyetracking, cognitive interference measures, viewing time, cortical measures of sexual stimulus processing using electroencephalograms, and functional magnetic resonance imaging (fMRI) assessment of neural responses. Many of these same studies have shown gender-specific patterns of response among gynephilic women (see Chivers, 2016). Meaningful associations between sexual response and other dimensions of women’s sexuality have, however, been demonstrated. Sexual activity preferences, such as preferences for conventional sex acts versus sexual masochism (Chivers et al., 2014), are associated with significantly greater genital and subjective sexual response to narratives describing conventional sex acts than those describing sexual masochism. Notably these effects were mostly independent of the gender of actor described in the stimulus, suggesting that individual differences in sexual activity preferences may also be more relevant to women’s sexual response than gender cues. Sociosexuality, one’s willingness to engage in sexual activity as a function of relationship commitment, is also associated with greater genital response to narratives describing sex with unfamiliar than familiar persons, and higher genital response to stimuli depicting low versus high relationship commitment (Timmers & Chivers, 2012). These effects were most pronounced for male sexual stimuli among androphilic women, suggesting that the stimulus cues of relationship context interact with individual differences in sociosexuality and gender attractions to influence patterns of sexual response. Women’s genital responses have also been found to vary more strongly with relationship context cues than with gender cues (Chivers & Timmers, 2012), with greatest genital response to stranger and long-term partner versus friendship conditions, but did not differentiate between stories describing women or men; self-reported responses, on the other hand, were gender-specific. Indeed, contextual elements of sexual stimuli have been theorized as relevant to women’s sexual response (e.g., Basson, 2000; Rupp & Wallen, 2007), thus we could speculate that preferred sexual activity cues, certain relationship European Psychologist (2017), 22(1), 5–26


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contexts, and other contextual features might be more salient to eliciting women’s sexual response than the gender of the sexual stimulus. In an indirect test of this hypothesis, we used images of sexually-aroused genitals to examine whether core sexual stimuli, unlike the context-laden complex stimuli such as films, stories, and interpersonal interactions, would be associated with gender-specific responses in androphilic women (Spape, Timmers, Yoon, Ponseti, & Chivers, 2014). Both genital and subjective sexual responses were significantly greater to male than female prepotent sexual stimuli, the only published study thus far demonstrating gender-specific genital response in androphilic women, other than Pulverman et al. (2015). Other features of sexual stimuli, such as relationship context, sexual activities depicted, and a host of other possible cues, are also capable of activating sexual response in women. In a practical sense, women can become aroused by a broad range of sexual cues, including seeing her (male) partner’s arousal, countering long-held myths about women’s sexual response being less visual, or negative associations with seeing a partner’s genitals. The most frequent misinterpretation of gendernonspecific sexual response among androphilic women reflects assumptions that genital responses are truer reflections of women’s sexual desires than her self-reported feelings of sexual arousal, or self-described sexual attractions. A common confusion from this research is that androphilic women must be ambisexual/bisexual because these women physically respond to sexual images of both women and men. The conceptual incoherence of this argument becomes apparent when considering the broader research showing women can experience genital responses to depictions of nonhuman primate sex acts (Chivers & Bailey, 2005; Chivers et al., 2007) and depictions of heterosexual rape (Both et al., 2004; Laan, Everaerd, van der Velde, & Geer, 1995; Suschinsky & Lalumière, 2011; Suschinsky et al., 2009). If genital response is an objective indicator of women’s “true” sexual desires, then we are left with the disturbing and false conclusion that women are sexually aroused by depictions of sexual assault, even in the notable absence of self-reported feelings of sexual arousal. As we recently commented, “Sexual identity (how the individual conceptualizes and socially describes their patterns of sexual attractions and desires), sexual attractions (sexual orientation), and sexual response (sexual arousal and desire) are not interchangeable constructs in women, such that a woman’s sexual desires and attractions can be deduced from sexual response patterns (Chivers et al., 2015, pp. 15).” Instead, the variation in the genderand activity-specificity of women’s sexual response provides an opportunity to understand factors associated with the incentivization of sexual cues in women. European Psychologist (2017), 22(1), 5–26

Assumption #2: Physiological and Psychological Components of Women’s Sexual Response Should Align Variation in the specificity of sexual response highlights the capacity for components of women’s sexual response to operate with some independence. Agreement between multiple measures of a phenomenon is traditionally an index of its construct validity (Campbell & Fiske, 1959). Given this precept, it is therefore reasonable to question whether the low(er) sexual concordance observed among women assessed using VPP, typically in the direction of significant genital response in the absence of concomitant self-reported arousal, might suggest that the VPP is not a valid measure of women’s sexual response. Indeed, debate exists regarding the validity of models of sexual response whereby genital and affective responses are expected to be strongly related among women (cf. Basson, 2000). The case of sexual concordance, or agreement between genital and subjective states of sexual response, provides a second example of systematic and meaningful variability in physiological-psychological aspects of sexual response in women. The most conclusive evidence regarding women’s sexual concordance comes from a meta-analysis conducted by Chivers and colleagues (2010) quantifying the often-reported gender difference in sexual concordance. Chivers, Seto, Lalumière, Laan, and Grimbos (2010) noted that, although women’s sexual concordance tends to be lower on average than men’s (average Pearson r = .26 compared with r = .66 for men based on total samples of 2,505 women and 1,918 men), the confidence intervals for these estimates do not include 0, as would be expected if genital and subjective sexual responses were unrelated. In the meta-analysis, we explored a number of methodological and theoretically-informed factors to understand the wide variation observed in women’s sexual concordance. Higher concordance among women was associated with variability in stimulus content, intensity, or modality (r = .49), methods of calculating concordance (when operationalized as an individual difference, using within-subjects correlations, r = .43), and method of assessing genital response, such that genital temperature methods yield higher estimates than VPP (.55 vs. .26, respectively). Remarkably, however, some have concluded from these meta-analytic data that sexual concordance assessed using VPP is negligible, for example, “most studies have found weak to non-existent relationships between VPA and self-reported sexual response” (Kukkonen, 2014, p. 31), and “there are mixed findings though most studies have low to no correlation” (Kukkonen, 2014, Ó 2017 Hogrefe Publishing


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p. 34) or even that women’s sexual responses are “discordant.” Additional misconceptions frame sexual concordance through a gendered lens, relative to men’s typically higher concordance, with the tacit assumption that higher concordance is a more valid expression of sexual response; women’s lower sexual concordance is therefore, in relative terms, viewed as deficient or problematic. Although women show lower sexual concordance than men do, on average, lower sexual concordance among women is not universal. There is significant variation in agreement between physiological and subjective components of sexual response among women, regardless of methodology used to assess this relationship. Among women without sexual concerns, individual sexual concordance estimates vary widely. Some women’s reports of sexual arousal are unrelated or even negatively related to genital responses, whereas other women show large and positive correlations between sexual affect and genital arousal, even for thermographic assessments of genital response (Kukkonen, 2014; Kukkonen et al., 2007). Variation such as this strongly suggests the presence of moderators in the agreement of components of sexual response (Boyer, Pukall, & Holden, 2012). For example, in the meta-analysis, we estimated average sexual concordance correlation for women with various sexual difficulties (n = 235) as .04 ( .10 to .17) versus .26 (.21 to .37) for women without sexual difficulties (n = 1,144). In subsequent studies of clinical populations, lower sexual concordance has been reported for women with subtypes of DSM-IV female sexual arousal disorder (FSAD) (Meston, Rellini, & McCall, 2010) and FSAD and low desire (DSM-IV hypoactive sexual desire disorder, HSDD; Sarin et al., 2015). Among healthy women, several studies report higher concordance among women who more frequently experience orgasm (Adams, Haynes, & Brayer, 1985; Brody, 2007; Brody, Laan, & van Lunsen, 2003), also suggesting an association between concordance and sexual functioning. In a recent study of women seeking treatment for low sexual desire, the mean concordance estimate was 0.30, and it ranged considerably from .90 to +0.91 (Brotto et al., 2016). In this study, increased concordance was not associated with greater clinical symptoms of sexual desire or distress; however, this may have been limited by the sample size. Taken together, this body of research consistently finds overall low agreement between genital and self-reported sexual arousal; however, the considerable range evidenced in concordance suggests that, for some women, there is strong alignment between the physical and mental aspects of sexual response, whereas for other women, these components may indeed be “discordant.” Rather than viewing such nonalignment as indicative of faulty instrumentation, or a sign that women may be Ó 2017 Hogrefe Publishing

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consciously evading a declaration of sexual arousal, researchers should seek to understand the contributors (and possibly enhancers/inhibitors) to sexual concordance.

Assumption #3: Sexual Desire Precedes Sexual Arousal Although the general concept of sexual desire emerging after sexual arousal had been acknowledged by Helen Singer Kaplan (1979), it was Basson who developed this concept more fully for clinical populations, proposing a circular sexual response cycle model for women and men (Basson, 2000, 2001). Basson’s model articulated that the starting point in a sexual encounter is the individual’s consideration of reasons for engaging in sexual activity. Motivation for sex that stemmed from sexual desire experienced spontaneously, or “out of the blue,” was not the main trigger for women (Meston & Buss, 2007). Meston and Buss (2007), Impett et al. (Impett, Peplau, & Gable, 2005; Impett, Strachman, Finkel, & Gable, 2008), and others have identified a vast array of reasons why women engage in sexual activity, ranging from a wish for emotional intimacy, to expressions of love, to seeking revenge, versus a primary need to relieve sexual tension. Basson’s (2000, 2001) model normalized receptivity to sexual activity for non-desire related reasons, and posited that once physical signs of arousal emerged, and as long as the stimuli continued to be effective and the context in which they were delivered was appropriate for women, then the desire for ongoing sexual stimulation (i.e., responsive sexual desire) was accessed. At this point in the cycle, women had both their initial motivations for engaging in sexual activity (which may have been nonsexual) fulfilled, plus their now accessed responsive sexual desire further motivating them throughout the sexual encounter. If the outcome was experienced as rewarding for the woman (i.e., emotionally and/or physically, as in the case of orgasm), such rewards may impact her motivation for sex on a subsequent encounter. If the outcome of the event was negative (e.g., her desire for emotional connection was not fulfilled), this would negatively impact her motivation for sex in the future. Although theoretically and clinically useful, one significant criticism of Basson’s (2001) model of responsive sexual desire is that it has not (yet) been directly empirically tested (Segraves & Woodard, 2006) and may apply only to women with sex-related concerns. Indeed, women with lower scores on the FSFI were more likely to endorse the circular/responsive desire cycle, even though about equal groups of women endorsed the circular sexual European Psychologist (2017), 22(1), 5–26


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response cycle versus linear models of sexual response (Giraldi, Kristensen, & Sand, 2015; Sand & Fisher, 2007). In contrast to these studies, Nowosielski, Wróbel, and Kowalczyk (2016), and Brotto et al. (2009) found that sexual functioning did not predict adoption of the different models. In their study of women with a variety of DSM-5 sexual dysfunctions (with 80% of them meeting criteria for Sexual Interest/Arousal Disorder) and sexually healthy controls, Nowosielski et al. reported that over a quarter of the women (28.7%) endorsed a linear model, and only 19.5% of women endorsed a circular-type model (with nonsexual motives for sexual activity) but the majority of participants (40.8%) endorsed a model with a combination of sexual and nonsexual reasons for engaging in sexual activity. It is also worth noting that methodological flaws in these studies (Giraldi et al., 2015; Sand & Fisher, 2007) such as concerns regarding order of presentation, model complexity, and differences in model accuracy may have impacted participants’ endorsement of the different models (Brotto, Graham, Paterson, Yule, & Zucker, 2015). Most recently, and contrary to prevailing myths about the ever-ready and spontaneous potency of men’s sexual desire, an Australian study of 573 men found that men were more likely to endorse a circular model of sexual response compared to the linear “desire first then arousal” model of Masters and Johnson (Connaughton, McCabe, & Karantzas, 2016). Thus, it seems as though prevailing beliefs about the relationship between desire and arousal in women may also apply to men. Individual endorsement of models is one method of assessing validity: Empirical research testing theoreticallyinformed predictions regarding the nature of sexual motivation is another. A programmatic body of research from The Netherlands (e.g., Both et al., 2003, 2004; Everaerd & Laan, 1995; Laan & Everaerd, 1995; Laan, Everaerd, et al., 1995) has tested and found support for an Incentive Motivation Model (Toates, 2009) of sexual response, which accounts for the research findings of desire-arousal overlap. Further research in clinical populations testing predictions from the IMM will be useful in identifying effective treatment targets, in addition to addressing controversies regarding spontaneous versus responsive sexual desire. It is unfortunate that the circular sexual response cycle has been misinterpreted as suggesting that women’s motives for sex are entirely nonsexual given that a careful reading of the model clearly demonstrates that nonsexual as well as sexual motives may move a woman from neutral toward being receptive to sexual stimuli. More broadly, and in line with IMM, it is likely that this distinction between “spontaneous” and “responsive” sexual desire is false; after all, the model asserts that sexual response is just that – a response, and that what European Psychologist (2017), 22(1), 5–26

spontaneous sexual desire may, in fact, reflect is that the triggers are not apparent to the woman. That sexual desire emerges “spontaneously” is also not supported by the evidence. In a direct comparison of women without sexual problems to women scoring low on the sexual desire subscale of the FSFI, McCall and Meston (2006, 2007) found that what distinguished the two groups was not whether one group experienced desire in the absence of triggers and the other group experienced it in response to triggers, as might be predicted by the Sand and Fisher (2007) study, but rather in the variety of cues that elicited motivation for sex. Specifically, women with sexual dysfunction had a smaller range of cues. There is also some evidence that some women with low sexual desire may have a blunted sensitivity to sexual stimuli (Bloemers et al., 2013). Further support for the dissolution of a “spontaneous desire” concept stems from findings of the “Study of Women’s Health Across the Nation” which found that among the 2,400 women sampled, 41.4% reported that they never or infrequently felt sexual desire prior to sex (Avis et al., 2005); however, nearly all of the sample reported moderate to extreme levels of sexual satisfaction. Moreover, even among women who report high levels of sexual arousal, the majority (85%) reported that they at least occasionally began a sexual encounter with no awareness of sexual desire but then experience responsive desire as the encounter unfolds (Carvalheira, Brotto, & Leal, 2010). Interestingly, although Kaplan introduced the term “spontaneous sexual desire” (Kaplan, 1977, 1979), a more careful investigation of her description reveals that it made room for the responsive, or triggered, nature of sexual response, compatible with a model of incentivized sexual response. Specifically, spontaneous desire was defined by Kaplan as desire triggered by internal stimulation, which, upon further reflection, depicted a responsive model of desire, but one in which the triggers (or stimuli) are internal (or perhaps unconscious) rather than external. When considering the IMM, which predicts that sexual desire and arousal emerge simultaneously in response to effective (competent) sexual stimuli, what may appear to be “spontaneous desire” may actually reflect an individual’s inability to identify those triggers (Both, Laan, & Schultz, 2010; Both et al., 2004). We agree that “spontaneous sexual desire” is a misnomer, and we encourage researchers to cease making distinctions between “spontaneous” and responsive sexual desire in their work, and instead, to work toward better identifying triggers for sexual response that fall within and outside of the individual’s subjective awareness. As articulated in an excellent review of the spontaneous-responsive sexual desire debate by Meana (2010), we support her recommendation that the field “stop making spontaneous sexual desire the default explanation when we fail to identify a sexual stimulus” (p. 117). Ó 2017 Hogrefe Publishing


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State Versus Trait Sexual Desire As introduced in the earlier section on self-report measures of sexual desire, another important consideration of sexual response relates to its state versus trait properties. A trait view of sexual response aligns with the historic “internal combustion” model that postulates that sexual desire resides within an individual, is tonic, and shows interindividual variation, with men typically having more sexual desire than women. As articulated more fully by Dawson and Chivers (2014a), the trait model of desire frames it as an aspect of personality similar to trait theory, which states that traits are relatively stable and enduring across time and contexts (Eysenck & Eysenck, 1985). Many existing selfreport measures of sexual response (e.g., FSFI; Rosen et al., 2000; SDI, Spector et al., 1996) adopt a trait-like approach to assessing sexual desire wherein an individual is asked to recall the intensity and frequency of sexual desire (or arousal) over a specified period of time. However, these measures have been criticized as lacking in content validity and failing to capture the responsive nature of women’s sexual desire, which is contextually- and situationallydependent (Dawson & Chivers, 2014a; Forbes, 2014; Forbes et al., 2014). In contrast to predictions from trait theory, sexual response in women is highly variable, both between and within women (Meana, 2010). One implication of studying state versus trait sexual desire is that it may help to clarify whether or not gender differences exist in the experience of sexual desire. As noted by Dawson and Chivers (2014a), gender differences emerge when desire is measured as a trait (i.e., enduring and temporally stable) but not when measured as a state (i.e., responsive sexual desire following exposure to sexual stimuli), calling into question many of the prevailing conclusions about men having more sexual desire than women (Baumeister et al., 2001). Additionally, experimental paradigms have shown that when trait measures of desire, such as the SDI, are adapted to be administered before and after presentation of erotic stimuli, they are sensitive to arousal induction and potentially tap into state desire, whereas trait desire is not similarly responsive in men (Goldey & van Anders, 2012). It is possible that considering sexual desire as a state versus a trait may help to reconcile the somewhat paradoxical findings in the literature which find low levels of sexual desire in samples of women despite their reported high levels of sexual satisfaction. For example, in a sample of community-recruited women aged 40–60, reports of “spontaneous” sexual thoughts (tapping into a trait-like sexual desire) were low, and the majority of women, across menopausal categories, reported the frequency of sexual thoughts as occurring mostly “never” or “once/month” (Cawood & Bancroft, 1996). Nonetheless, most of the sample reported a high level of sexual satisfaction. An earlier random sample

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of 40-year-old Danish women found that a significantly greater proportion of women endorsed sexual desire in response to something the partner did (i.e., state desire) as opposed to having sexual desire at the outset (i.e., trait desire) (Garde & Lunde, 1980). Similarly, 78% of women in the Study of Women’s Health Across the Nations engaged in sexual activity and the majority were physically, emotionally, and sexually satisfied, experienced physical pleasure, almost always experienced arousal, and usually did not have pain (Cain et al., 2003). Yet, most of the women reported infrequent (presumably trait) sexual desire (0–2/month). We would posit that had the sexual desire of these samples of women been assessed during a sexual encounter that they would have reported state-dependent sexual desire. Such a possibility remains open to empirical study. One important clinical implication of adopting a state-like view of sexual response is that for women who may believe that they have “lost their sexual desire,” or that their sexual desire is fundamentally (and permanently) lower than their partner’s, it may be fruitful for them to reframe their desire as responsive and explore the triggers of their sexual response. In other words, moving away from a pathologizing deficit model of sexual function, women may be encouraged to explore the variety of different elicitors of sexual desire, to consider their effects across contexts, and to appreciate their interaction with emotional states. In adopting a state model of sexual response, women may come to experience that a key inhibitor of sexual desire pertains more to restricted exposure to effective sexual cues, rather than her own innate deficit of desire. Treatment-outcome research in women’s sexual desire has unfortunately adopted solely trait-based assessments that ask the woman to recall “how much sexual desire” she had over the past month. The content validity of these measures of desire has been questioned (e.g., Forbes et al., 2014) and some experts have advocated that researchers cease using these measures to capture changes in sexual desire within treatment-outcome research (Forbes, 2014). We agree that advancements in the science of improving women’s sexual desire are dependent on the availability of more comprehensive and valid measures of sexual motivation.

Assumption #4: Pill Versus Skill: Restoring Brain Chemistry Is Sufficient for Cultivating a Satisfying Sexual Experience in Women Until now, we have focused our remarks on sexual response, and we have considered the contextual,

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stimulus-dependent, individual, and relational factors that elicit sexual response. Several large population-based studies have found that a significant proportion of women experience difficulties with sexual response, and that for some of those women, the distressing nature of those symptoms can persist for years (or decades). Cross-sectional, population-based studies of Western samples report that between 30% and 41% of women have experienced low sexual desire lasting several months over the past year, and between 7% and 10% of women report these problems plus significant associated distress (Mitchell et al., 2013; Shifren, Monz, Russo, Segreti, & Johannes, 2008). Rates appear to be even higher in non-Western samples of women, and a multinational study of individuals aged 40–80 in 29 countries found that the prevalence of a lack of interest in having sex for 2 months or more was particularly pronounced among women residing in Middle Eastern and Southeast Asian nations (up to 43% of women) (Laumann et al., 2005). Difficulties with sexual desire/arousal continue 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) state that their low sexual desire is the main source of their distress (Hayes, Bennett, Fairley, & Dennerstein, 2006).

Psychological Treatments Surprisingly, given the high prevalence of sexual response concerns among women, there are relatively few controlled treatment-outcome studies evaluating psychological therapies. Two treatment modalities, cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy (MBCT), involve skills aimed at challenging problematic thoughts that interfere with sexual response (in the case of CBT) and enhancing sensitivity to sexual stimulation through attentional mechanisms (in the case of MBCT). CBT is a change-oriented approach that involves identifying and challenging problematic beliefs that give rise to sexrelated avoidance and negative emotions. MBCT, on the other hand, espouses an acceptance-based approach, and involves the cultivation of present-moment, nonjudgmental awareness, without any deliberate attempt to change one’s experience. Unlike pharmaceutical approaches to treating women’s low sexual desire, which rest on the assumption that an imbalance in neural transmitters is the cause of women’s loss of sexual desire (Kingsberg, Clayton, & Pfaus, 2015), psychological approaches adopt a broader approach to addressing low sexual desire by considering the whole woman in the context of her environment, relationship, culture, and society. 1

Cognitive Behavioral Therapy A recent meta-analysis by Frühauf, Gerger, Schmidt, Munder, and Barth (2013) identified a total of 20 studies focused on women with sex-related difficulties that included a wait-list control group, and another eight studies that included direct comparisons with other therapies; however, only four of those studies were focused on women with low sexual desire. The interventions were largely cognitive behavioral and included behavioral skill training to improve communication between partners, increase sexual skills, and reduce sexual and performance anxiety. The meta-analysis found an overall large effect size of d = 0.91 for the primary endpoint of low desire and a moderate effect on improving sexual satisfaction, d = 0.51. These treatment gains, along with quality of sexual and marital life, sexual satisfaction, perception of sexual arousal, sexual self-esteem, depression, and anxiety, persist up to a year following treatment. Notably, partner presence during therapy is a significant predictor of better outcomes (Günzler & Berner, 2012). Unfortunately, there have not been any controlled psychological treatment outcome studies focused specifically on women with (genital) sexual arousal complaints. Of note, however, given our support for the IMM, which considers sexual desire and arousal as emerging simultaneously in response to effective stimuli within a responsive sexual system, we would predict that approaches found effective for women with low desire for sex would also be effective for sexual arousal. Not surprisingly, past studies showing the efficacy of CBT for women with low desire typically also found significant improvements in self-reports of arousal. In spite of a moderate/strong effect size for CBT in the treatment of low sexual desire, it bears mentioning that the change-based approach of CBT does not fit for all treatment-seekers (Mace, 2005), highlighting the need to consider other psychological treatment approaches. Considering this through the lens of IMM, approaches designed to target the relationship between awareness of (competent) sexual stimuli and responsive sexual desire may hold promise for improving sexual response. One approach that lends itself to this particularly well is mindfulness meditation. Mindfulness-Based Cognitive Behavioral Therapy Mindfulness is described as “non-judgmental, presentmoment awareness” and has long-standing roots in Buddhist meditation (Austin, 1999). Since 2003, mindfulness1 has been studied in the context of treating a variety of women’s sex-related difficulties. Although a

The instructions in a mindfulness-based approach guide the participant to focus their attention on a particular target (e.g., the breath), to notice when the mind wanders, and to guide attention compassionately and nonjudgmentally back to the target.

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number of small noncontrolled trials have found 3–4 sessions of group or individual mindfulness to improve sexual arousal and desire (Brotto, Basson, & Luria, 2008; Brotto, Heiman, et al., 2008), to date there have been only two published studies using a control group (Brotto & Basson, 2014; Brotto, Erskine, et al., 2012) and one study that compared mindfulness to CBT (Brotto, Seal, & Rellini, 2012). Compared to a wait-list control group, women receiving three monthly mindfulness sessions had significant improvements in sexual desire (d = 1.07), arousal (d = 1.34), lubrication (d = 1.37), orgasm (d = 0.73), satisfaction (d = 0.97), and sex-related distress (d = 0.89), and effects were retained at a 6-month follow-up assessment (Brotto, Erskine, et al., 2012). In another study employing a group format and a larger sample, mindfulness-based therapy led to significant improvements, compared to wait-list control, in sexual desire (d = 0.97), sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning (from d = 0.75 to d = 1.07) (Brotto & Basson, 2014). Compared to group CBT, group mindfulness led to significant increases in subjective-genital concordance in a sample of women with sexual distress associated with a history of childhood sexual abuse (Brotto, Seal, et al., 2012). The mechanisms by which mindfulness-based therapy leads to improvements in sexual desire and other domains of function have only begun to be explored, and may include improvements in ability to attend to physiological sexual arousal, reduced anxiety and spectatoring (or, watching oneself critically), improvements in mood, and reduced distraction and inattention. In a recent study, four sessions of group mindfulness similarly led to significant increases in sexual concordance (Brotto et al., 2016), and multilevel modeling revealed that changes in subjective sexual arousal predicted changes in genital response, but not the reverse. One mechanism by which mindfulness may increase sexual response is through increasing sexual interoception, the ability to perceive sexual sensations during sexual response in the laboratory. In a study of reaction time to sexual stimuli, Silverstein, Brown, Roth, and Britton (2011) found decreased reaction time following mindfulness training, and they speculated that this reflects an increase in interoceptive awareness (awareness of internal bodily sensations). Further evidence that mindfulness may improve sexual functioning by targeting interoceptive awareness comes from the finding that mindfulness training induces functional changes in the insula (an area of the brain associated with awareness of body states), and that it decreases activation of the amygdala and areas of ventromedial prefrontal cortex (Hölzel et al., 2011) associated with emotions. Experienced meditators have been found to maintain body awareness during periods of distraction, and this was associated directly with activity in the insula (Hölzel et al., 2011). Ó 2017 Hogrefe Publishing

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Extrapolating these findings to sexual response, mindfulness training may strengthen the association between a (sexual) stimulus and reward, and/or it may expand the range of (sexual) stimuli that are considered rewarding. For example, throughout these practices, women may have appraised stimuli in a more sexual (and less judgmental or negative) manner, and this may have triggered sexual response. Mindfulness also enhances attention (as reviewed by Wolkin, 2015), and by becoming experienced with sustained attention, women’s attention toward sexual stimuli and away from multiple distractions could have also increased sexual response. Mindfulness is not intended to “reassure women that it is normal to have no desire,” as postulated by pro-drug critics of the applicability of mindfulness for women’s sexuality (Pyke & Clayton, 2015a, 2015b), nor is it meant to cement women where they are (“stuck in the Basson model”; Pyke & Clayton, 2015a, p. 1977). Sadly, this view perpetuates a reductionistic understanding of women’s sexuality and stalls progress on psychological approaches for women. Moreover, it denies the prospect of bolstering the sexual response by teaching women to refocus attention to the present-moment sexual situation, thereby increasing the effectiveness of sexual stimuli to trigger responsive desire and to boost interoceptive awareness. Although this hypothesis is supported by neuroscientific data showing the mechanisms of mindfulness in other patient populations and conditions, these insights remain to be tested in samples of women with sex-related difficulties.

Pharmaceutical and Hormonal Treatments Sildenafil Citrate (Viagra) Following the approval of sildenafil citrate for men’s erectile dysfunction in the late 1990s, there was an intense race to find a medication for the treatment of female sexual dysfunction. Even sildenafil citrate (Viagra) held promise for several years as a treatment for sexual arousal disorder in women, and a small number of uncontrolled studies reported improvements to physical arousal impairments (e.g., Berman et al., 2001) and orgasm latency (Basson & Brotto, 2003). Although sildenafil produced modest increases in VPP-assessed vaginal vasocongestion (see Chivers & Rosen, 2010, for a review), self-reported feelings of sexual response were more strongly related to treatment expectancies. In a placebo-controlled study assessing expectancy effects, women who believed that had received sildenafil reported greater feelings of sexual arousal, regardless of whether they had receive placebo or active medication (Laan et al., 2002). Also problematic is the underlying assumption that increasing genital response should resolve sexual response concerns. This gender-blind approach assumes that women’s and men’s sexual European Psychologist (2017), 22(1), 5–26


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response, particularly the relationship between psychological and physiological sexual arousal, follows similar mechanisms, despite clear evidence to the contrary (Chivers & Rosen, 2010). Sildenafil also failed as a treatment for the much more common symptom of low sexual desire (Berman et al., 2003), and the sponsor stopped funding clinical trials. Testosterone (T) The role of sex steroids in sexual response is poorly understood, however, testosterone treatment for low desire is currently widely prescribed without regulation. Guidelines from the 2009 International Consultation on Sexual Medicine suggest that testosterone therapy is effective for postmenopausal women with low desire, but its use is strictly “off-label,” it should not be used long term, and it is not recommended for pre- or perimenopausal women (BioSante Pharmaceuticals, 2011; Wierman et al., 2010). In 2005, a transdermal form of testosterone became available in Europe for estrogen-treated women who had loss of sexual desire and bilateral oophorectomy plus hysterectomy. Notably, the testosterone patch was removed from the European market in 2012 for commercial reasons. Since then, other hormonal agents (e.g., tibolone, DHEA; Nappi & Cucinella, 2015) have also been the focus of study, but lack of effectiveness, a large placebo response, and concerns about side effects contributed to no hormonal agents being approved by the US Food and Drug Administration. Given the strong placebo response in testosterone trials with women (Bradford & Meston, 2009), concerns about its safety, and the relative lack of attention to psychosocial or contextual mediators of effect, testosterone administration alone is unlikely to address the psychological components, such as sexual concordance, thought to be integral to experiencing sexual desire. Moreover, the bulk of research examining the testosterone-desire link has focused on trait or baseline levels of serum or salivary testosterone and self-reported measures of sexual desire with mixed results (Alexander, Dennerstein, Burger, & Graziottin, 2006; Gerber, Johnson, Bunn, & O’Brien, 2005; Riley & Riley, 2000; Turna et al., 2004). Sex steroids are not static, but responsive to social contexts (Alexander et al., 2006; Gerber et al., 2005; Riley & Riley, 2000; Turna et al., 2004), therefore investigating testosterone responses to sexual stimuli may be more informative than trait levels in understanding its links to sexual desire. Testosterone is proposed to modulate responses to sexual stimuli over a course of hours or days (Bloemers et al., 2013), thereby increasing the salience of sexual stimuli (Goldey & van Anders, 2012) and a woman’s sensitivity to future sexual stimuli (Both, Everaerd, & Laan, 2007). Responsive testosterone is significantly associated with

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women’s self-reported desire for solitary sexual activity, and with mental and physical sexual arousal in nonlaboratory environments (van Anders, Brotto, Farrell, & Yule, 2009), despite lack of associations between perceptions of genital response, subjective arousal, and dyadic sexual desire. Although statistically significant T increases following exposure to sexual stimuli have not been observed in healthy women (van Anders, Hamilton, Schmidt, & Watson, 2007; Heiman, Rowland, Hatch, & Gladue, 1991), small sample sizes, stimulus quality, and the lack of a neutral stimulus condition may be associated with null effect. Experiments involving sexual thoughts or dyadic sexual activity have been found to increase testosterone in women (Dennerstein, Hayes, Sand, & Lehert, 2009; Goldey & van Anders, 2012) suggesting that the effects of sexual stimuli on testosterone are mediated by other factors. Flibanserin, Lybrido, and Lybridos The pharmaceutical treatment landscape changed in August 2015 when flibanserin (trade name Addyi), then owned by Sprout Pharmaceuticals, became the first nonhormonal medication to be approved by the Food and Drug Administration for the treatment of premenopausal hypoactive sexual desire disorder. Flibanserin is a centrally-acting medication purported to increase dopaminergic activity and inhibit serotonergic activity, though no study to date has demonstrated resolution of neurotransmitter “imbalances” (i.e., that restoration of the brain’s dopamine, norepinephrine, and serotonin levels mediates flibanserin’s effects on desire) in flibanserin-treated women with low sexual desire. Concerns over interactions with alcohol, prescriber restrictions, and modest efficacy data, however, have been identified as shortcomings of the medication (e.g., Basson, Driscoll, & Correia, 2015), and demand for the drug in its first months of availability was very low. Furthermore, a meta-analysis of published and unpublished studies of flibanserin showed a mean increase of only 0.5 sexually satisfying events per month in the face of clinically significant risk of dizziness, somnolence, nausea, and fatigue (Jaspers et al., 2016). And although number of sexually satisfying events marginally increased, daily diary studies showed no increases in sexual desire or sexual satisfaction. Most recently, two combination pharmacological treatments, Lybrido (0.5 mg testosterone in a cyclodextrin carrier combined with 50 mg sildenafil citrate) and Lybridos (0.5 mg testosterone in a cyclodextrin carrier combined with 10 mg buspirone), have received much attention because their innovative mechanisms of action tap into the multiplicity of the sexual response system. Lybrido was found to improve sexual desire among women with relative insensitivity to sexual cues whereas Lybridos was effective Ó 2017 Hogrefe Publishing


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among women with strong inhibitory mechanisms (Bloemers et al., 2013; Poels et al., 2013; van Rooij et al., 2013). Each drug combination is designed to address central and peripheral mechanisms of response and putative factors influencing response; testosterone increases sensitivity of the sexual response system to sexual cues, and buspirone reduces inhibition of response; each combination therefore facilitates central processing of sexual stimuli and, with the addition of sildenafil, produces greater genital vasocongestion. Lybridos, in particular, may prove effective for attenuating inhibitory factors, thus allowing sildenafil’s effects on genital arousal to be more readily detected by the woman. Given that both of these medications address the potency of sexual stimuli and the importance of the brain’s processing of those stimuli, it may be that these two medications, which are currently the subject of Phase III clinical trials, possess the most promise for addressing the etiology of women’s impaired sexual responding. These and countless other pharmacological treatments have been disappointing for improving women’s sexual problems. We believe that a single pharmaceutical agent that addresses the multiple underlying contributors to low sexual response does not exist. Furthermore, we reject any treatment approach that fails to be sensitive to the contextual, psychological, relational, and larger sociocultural forces that shape sexual function and inhibit sexual response. When a woman has predominantly unrewarding sexual experiences, there will be very few stimuli that can elicit feelings of arousal. Furthermore, in a predominantly negative relational context, the woman will be reluctant to respond to sexual stimulation. Therefore, stimulation of sexual arousal with medication alone cannot be expected to be very effective (Laan & Both, 2011). Though pro-medication experts criticize psychological treatment outcome research for failing to meet the high methodological standards of drug trials (Pyke & Clayton, 2015b), this view ignores a large body of data repeatedly showing the responsiveness of women’s sexuality to contextual triggers that may offer a more holistic restoration of a woman’s sexual function which a single drug approach can only promise.

Conclusion In this review, we have reconsidered a body of literature that addresses four fundamental assumptions about women’s sexual response which have hampered forward movement in the field of women’s sexuality, and have contributed to a general public ignorance of women’s desire. Though countless other misconceptions continue to pervade sociocultural attitudes toward women’s sexuality, we focused specifically on (1) the assumption that Ó 2017 Hogrefe Publishing

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women should be aroused by stimuli that align with their stated preferences; (2) the assumption that women’s physiological and self-reported arousal should perfectly align; (3) the assumption that sexual desire precedes sexual arousal; and (4) the assumption that a single pharmaceutical compound will adequately restore women’s sexual response to her level of satisfaction. Though there is ample evidence challenging each of these assumptions, misleading headlines such as “The Lies Women Tell About Sexual Arousal?” (Cormier, 2015) and “FDA approves female Viagra” (Ault, 2015) continue to dominate the media and influence public perception about the nature of women’s sexual response. In this review, we have highlighted how models of spontaneous sexual desire are at odds with established psychological theory and data regarding incentive motivation. Similarly, we demonstrated how conceptualizing sexual desire as a trait is counter to a rich body of data suggesting sexual response is an emotional state, sensitive to contextual factors. We emphasized the multidimensional and multidetermined processes that contribute to women’s sexual response, thereby challenging and obviating singledimension approaches that fail to capture the entirety of women’s sexual experiences. In sum, we challenged current conceptualizations of women’s sexuality, and emphasized the need for an empirically-based approach that critically examines the multiple assumptions surrounding women’s sexual response. To move forward, data-driven, psychological models of conceptualizing, assessing, and treating women’s sexual response must continue to be developed, tested, and implemented. Crucial to this process is adopting a gendered approach, where the uniqueness of women’s sexuality is integral to theory development, testing, and clinical practice. Instead of concluding that women’s sexuality is “more complex” than men’s, thereby using male sexuality as a benchmark against which female sexuality is characterized, we encourage other researchers and clinicians to, instead, shed expectations for equivalence or similarity, and consider the gendered factors and sexed biological processes that contribute to a woman’s unique sexual experience.

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Tolman, D. L., & Szalacha, L. A. (1999). Dimensions of desire. Psychology of Women Quarterly, 23, 7–39. doi: 10.1111/ j.1471-6402.1999.tb00338.x Turna, B., Apaydin, E., Semerci, B., Altay, B., Cikili, N., & Nazli, O. (2004). Women with low libido: Correlation of decreased androgen levels with Female Sexual Function Index. International Journal of Impotence Research, 17, 148–153. doi: 10.1038/sj.ijir.3901294 van Anders, S. M. (2015). Beyond sexual orientation: Integrating gender/sex and diverse sexualities via sexual configurations theory. Archives of Sexual Behavior, 44, 1177–1213. doi: 10.1007/s10508-015-0490-8 van Anders, S. M., Brotto, L., Farrell, J., & Yule, M. (2009). Associations among physiological and subjective sexual response, sexual desire, and salivary steroid hormones in healthy premenopausal women. The Journal of Sexual Medicine, 6, 739–751. doi: 10.1111/j.1743-6109.2008.01123.x van Anders, S. M., Hamilton, L. D., Schmidt, N., & Watson, N. V. (2007). Associations between testosterone secretion and sexual activity in women. Hormones and Behavior, 51, 477–482. doi: 10.1016/j.yhbeh.2007.01.003 van Rooij, K., Poels, S., Bloemers, J., Goldstein, I., Gerritsen, J., van Ham, D., . . . Olivier, B. (2013). Toward personalized sexual medicine (part 3): Testosterone combined with a Serotonin1A receptor agonist increases sexual satisfaction in women with HSDD and FSAD, and dysfunctional activation of sexual inhibitory mechanisms. The Journal of Sexual Medicine, 10, 824–837. doi: 10.1111/j.1743-6109.2012.02982.x Waxman, S. E., & Pukall, C. F. (2009). Laser Doppler imaging of genital blood flow: A direct measure of female sexual arousal. The Journal of Sexual Medicine, 6, 2278–2285. doi: 10.1111/ j.1743-6109.2009.01326.x Webster, J. S., & Hammer, D. (1983). Thermistor measurement of male sexual arousal. Psychophysiology, 20, 111–115. doi: 10.1111/j.1469-8986.1983.tb00911.x Wierman, M. E., Nappi, R. E., Avis, N., Davis, S. R., Labrie, F., Rosner, W., & Shifren, J. L. (2010). Endocrine aspects of women’s sexual function. The Journal of Sexual Medicine, 7, 561–585. doi: 10.1111/j.1743-6109.2009.01629.x Wilson, G. T., & Lawson, D. M. (1978). Expectancies, alcohol, and sexual arousal in women. Journal of Abnormal Psychology, 87, 358–67. doi: 10.1037/0021-843X.87.8.358 Wincze, J. P., & Qualls, C. B. (1984). A comparison of structural patterns of sexual arousal in male and female homosexuals. Archives of Sexual Behavior, 13, 361–370. doi: 10.1007/BF01541908 Wolkin, J. R. (2015). Cultivating multiple aspects of attention through mindfulness meditation accounts for psychological well-being through decreased rumination. Psychology Research and Behavior Management, 8, 171–180. doi: 10.2147/PRBM.S31458 Zuckerman, M. (1971). Physiological measures of sexual arousal in the human. Psychological Bulletin, 75, 297–329. Received April 1, 2016 Revision received June 6, 2016 Accepted July 4, 2016 Published online March 23, 2017 Meredith L. Chivers Queen’s University Department of Psychology 218 Craine Hall, 62 Arch Street Kingston, ON K7L 3N6 Canada meredith.chivers@queensu.ca

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M. L. Chivers & L. A. Brotto, Controversies of Women’s Sexual Arousal and Desire

Meredith Chivers, PhD, is an Associate Professor, Queen’s National Scholar, and Canadian Institutes of Health Research New Investigator in the Department of Psychology at Queen’s University, Kingston, Canada. Dr. Chivers’ research program, supported by the Canadian Institutes for Health Research, the Social Sciences and Humanities Research Council of Canada, and the Natural Sciences and Engineering Research Council of Canada, examines gendered sexuality, including sexual psychophysiology, sexual orientations, and sexual functioning, with a focus on women.

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Lori Brotto, PhD, is a Professor in the UBC Department of Obstetrics and Gynaecology and a registered psychologist in Vancouver, Canada. She has recently become Executive Director of the Women’s Health Research Institute of BC. Dr. Brotto holds a Canada Research Chair in Women’s Sexual Health (2016– 2021). She is the director of the UBC Sexual Health Laboratory where research primarily focuses on developing and testing psychological and mindfulness-based interventions for women with sexual desire and arousal difficulties and women with chronic genital pain.

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Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science Original Articles and Reviews

Women’s Sexual Desire Challenging Narratives of “Dysfunction” Cynthia A. Graham,1 Petra M. Boynton,2 and Kate Gould3 1

Department of Psychology, University of Southampton, UK

2

Independent Researcher, East Sussex, UK

3

Department of Applied Social Sciences, University of Stirling, UK

Abstract: Recent changes in the classification of female sexual dysfunction in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the US Food and Drug Administration’s (FDA) approval of the first drug to treat low sexual desire in women (flibanserin) have highlighted the intense focus on sexual desire problems in women. We first discuss the rationale for the DSM changes and outline the DSM-5 criteria for Female Sexual Interest/Arousal Disorder. We provide an overview of some of the key events leading up to the approval of flibanserin for the treatment of hypoactive sexual desire disorder in women, including the role of the “Even the Score” advocacy campaign, that accused the FDA of gender bias in not giving women with sexual desire problems access to treatment options. Incorporating narratives from testimonials of female patients attending the 2014 FDA Patient-Focused Drug Development Public Meeting, we examine some of the prevalent beliefs around sexual “normalcy” and the immutability of sexual desire. We critique how the media and pharmaceutical companies depict sexual norms and female sexual desire and how pharmaceutical trials often narrowly define and assess sexual desire and “sex.” We end with some recommendations for how researchers, clinicians, and journalists can better acknowledge that sex and desire have multiple meanings and interpretations with a view to women being offered a truly informed choice when seeking help for sexual problems. Keywords: sexuality, women, sexual desire, dysfunction, pharmacological treatment

Historical Aspects of the Classification of Female Sexual Dysfunction The concept of “psychosexual dysfunction” first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 1980). The first two versions of the DSM did not include sexual disorders, although “frigidity” and vaginismus were listed in a section on “supplementary terms of the urogenital system” in DSM-I (APA, 1952). DSM-II included dyspareunia as an example of a “psychophysiologic genitourinary disorder in which emotional factors play a causative role.” (APA, 1968, p. 47). Based on the Human Sexual Response Cycle (HSRC) developed by Masters and Johnson (1966), and later expanded to include the desire phase (Kaplan, 1974), a number of psychosexual dysfunctions were introduced in DSM-III (1980), including “inhibited sexual desire” (APA, 1980). In DSM-IV the terminology related to “inhibition” disappeared but psychosexual disorders were still organized around the HSRC model and defined as “disturbances in sexual desire and in the physiological changes that characterize the sexual response cycle” (APA, 1994, p. 493).

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An inherent feature of the HSRC is that it proposes a universal, linear series of “phases” of sexual response – excitement, arousal, orgasm, and resolution – that are essentially the same in women and men. In DSM-IV-TR the essential criterion for Hypoactive Sexual Desire Disorder (HSDD) was identical for women and men: “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity” that causes “marked distress or interpersonal difficulty” (APA, 2000, p. 498). In the last two decades many critiques of both the HSRC and the DSM-IV classification have been put forward (Boyle, 1994; Tiefer, 1991, 2001). Criticisms of DSM-IV included an overemphasis on genital response, inadequate acknowledgment of relationship and partner factors, and the lack of any defined severity or duration criteria (Graham, 2010; Mitchell & Graham, 2008; Tiefer, 1991). For example, the essential criterion for a DSM-IV-TR diagnosis of Female Sexual Arousal Disorder (FSAD) was “an inability to attain, or to maintain. . . an adequate lubrication-swelling response of sexual excitement.” (APA, 2000, p. 500). The criticism regarding absence of any defined severity or duration criteria is supported by the

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fact that many epidemiological surveys have reported extremely high prevalence rates for sexual “dysfunction,” for example, the highly cited figure that 43% of American women have a “sexual dysfunction” (Laumann, Paik, & Rosen, 1999). Surveys that included more stringent severity criteria and assessed individuals’ distress about a sexual problem have consistently produced much lower prevalence rates (Hayes, Dennerstein, Bennett, & Fairley, 2008; Mitchell et al., 2013, 2016; Oberg, Fugl-Meyer, & Fugl-Meyer, 2004; Witting et al., 2008). In the recent UK National Survey of Sexual Attitudes and Lifestyles (NATSAL-3), among sexually active women aged 16–74, the 1-year population prevalence estimate of “lack of interest and arousal” was 6.5%, but after applying severity (6 months or more), duration (always/very often symptomatic), and distress (fairly/very distressing) criteria, the estimate dropped to 0.6% (Mitchell et al., 2016). After the publication of DSM-IV-TR (2000), a number of consultation groups and consensus panels proposed revisions to the DSM classification system (Basson et al., 2000, 2003; Lue et al., 2004). With the exception of the New View classification system (Kaschak & Tiefer, 2001), however, most of the revisions recommended were minor and maintained the HSRC structure of the DSM (Bancroft, Graham, & McCord, 2001). The 5th edition of DSM (APA, 2013) comprised major changes in the classification of sexual disorders, particularly for female sexual disorders (Graham, 2016). Firstly, the diagnostic categories no longer map onto Masters and Johnson’s HSRC phases. The revised definition of sexual dysfunction in DSM-5 reflects this: “a group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure.” (APA, 2013, p. 423). Secondly, specific duration and severity criteria were added to all of the sexual dysfunctions: a requirement that the symptoms must have persisted for a minimum duration of approximately 6 months and have been experienced on all or almost all (approximately 75–100%) of sexual encounters. As in DSM-IV, there is also a requirement that the symptoms cause “clinically significant distress in the individual.” The introduction of more stringent severity and duration criteria was an attempt to distinguish between transient difficulties and more persistent, distressing problems and to “raise the bar” for diagnosis (Graham, Brotto, & Zucker, 2014). Other major changes in DSM-5 were that both Female Sexual Arousal Disorder and Female HSDD were deleted and a new disorder – Female Sexual Interest/Arousal Disorder (FSIAD) – was added. Qualitative, experimental, and clinical studies, in particular research on the incentive motivation model (Chivers & Brotto, 2017;

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Laan & Janssen, 2007), had demonstrated no empirical basis for any distinction between subjective arousal and desire (Laan & Both, 2008; Meana, 2010) (for a more detailed justification for the DSM-5 changes, see Brotto, 2010; Graham, 2010, 2016). The criteria for low sexual desire/arousal were expanded in FSIAD to include subjective, behavioral, and physical aspects of desire/arousal. To meet criteria for FSIAD, a woman needs to meet three of six possible criteria: (1) absent/reduced interest in sexual activity; (2) absent/reduced sexual/erotic thoughts or fantasies; (3) no/reduced initiation of sexual activity and typically unresponsive to a partner’s attempts to initiate; (4) absent/reduced sexual excitement/pleasure during sexual activity on all or almost all. . . sexual encounters; (5) absent/reduced sexual interest in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual); (6) absent or reduced genital or nongenital sensations during sexual activity on all or almost all. . . sexual encounters (APA, 2013, p. 433). This polythetic approach was chosen to recognize the fact that women do not experience desire/arousal problems in a uniform way (Brotto, Graham, Paterson, Yule, & Zucker, 2015). Many studies have demonstrated both women’s (Giles & McCabe, 2009; Sand & Fisher, 2007) and men’s (Connaughton, McCabe, & Karantzas, 2016; Giraldi, Kristensen, & Sand, 2015) sexual experiences do not fit any “one size fits all” model of sexual response. Some authors have asserted that the FSIAD diagnosis replaces the HSRC model as a framework with Basson’s (2000) circular model of sexual response, which emphasizes the role of “responsive” sexual desire rather than so-called “spontaneous” desire (Giraldi et al., 2015; Spurgas, 2016). However, in developing the polythetic criteria for FSIAD no one model of sexual response was privileged (Graham et al., 2014) and, unlike DSM-IV, the criteria allow for the fact that there is variability in how sexual interest/arousal problems may be expressed (Meana, 2010). Other critics have expressed concern that the new criteria will mean that some women who would have met criteria for a DSM-IV diagnosis would no longer do so and would be excluded from treatment (DeRogatis, Clayton, Rosen, Sand, & Pyke, 2011). It is important to note, however, that the explicit duration and severity criteria introduced in DSM-5 were, as discussed above, intended to raise the threshold for diagnosis of a sexual disorder (Graham et al., 2014), given the previous very high prevalence estimates of sexual problems (Laumann et al., 1999).

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Pharmaceutical Treatments for Women’s Low Sexual Desire In parallel with the criticisms of the DSM classification of sexual dysfunction, there has also been a longstanding critique about the growing medicalization of sexuality (Bancroft, 2002; Moynihan, 2003; Tiefer, 2001) that “prescribes and demarcates sexual interests and activity, defining normality and deviance in the language of sexual health and illness” (Tiefer, 2001, p. 65). After the approval in 1998 of sildenafil (Viagra®) for men, there were sustained efforts by pharmaceutical companies to find a “female Viagra” (see Table 1 for a timeline of key events). Creating a market for sexual pharmaceuticals for women included promoting the idea that Female Sexual Dysfunction (“FSD”) was a serious public health concern and an unmet treatment need; Continued Medical Education (CME) workshops, professional meetings, and media all contributed to this process (Cacchioni, 2015). Initial trials of the use of sildenafil for Female Sexual Arousal Disorder proved disappointing (Basson, McInnes, Smith, Hodgson, & Koppiker, 2002) and in 2004 Pfizer discontinued their clinical trials of Viagra® for women with arousal disorders (Mayor, 2004), citing the fact that “men and women have a fundamentally different relationship between arousal and desire” (Harris, 2004). The failure of sildenafil to effectively treat female sexual arousal problems may have been a factor in why attention from pharmaceutical companies shifted to treatment of low sexual desire. There were attempts to gain FDA approval for Intrinsa®, a testosterone patch for treatment in surgically menopausal women, and Libigel®, a transdermal testosterone gel, for postmenopausal women with HSDD.1 In the case of Intrinsa®, concerns over whether efficacy outweighed the safety risks led the FDA to reject the drug (although it was approved in 2006 by the European Medicines Agency, the European counterpart of the FDA, as a treatment for HSDD in women with surgically induced menopause) (see Table 1). Libigel® was not approved by the FDA because of poor clinical efficacy data (Waldman, Shufelt, & Braunstein, 2012). Other more promising drugs to treat women’s desire problems are in development; for example, subcutaneously administered bremelanotide, formally known as PT-141, is a peptide drug (a melanocortin agonist) that is now in Phase III trials as a treatment for FSAD and HSDD (http://www. palatin.com/products/bremelanotide.asp) (Clayton et al., 2016). Lybrido, containing testosterone and sildenafil, and

1

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lybridos, containing testosterone and buspirone (van Rooij et al., 2015), are other drugs intended to treat HSDD in women which are currently at the stage of Phase III trials.

Flibanserin and the Even the Score Campaign The first medication to receive FDA approval for the treatment of HSDD in premenopausal women was flibanserin (Addyi®) in 2015 (see Table 1 for timeline). Flibanserin is a drug with mixed effects on serotonergic and dopaminergic transmitter systems that was originally tested as an antidepressant but was ineffective (Basson, Driscoll, & Correia, 2015). In 2010 the FDA rejected Boehringer Ingelheim’s application for approval because of lack of clinical efficacy in two Phase II trials. Sprout Pharmaceuticals then acquired the drug and reapplied for FDA approval in 2013 with data from a third trial, but again the FDA did not grant approval, citing safety concerns, which included somnolence, hypotension, and syncope, and limited efficacy. The final, and successful, FDA application for the drug was submitted in 2015. Interestingly, this application contained no additional efficacy data and only limited additional safety data (Woloshin & Schwartz, 2016). For example, concerns about possible interactions of flibanserin with alcohol were addressed with a study of 23 men and 2 women. The drug received approval for the treatment of HSDD in premenopausal women in August 2015, but with a “black box warning,” the most serious FDA safety alert, and the inclusion of risk evaluations and mitigation strategies (REMS), requiring prescriber and pharmacy certification to prescribe the medication. Although flibanserin was only approved for premenopausal women, many have argued that it will almost certainly be used “off-label,” for example, among women who are postmenopausal and women with health conditions who were excluded from the trials (Gellad, Flynn, & Alexander, 2015). Since approval of the drug, two systematic reviews and meta-analyses on the impact of flibanserin in women with HSDD have been published (Gao, Yang, Yu, & Cui, 2015; Jaspers et al., 2016). The review by Gao et al. only included published trials, whereas the Jaspers et al.’s review involved both published and unpublished studies. The findings from these reviews differed. While Gao et al. concluded that flibanserin was “an effective and safe treatment for

Because of space constraints, we discuss only a few of the drugs that have been tested, or are under development, to treat sexual desire disorders in women. For a recent review of future treatment targets for female sexual disorders, see Farmer, Yoon, & Goldstein, 2016.

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Table 1. Summary of key events leading up to and beyond the FDA hearings for flibanserin/Addyi® Date

Event(s)

1999

– Journal of the American Medical Association publishes article claiming 43% US women and 31% men have a sexual dysfunction. – Invitation-only pharmaceutical conference “New Perspectives in the Management of Sexual Dysfunction,” Boston.

2000

– FDA approves Eros Clitoral Therapy Device. – Proctor and Gamble begins trials of Intrinsa (testosterone patch). – Second Boston Conference “New perspectives in the Management of Sexual

Cited in/by Laumann et al. (1999), Tiefer (2006), Moynihan (2005)

Tiefer (2006)

Dysfunction.”

– FDA issues draft guidelines for research protocols on drug development for Female Sexual Dysfunction (FSD). As yet these guidelines have not been formalized. – New View Campaign launched. 2001

– Pfizer begins sponsoring Continued Medical Education (CME) courses on

Tiefer (2006)

FSD. – International Society for the Study of Women’s Sexual Health (ISSWSH) launched, followed by regular local meetings and annual conferences. 2003

– Nondrug company funded research from the UK finds far lower levels of reported FSD and desire. Problems clearly linked to mental or physical health problems or relationship/cultural factors.

2004

Nazareth, Boynton, and King (2003), Mercer et al. (2003)

– Drug trials by Pfizer on Viagra for women are discontinued. – Proctor and Gamble files drug application for Intrinsa (see above) for surgically menopausal women who have Hypoactive Sexual Desire Disorder (HSDD). Application withdrawn when FDA raises concerns over risks of breast cancer and coronary heart disease outweighing benefits of drugs. Proctor and Gamble begins funding CME courses on FSD. – New View CME course launched on Medscape.

2005

– Journalist Ray Moynihan claims pharmaceutical industry has created a

Moynihan (2005)

financial market by redefining normal variations in sexual desire as diseases. 2006

– Intrinsa approved by the European Medicines Agency for surgically postmenopausal women with Hypoactive Desire Disorder.

– Vivus Inc. develops Alista testosterone to treat low desire in women but drug fails during trials.

– Boehringer Ingelheim discovers during trials of an antidepressant (flibanserin) that it potentially enhances libido for women. 2008

– A number of surveys are published on the prevalence of Hypoactive Sexual Desire Disorder.

2009

– Boehringer Ingelheim files drug application for flibanserin (aka Girosa) with

Nappi et al. (2010), Shifren, Monz, Russo, Segreti, and Johannes (2008) Snabes and Simes (2009)

FDA. – Off-label prescriptions for testosterone for women with Hypoactive Sexual Desire Disorder are recorded despite no standard guidance on appropriate testosterone therapy for women. 2010

– Flibanserin is rejected in June by FDA advisory panel after trials show drug performs no better than placebo. Following this, in October Boehringer Ingelheim discontinues its development of the drug.

2011

– Sprout Pharmaceuticals acquires flibanserin. FSD (including HSDD) is

described by the FDA as one of 20 core “unmet medical needs” that have no safe/proven treatments. – Trials on a testosterone gel (Libigel) for surgically menopausal women developed by BioSante Pharmaceuticals are discontinued when it performs no better than placebo in trials. (Continued on next page)

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Table 1. (Continued) Date

Event(s)

2012

– Transparency Market Research estimates the global erectile dysfunction market

Cited in/by

(including Viagra, Cialis, Stendra/Spedra, Levitra, Staxyn, MUSE, Zydena, Mvix, and Helleva) is worth $4.3 billion. – European drug marketer for Intrinsa withdraws the drug citing “commercial reasons.” 2013

– HSDD is deleted from the DSM-5 and a new disorder - Female Sexual Interest/

IsHak and Tobia (2013)

Arousal Disorder (FSIAD) - added. FSIAD requires that 3 of 6 possible symptoms be present for at least 6 months and cause clinically significant distress. DSM-5 text stresses need to assess relationship problems, medical, cultural, religious factors, partner difficulties, body image, and existing physical or mental health problems. – Sprout Pharmaceuticals reapplies to the FDA following additional data collected on flibanserin. FDA rejects application requesting further studies due to risks of side effects (somnolence, fainting, dizziness, exhaustion, and nausea) and unknown long-term effects. Concerns outweigh the modest benefit over unknown long-term effects. Sprout later appeals this and applies for a formal Dispute Resolution with the FDA. ISSWSH sends a petition signed by 4,000 people to the FDA. The FDA’s recommendation for more research stands. 2014

– In April a collective of health organizations, including the New View Campaign, Our Bodies Ourselves, the National Women’s Health Network, and the American Medical Women’s Association, write to the FDA’s Director requesting the FDA to reject flibanserin on the grounds that risks outweigh any minimal benefits. – Two months later, on June 24, health and women’s groups, backed by Sprout Pharmaceuticals, introduce “Even The Score” campaign and accuse the FDA of “persistent gender inequality” regarding treatment of sexual problems in women. – October: FDA holds a 2-day hearing on October 27–28 on the “unmet medical need” for treatment of FSD, with the first day a “patient-focused” event. There were some activists in the public comments section at the end of the meeting when anyone wishing to contribute was given 2 min.

2015

– February: Sprout resubmits flibanserin application, including the additional safety

– –

– – – – 2016

studies requested. Three trials were cited that show that between 46 and 60% of the female participants responded to the drug, and that levels of desire and the number of satisfying sexual events increased, and distress levels decreased, at rates modestly higher than placebo. March: “Even the Score” announces 11 members of Congress have written to the FDA Commissioner Margaret Hamburg to urge the approval of flibanserin, in addition to earlier pleas from five other lawmakers. All are Democrats. June 1: An “Even the Score” online petition appears on change.org to change “#HERstory,” urging the FDA to approve flibanserin and garners more than 60,000 signatures. A New View online petition on change.org urging the FDA to reject flibanserin garners 652 supporters. June 4: An FDA advisory committee votes 18-6 to recommend the FDA to approve flibanserin for premenopausal women with conditions – a risk evaluation and mitigation strategy, including warnings not to take the drug with antifungal medications or alcohol. June 5: The stock price of Palatin Technologies, manufacturers of another female desire medication seeking FDA approval, soars 46%, Business Insider reports. August 18: FDA approves flibanserin (Addyi®). The following day Valeant Pharmaceuticals acquired Sprout Pharmaceuticals for $500 million in cash initially and another $500 million in the first quarter of 2016. August 20: Sale of Sprout Pharmaceuticals to Valeant Pharmaceuticals announced. Valeant stock price drops 6%, New York Times reports. Valeant states it will make back investment if sales are $200 million, but potential sales could be greater. October 16: Addyi® becomes available on prescription. There are a reported 227 prescriptions issued in the first month following its release.

– JAMA publishes research overviewing the efficacy of Addyi® finds it ineffective , FDA hearings. compared to placebo while an editorial notes problems with the

Jaspers et al. (2016), Woloshin and Schwartz (2016)

Note. Adapted from 1952 to 2015: The path to “female Viagra” has been a rocky one. Washington Post, August 18, 2015. Retrieved from https://www.washingtonpost.com/news/to-your-health/wp/2015/08/17/female-viagra-could-get-fda-approval-this-week/ Ó 2017 Hogrefe Publishing

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HSDD in women” (p. 2095), Jaspers et al. found that the benefits of flibanserin treatment were “marginal,” particularly when taking into account the significant occurrence of adverse events such as dizziness, somnolence, nausea, and fatigue. One notable difference from the earlier unsuccessful applications was that in the year leading up to FDA approval there was a concerted advocacy campaign (“Even the Score”), supported by some women’s health organizations, health professionals, and patients, and backed by Sprout Pharmaceuticals. The group’s purpose was to increase awareness of HSDD and to address what it considered a “persistent gender inequality” within the FDA regarding treatments for sexual dysfunction. Over the course of the campaign, an online petition was organized, urging the FDA to approve flibanserin (see Table 1). Even the Score argued that the FDA had approved 26 drugs marketed for male sexual dysfunction, compared to zero for women. This claim was misleading; there are no approved medications for low sexual desire for men and almost all of the 26 drugs are either different formulations of testosterone or are PDE5 inhibitors used to treat erectile disorder. The Even the Score campaign gathered momentum and support from congresswomen and some women’s organizations in the months leading up to the first Patient-Focused Drug Development Public Meeting on Female Sexual Dysfunction held at the FDA on October 27–28, 2014 (Tiefer, Laan, & Basson, 2015) (see Table 1). The aim of this initiative was to gain patient input on the impact of FSIAD on women’s daily life and their views on currently available therapies to treat the condition. Women spoke at the meeting about their experiences of sexual problems (termed by the FDA as “testimonials”). The meeting was recorded and the transcripts were made available on the FDA website.2 Taken from the transcripts of the meeting, we examine the narratives of these women about their experience of sexual desire problems and highlight the concepts of normalcy of sexual desire and of expectations regarding treatment of FSD inherent in their accounts.

Women’s Narratives and the FDA-Sponsored Patient-Focused Drug Development Public Meeting Most of the women attending the meeting had sought pharmaceutical treatment (predominantly testosterone 2

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treatment), some were still taking medication, and others had stopped due to side effects and lack of efficacy. Two women had participated in the flibanserin clinical trials, describing themselves as “devastated” when the trials ended (pp. 137, 149). During the trials, both described dramatic effects on their sexual desire: “Going from no thoughts during the day and really no desire, no initiation to suddenly. . . I’d text him in the middle of the day and get a flutter and I did not mean in my heart. . . I began initiating where I had not in a long time.” (p. 148) “Within a couple of weeks [of being on the trial] my feelings had changed dramatically. I had sexual feelings which I had not felt in many, many years. I was the one initiating sex, much to the surprise of my husband, and the experiences were very pleasurable.” (p. 136) Other women described similar feelings. Women talked of wanting to be “the woman my husband married not too long ago” (pp. 134–135) and feeling guilty that their desire for their partners was no longer the same as it was when their relationship began. One woman described this guilt as feeling like “I pulled a bait and switch with my poor husband who is undoubtedly wondering where the old me has run off to.” (p. 134). Wanting to return to the level of sexual desire they experienced earlier in their relationships was a theme that ran through all of the women’s testimonials, whether or not they had explored and/or received treatment. The women spoke of wanting “the closeness, the feeling of well-being that comes with the passionate, satisfying sexual relationship,” (p. 129) and “to want to want it all the time; I want to always desire my husband and I don’t want it to be situational. . . and for it to not cause distress.” (pp. 185–186). One woman described the meaning of sexual desire to her: “Sex is not just about orgasm. I mean a successful or satisfying event for me is more about feeling connected [to my husband] and being close and feeling arousal. . . it is not an issue of being able to have sex because I can perform any time. The difference in desire is that comes from within and that makes me feel alive and like a woman and desirable and feminine.” (p. 121). Lacking such desire, women spoke of feeling “dead inside” (p. 135) and “less of a woman,” (p. 129) as though “my body was like a shell with nothing inside.” (p. 49). For some this lack affected every aspect of their lives, forcing them to structure their lives around it. Some spoke of effects on familial relationships and friendships; others

The transcript of the FDA Patient-Focused Drug Development Meeting can be found at http://www.fda.gov/downloads/drugs/newsevents/ ucm423113.pdf

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told of its impact on their work lives; one woman recounted effects on her ability to concentrate and deal with colleagues. Not surprisingly, many women reported that their loss of desire had impacted their relationships with their partners. Many felt guilty for rebuffing attempts by their partners to initiate sex, some avoiding any situations with the potential for these attempts by, for example, going to bed after their partners and getting up before they woke. This guilt led others to report engaging in what they referred to as “duty sex,” (pp. 78–79) an activity they defined as having sex with their partners out of obligation rather than for pleasure. Aging, childbirth, hysterectomy, breast cancer, the stresses of raising children, depression and anxiety symptoms, fatigue, and side effects from medication, though mentioned by the women, seemed to be dismissed as possible causes or contributors to their lack of desire. There is a sense that the women felt that desire should remain unaffected by anything outside of the bedroom, from the stresses of everyday life to the trauma of cancer. All of the women described their lack of desire in physiological terms and in the context of sexual interactions with their partners: they referred to having intercourse to please their partner despite it giving themselves no pleasure, their partners being understanding, knowing when their testosterone pellets needed to be replaced because their desire level would drop and, discussing their low libido. The women frequently referred to their previous sex lives (when they had sexual desire) as “normal.” Without speaking to the women to clarify their definition of “normal,” (pp. 48, 81, 87) it is not possible to ascertain whether they meant “normal” for them or what they considered normal based on cultural cues. The subject of sexual normalcy on a cultural level was raised by the one woman who was not seeking a pharmaceutical treatment. Her concern over her loss of libido had taken her away from “the pathological” (p. 141) to an exploration of her relationship with her husband and her own feelings about desire. The women attended the FDA meeting to discuss their sexual difficulties, their hopes for treatment choices, their attempts to obtain treatment, and their belief that they have a right to sexual health. However, their dismissal of potential contributors other than physiological ones echoes a medicalized approach to sex encouraged by physicians to whom a number of women said they had received treatment. Subsequent assessment of the lobbying of the FDA (Gellad et al., 2015; Sanders, 2016), along with the testimonies of the women described above, indicates that “sex” is often framed in a highly specific way – although this may not be initially apparent. The next section explores this in more depth, unpacking what “sex” might mean to the public, media, and healthcare professionals and how Ó 2017 Hogrefe Publishing

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sexual desire disorders are marketed to women. We also discuss how definitions (or the lack of definitions) of terms impact on research and on clinical trials.

The Meaning of “Sex” in Research on Women’s Sexual Desire Within research and clinical work it is standard practice to operationalize definitions and clearly understand the meanings of terminologies to be certain all involved – participants, researchers, and wider audiences – will follow and agree upon descriptors used to gather research data and interpret findings. Thus, it would be expected for terms like “sex” to be specifically defined, not least because the term has multiple meanings and understandings across cultures, genders, sexualities, and history (Carpenter, 2001; Jutel, 2010; Pitts & Rahman 2001; Sanders & Reinisch, 1999; Sanders et al., 2010). If this does not happen it is difficult to draw reliable conclusions from studies. While this remains a problem across sex research and is mirrored in much mainstream media coverage and the self-help market (Attwood, Barker, Boynton, & Hancock, 2015), it is particularly a problem in pharmaceutical trials of treatments for low sexual desire in women (Angel, 2012; Moynihan & Mintzes, 2010). This is because “sex” within these clinical trials is often taken to mean penis in vagina (PIV) intercourse. Yet participants may not necessarily conceptualize their sexual lives in this way, and definitions may not capture all of the pleasurable activities women might be engaging in. Where terminologies are not defined, it is unclear when participants are asked about “sex” and “desire,” what they are recalling or recording when they respond to open or closed research questions. “Sex” for participants in research (and society more generally) might include giving/getting masturbation, oral or anal sex; or other activities, including fantasy and role-play, BDSM (bondage and discipline, domination and submission, sadism and masochism), or other pleasurable touch. By not assessing other possible means of enjoying “sex” (or letting participants clearly self-define what their sexual lives entail) there is limited scope for noting exactly where “problems” with desire/ orgasm may exist. This is problematic as it limits both what might be deemed as sex for participants and creates hierarchies where “proper” sex is penetrative and goal-focused with the end aim of it being the “achievement” of orgasm (Angel, 2010; Moynihan & Mintzes, 2010; Wood, Mansfield, & Koch, 2007). Participants in clinical trials who may experience desire, pleasure, or orgasm through activities other than intercourse do not have scope to record those activities and may well be categorized as dysfunctional as a consequence. Moreover, in defining European Psychologist (2017), 22(1), 27–38


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“normal� sex in terms of the frequency of PIV penetrative activity that culminates in male ejaculation, options for exploring pleasure as reported via the media, sex education, therapy, and research are limited, meaning people who may well benefit from having additional means to enjoy sexual pleasure are not informed of their choices (Attwood et al., 2015; Frith, 2015). In turn, this creates both a means of problematizing desire, defining “normality� and offering solutions to fix those who do not fit the following representations of sex and relationships. Examining the publicity materials for Even the Score, press releases, and media coverage) for flibanserin/AddyiŽ, previous iterations of the DSM, the testimonies given at the FDA hearings (see above), and the content of pharmaceutically funded Continuing Medical Education courses and materials, we noted the following broad themes around how sex is represented (see also Fishman & Mamo, 2002; Frith, 2015; Meana, 2010; Moynihan & Mintzes, 2010). We offer these within this paper both as a means of explaining limitations in existing pharmaceutical research and the lobbying of the FDA, and as a framework for future analysis others may wish to embark on.  “Desire� is strong and spontaneous rather than reactive and responsive.  Orgasms are goals to be achieved.  “Sex� is taken to mean PIV intercourse. And “good� or “healthy� sex requires frequent and novel sexual experiences.  While other sexual activities (including but not limited to kissing, cuddles, massage; sharing fantasies; talking about, reading or watching erotica/porn; mutual or solo masturbation; giving or receiving oral sex [including oral or analingus]; using sex toys; BDSM; role-play; anal intercourse) may be mentioned these are not commonly assessed in research on female sexual desire problems. They are presented as precursors or inferior alternatives to PIV intercourse.  Life events, for example, illness, birth of a child should not intrude into the regular schedule of having sex.  Sex is the “glue� that holds relationships together.  Sex is a vital, healthy/healthful, and central part of any relationship.  Male desire and orgasm are uncomplicated and everpresent, women’s desire and orgasm are complex, elusive, and difficult/time consuming to “achieve.� Awareness of underpinning values, limitations, and multiple meanings of core terminologies and assumptions of research, teaching, and classification of problems should be a key component of medical education, clinical trials, and journalism. However, several examples indicate that this has not been the case. Close readings of publicity materials around drug development for women’s lack of European Psychologist (2017), 22(1), 27–38

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desire (Moynihan, 2005; Sanders, 2016) reveal themes that are ahistorical and inaccurate. These include the erroneous claim that women have been historically neglected from, or understudied in, sex research (Hall, 2003) and the misleading statement, discussed above, that there are 26 drugs available to treat sexual disorders in men but none for women. Other rhetorical devices include reclaiming feminist narratives with arguments like “my turn nowâ€? or “my rightâ€? to medication (Gellad et al., 2015; Goldstein, 2009; Sanders, 2016), accompanied by “choice-â€? based arguments such as women ought to have the right to choose drugs that might overcome sexual problems and would be able to weigh up any possible risks associated with any available medication. We consider these approaches to be problematic given how they initially appear to offer informed choices and unbiased information about drugs, but in reality do not alert women to side effects of medications and limitations and biases of existing studies, nor suggest nondrug alternatives that could be attempted to boost desire or enhance sexual enjoyment. Rather than seeing “sexâ€? as varied and diverse – and desire in a similar way – and noting the multiple, legitimate, reasons women may not desire sex (Brotto, 2010; Meana, 2010) pharmaceutically funded trials and associated press coverage portray women who do not desire “sexâ€? as having a clinical problem requiring a medical solution (Angel, 2010, 2012; Moynihan & Mintzes, 2010). The combination of sex and science is irresistible to the mainstream media and, while a worthy topic to cover, often results in misleading or inaccurate information about gender, sex, and relationships being shared (Attwood et al., 2015). In the case of drugs developed for desire disorders problematic press coverage has included incorrectly and persistently referring to all medications aimed at women as “Viagra for Womenâ€? or “Pink Viagraâ€? and not fully investigating trials nor reading original research before going to press, or reporting from conference proceedings or press releases rather than critically appraising published articles (Angel 2010; Moynihan & Mintzes, 2010). At the same time, while ostensibly following a model of “balance,â€? press coverage sets up this area as a clearly delineated two-sided debate topic – with print and online media asking whether women’s sexual problems truly exist (and the suggestion that those questioning medicalizing sexuality are denying women have problems); re-rehearsing the aforementioned reclaimed feminist narratives of alleged drug inequality (where women are claimed to be missing out); or wrongly implying women’s sexual desire is understudied, complicated, difficult, and highly mysterious (Attwood et al., 2015). While desire may be experienced and defined in terms of biology, psychology, or related social or cultural factors, media coverage tends to present it through a science discourse of hormones and physical Ă“ 2017 Hogrefe Publishing


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response. Whether due to time pressures, a lack of scientific understanding, or a lack of awareness about the history of drugs in this area, press coverage has tended to be uncritical around key terms, identifying conflicts of interest, or addressing core issues of trial design or safety/efficacy of drugs (Attwood et al., 2015; Moynihan & Mintzes, 2010).

Limitations of Clinical Trials Alongside difficulties of defining key terminologies, the drug trials for FSD treatments have been limited by strict exclusion criteria for participants. Studies have centered around heterosexual, Western (commonly American) middle-aged, women in monogamous, long-term relationships (cohabitation or marriage) (Goldfischer et al., 2011; Katz et al., 2013; Simon et al., 2014). Trial designs ensure that participants are not experiencing concurrent physical or mental health difficulties or relationship problems that might also account for psychosexual problems. Single women, younger and older women (under 30 and over 60), black and other ethnic minority women, and lesbian, bisexual, and Trans women are either unrepresented or excluded from trials. It is therefore unwise to draw conclusions about the sexual lives and desires of all women globally from these studies (Moynihan & Mintzes, 2010). Indeed in some cases trials that are primarily about drugs to boost desire in women have not included women at all. For example, as discussed above, although the efficacy trials were based on data from women, the additional safety trials required for Addyi® on the interaction between alcohol use and the drug included a sample of 25 participants, 23 of whom were men. Finally, while it is common for drug trials to be tested against placebo, it would be useful, in an area where there are multiple factors that might influence desire, to test drugs against other kinds of intervention. For example, desire-enhancing drugs could be tested against sex education, using sex toys and/or lubricant, relationship therapy, or confidence/assertiveness courses. Aside from giving an indication of what therapies or devices may assist different women and their partners, this would also provide a stronger context for how specific drugs genuinely perform in terms of increasing sexual desire.

Recommendations We have several recommendations for researchers, clinicians, and journalists. Regarding research and clinical work, there is a pressing need for better definitions and assessments that acknowledge that sex and desire have multiple meanings and interpretations. Although qualitative research on women’s Ó 2017 Hogrefe Publishing

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sexual experiences has increased in the last decade, we still understand little about what terms such as “desire” or “distress” about lack of desire mean to women themselves. There also needs to be a better acknowledgment by researchers of the variability of women’s sexual experiences. More research is required on the experiences of women from different cultures and of different ages, ethnicities, and sexual orientation, all of whom have been underrepresented, particularly in pharmaceutical trials. As discussed above, treatment outcome studies should move beyond the drug versus psychological therapy divide and evaluate the effects of combined or integrated treatments (e.g., drug treatment and psychological therapies, such as cognitivebehavior therapy or mindfulness). These trials will require careful selection of study design and outcome variables (Brotto, Basson, et al., 2016). Regarding the media, more comprehensive and critical coverage is needed, where the history, conduct, and outcomes of trials (including limitations and side effects) are noted. Media articles should also acknowledge where previously “hyped” trials were discontinued or where treatments were not approved. Any potential conflicts of interest of researchers involved in trials should be declared in media articles (as they are in scientific journal articles). This is challenging in the fast-paced media environment where journalists are often not trained or supported to find, critique, and explore research, especially in the area of “sex science.” Creating guidance for journalists on how to cover sex research and further training for the media would be valuable. In conclusion, while the “Even the Score” campaign used the slogan that women have the right to make their own “informed choices” concerning their sexual health, we believe that to offer women a truly informed choice means more than making safe and effective drug treatments for low desire available. Women should also be reassured that transient (and often adaptive) fluctuations in sexual desire are not evidence of “dysfunction” and informed of the many non-pharmacological approaches to enhancing their sexual desire that are available. Acknowledgments Cynthia A. Graham was a member of the DSM-5 Sexual and Gender Identity Disorders Working Group. She is also currently a member of the American Psychiatric Association DSM Review Committee.

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Tiefer, L. (2001). Arriving at a “New View” of women’s sexual problems: Background, theory, and activism. In E. Kaschak & L. Tiefer (Eds.), A new view of women’s sexual problems (pp. 63–98). New York, NY: Haworth Press. Tiefer, L. (2006). Female sexual dysfunction: A case study of disease mongering and activist resistance. PLoS Medicine, 3, 3178. doi: 10.1111/j.1743-6109.2009.01294.x Tiefer, L., Laan, E., & Basson, R. (2015). Missed opportunities in the Patient-Focused Drug Development Public Meeting and Scientific Workshop on Female Sexual Dysfunction held at the FDA, October 2014. Journal of Sex Research, 52, 601–603. doi: 10.1080/00224499.2014.1003362 van Rooij, K., Poels, S., Worst, P., Bloemers, J., Koppeschaar, H., Goldstein, A., . . . Tuiten, A. (2015). Efficacy of testosterone combined with a PDE5 inhibitor and testosterone combined with a serotonin 1A receptor agonist in women with SSRIinduced sexual dysfunction. A preliminary study. European Journal of Pharmacology, 753, 246–251. doi: 10.1016/j.ejphar. 2014.10.061 Waldman, T., Shufelt, C. L., & Braunstein, G. D. (2012). Safety and efficacy of transdermal testosterone for treatment of hypoactive sexual desire disorder. Clinical Investigation, 2, 423–432. doi: 10.4155/cli.12.18 Witting, K., Santtila, P., Varjonen, M., Jern, P., Johansson, A., von der Pahlen, B., & Sandnabba, K. (2008). Female sexual dysfunction, sexual distress, and compatibility with partner. Journal of Sexual Medicine, 5, 2587–2599. doi: 10.1111/j.17436109.2008.00984.x Woloshin, S., & Schwartz, L. M. (2016). US Food and Drug Administration approval of flibanserin: Even the Score does not add up. JAMA Internal Medicine, 176, 439–442. doi: 10.1001/jamainternmed.2016.0073 Wood, J., Mansfield, P., & Koch, P. (2007). Negotiating sexual agency: Postmenopausal women’s meaning and experience of sexual desire. Qualitative Health Research, 17, 189–200. doi: 10.1177/1049732306297415 Received July 28, 2016 Revision received November 7, 2016 Accepted November 30, 2016 Published online March 23, 2017

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C. A. Graham et al., Women’s Sexual Desire

Cynthia A. Graham Department of Psychology Room 44/3016 Faculty of Social and Human Sciences Shackleton Building (B44) University of Southampton Highfield, Southampton SO17 1BJ UK c.a.graham@soton.ac.uk

Cynthia Graham is Professor of Sexual and Reproductive Health at the University of Southampton and a Research Fellow at the Kinsey Institute. She is the Editor-in-Chief of the Journal of Sex Research. Her current research interests are in the area of women’s sexuality, hormonal contraceptives, condom use errors and problems, and sexual health in older adults.

Petra Boynton is an advice columnist and social psychologist. She researches sex and relationships in pregnancy and early parenthood and runs the global Research Companion project, making research skills accessible to researchers in the social sciences, health and development: http://theresearchcompanion.com

Kate Gould is a PhD student at the University of Stirling, researching the representations of female sexuality in the media coverage of Flibanserin. She has written for The Huffington Post, Good Vibrations, The Telegraph, Scotland on Sunday, Cosmopolitan, and The List. Her research interests include sexual health and education, medical history, and medicalization.

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Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science Original Articles and Reviews

Autogynephilia and the Typology of Male-to-Female Transsexualism Concepts and Controversies Anne A. Lawrence Department of Psychology, University of Lethbridge, AB, Canada Abstract: Sexual scientists have recognized for over a century that biologic males who seek sex reassignment – male-to-female (MtF) transsexuals – are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard’s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care. Keywords: autogynephilia, transsexualism, sexual orientation, paraphilia, gender dysphoria

Despite increasing recognition of the wide range of genderatypical identities and behaviors that humans exhibit, there is still considerable popular and scientific interest in adolescents and adults who manifest extreme discomfort with their biologic sex or assigned gender. These persons are referred to as transsexuals. Transsexualism remains an official diagnosis in the most recent edition of the International Classification of Diseases (World Health Organization, 1992). In the Diagnostic and Statistical Manual of Mental Disorders (DSM), the diagnosis of Transsexualism appeared in the DSM-III and DSM-III-R (American Psychiatric Association [APA], 1980, 1987) but was subsumed under the more inclusive diagnoses of Gender Identity Disorder (GID) in the DSM-IV and DSM-IV-TR (APA, 1994, 2000) and Gender Dysphoria in the DSM-5 (APA, 2013). The DSM-5 GID Subworkgroup (Zucker et al., 2013) proposed that the term transsexualism was applicable to a person who identifies completely with the other gender, can only relax when permanently living in the other gender role, has a strong aversion against Ó 2017 Hogrefe Publishing

the sex characteristics of his/her body, and wants to adjust his/her body as much as technically possible in the direction of the desired gender. (p. 905) Biologic males with transsexualism, referred to as male-tofemale (MtF) transsexuals, significantly outnumber their female-to-male (FtM) counterparts and display greater clinical diversity. Accordingly, particular scientific and clinical interest has been devoted to formulating descriptive typologies of MtF transsexualism, some of which have also been applied to FtM transsexualism. Most MtF transsexual typologies have used either sexual orientation or age of onset of symptoms as the basis for categorization (for a review, see Lawrence, 2010a). Typologies based on sexual orientation have been more widely utilized and were relatively uncontroversial until about 2003. Specifiers based on sexual orientation (i.e., sexually attracted to males, females, both, or neither) were used to define typologies (subtypes) of transsexualism and GID in the DSM-III, III-R, IV, and IV-TR (APA, 1980, 1987, 1994, 2000). When applied to MtF transsexuals, these four-category typologies have often been simplified to distinguish only two European Psychologist (2017), 22(1), 39–54 DOI: 10.1027/1016-9040/a000276


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fundamental subtypes: persons attracted exclusively to males (androphilic MtF transsexuals) and persons attracted to females, males and females, or neither gender (nonandrophilic MtF transsexuals). Androphilic MtF transsexuals are also called homosexual MtF transsexuals, because they are exclusively homosexual relative to natal sex, whereas nonandrophilic MtF transsexuals are also called nonhomosexual MtF transsexuals, because they are not exclusively homosexual relative to natal sex (Lawrence, 2013). In the late 1980s, psychologist Ray Blanchard proposed that almost all nonandrophilic MtF transsexuals exhibit a paraphilic sexual orientation he called autogynephilia (literally “love of oneself as a woman�; Blanchard, 1989a, p. 323), which he formally defined as “a male’s propensity to be sexually aroused by the thought of himself as a female� (Blanchard, 1989b, p. 616). Autogynephilia was recognized in the DSM-IV-TR (APA, 2000) as a symptom of many cases of GID in males (p. 578) and most cases of Transvestic Fetishism (p. 574). Autogynephilia became a controversial topic after it was discussed in a contentious book by psychologist Bailey (2003). Autogynephilia and the ideas associated with it, including transsexual typologies based on sexual orientation, have subsequently been criticized by some clinicians and researchers and by many transsexual activists. Autogynephilia and the typology of MtF transsexualism is therefore an appropriate topic for this special issue of European Psychologist.

History and Development of the Concept of Autogynephilia Several detailed accounts of the clinical observations and research that gave rise to the concept of autogynephilia and the theories associated with it have been published (Blanchard, 2005; Lawrence, 2011, 2013). This section offers a concise summary, intended to provide the background necessary to understand the ensuing controversies. Blanchard’s realization of the conceptual link between transsexual subtypes based on sexual orientation and the phenomenon that he would later call autogynephilia derived from decades of earlier observations concerning transvestism or erotic cross-dressing, MtF transsexualism, and the relationship between them. By the early 1980s, many clinicians had recognized that there were at least two distinctly different types of MtF transsexualism, plausibly reflecting entirely different etiologies (for a review, see Lawrence, 2010a). No one MtF transsexual typology, however, was generally accepted. Although transvestism was generally regarded as a disorder of sexuality – a paraphilia – and MtF transsexualism as a disorder of gender identity, clinicians had observed many European Psychologist (2017), 22(1), 39–54

similarities and connections between the two conditions. Specifically:  transvestism sometimes evolved into MtF transsexualism (Lukianowicz, 1959);  the boundary separating transvestism and MtF transsexualism was not distinct (Benjamin, 1966);  both transvestites and MtF transsexuals experienced types of cross-gender identities (Stoller, 1968);  some MtF transsexuals were effeminate and androphilic, whereas others were primarily sexually attracted to women (gynephilic) and had a history of transvestic fetishism (Money & Gaskin, 1970–1971);  the essential fantasy for transvestites, as well as for MtF transsexuals, was becoming a woman, not just dressing as one (Ovesey & Person, 1976);  MtF transsexualism was nearly always associated with either (a) androphilia and childhood femininity or (b) gynephilia and erotic arousal in association with cross-dressing or cross-gender fantasy (Freund, Steiner, & Chan, 1982). Operating from this background, Blanchard began to investigate the relationship between sexual orientation and what he would later call autogynephilia. In an early study, Blanchard (1985) divided 163 MtF transsexual participants into four groups based sexual orientation: a androphilic group, a gynephilic group, a bisexual group (attracted to both sexes), and an analloerotic group (not attracted to other people). He found that 73% of the combined gynephilic, bisexual, and analloerotic participants reported a history of sexual arousal with cross-dressing, compared with only 15% of the androphilic participants. The observed relationship between sexual orientation and sexual arousal with cross-dressing was statistically strong, with a calculated effect size of .58 (see Table 1). Based on this evidence, Blanchard reaffirmed Freund et al.’s (1982) conclusion that there were probably only two basic subtypes of MtF transsexuals: a nonandrophilic subtype, composed of persons who, like transvestites, had a history of sexual arousal with cross-dressing; and an androphilic subtype, composed of persons without any history of erotic crossdressing. More evidence of the strong relationship between autogynephilia and sexual orientation emerged in research by Blanchard, Clemmensen, and Steiner (1987). They studied 125 gender dysphoric males and found that 82% of nonandrophilic participants gave a history of sexual arousal with cross-dressing, compared with only 10% of androphilic participants, yielding an effect size of .72 (see Table 1). The nonandrophilic participants were also significantly older at time of assessment and reported a significantly later onset of cross-gender wishes. Blanchard et al. interpreted these data as “consistent with the view that heterosexual Ă“ 2017 Hogrefe Publishing


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Table 1. Associations between sexual orientation and autogynephilia in male-to-female transsexuals and transgender persons Study

Nonandrophilic/ Autogynephilic

Nonandrophilic/ Nonautogynephilic

Androphilic/ Autogynephilic

Androphilic/ Nonautogynephilic

Cohen’s ω

46

17

15

85

.58

Blanchard (1985) Blanchard, Clemmensen, and Steiner (1987)

60

13

5

47

.72

178

21

6

9

.36

28

16

18

40

.32

Nuttbrock et al. (2011)

131

48

90

301

.48

Total

443

115

134

482

.58

Lawrence (2005) Smith, van Goozen, Kuiper, and Cohen-Kettenis (2005)

Note. The four center columns display numbers of participants.

[nonandrophilic] and homosexual [androphilic] gender dysphoria are likely to prove etiologically distinct conditions” (p. 149). The postulated etiological distinction was this: Androphilic MtF transsexuals were extremely feminine androphilic men whose cross-gender identities derived from their female-typical attitudes, behaviors, and sexual preferences. Nonandrophilic MtF transsexuals, in contrast, were conventionally masculine, fundamentally gynephilic men who resembled transvestites in that they experienced paraphilic arousal from the fantasy of being women (autogynephilia); their cross-gender identities derived from their autogynephilic sexual orientations.

The Concept of Autogynephilia Blanchard introduced the term autogynephilia in two articles published in 1989. In the first of these (Blanchard, 1989a), he described past and current efforts to frame clinically useful typologies of MtF transsexualism; he concluded that autogynephilia was an appropriate term to describe the paraphilic sexual interest that apparently gave rise to both transvestism and nonandrophilic MtF transsexualism. He noted that many different fantasies or behaviors could be a source of autogynephilic arousal: wearing women’s clothing, having female-typical physical features or physiologic capabilities (e.g., becoming pregnant), engaging in female-typical social behaviors, or being admired or sexually desired as a woman by another person. In a second article, Blanchard (1989b) described new scales for measuring elements of autogynephilia. He studied 212 MtF transsexuals, whom he again divided into four groups based on sexual orientation. On the Core Autogynephilia Scale, which measured self-reported sexual arousal in association with the fantasy of having female anatomic features, the three nonandrophilic groups reported significantly higher scores than the androphilic group. On the Autogynephilic Interpersonal Fantasy scale, which measured self-reported sexual arousal in association with the fantasy of being admired as a female by another

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person, the bisexual group reported significantly higher scores than the other three groups. This latter finding suggested that bisexual MtF transsexuals’ “interest in male sexual partners is mediated by a particularly strong desire to have their physical attractiveness as women validated by others” (Blanchard, 1989b, p. 622). This point is essential to understanding how autogynephilia affects self-reported sexual orientation: Blanchard theorized that a substantial number of fundamentally gynephilic MtF transsexuals develop a secondary sexual interest in male partners – he called this interest pseudoandrophilia – based on the autogynephilic desire to have their femininity validated by the admiration or sexual interest of men. Pseudoandrophilic transsexuals might describe themselves as bisexual or might declare that they had become exclusively attracted to men (i.e., androphilic). Other studies have also investigated the relationship between autogynephilia and sexual orientation in MtF transsexuals (Lawrence, 2005; Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005) and in MtF transgender persons, only some of whom could be classified as transsexuals (Nuttbrock et al., 2011). The results of these three investigations are summarized in Table 1: All reported medium-tolarge effect sizes. When data from the five studies in the Table 1 are combined, the overall effect size is .58. In each of these studies, however, many ostensibly androphilic MtF persons reported experiencing autogynephilia, whereas many ostensibly nonandrophilic persons denied experiencing it. How could Blanchard’s theory account for these deviations from its predictions?

Explaining Deviations From the Predicted Relationship Between Autogynephilia and Sexual Orientation Autogynephilic transsexuals tend to underreport autogynephilic arousal and overreport androphilic attraction, and these tendencies provide the most straightforward explanation of deviations from the predicted relationship between

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autogynephilia and sexual orientation. MtF transsexuals and transgender persons routinely minimize or deny autogynephilic arousal in association with cross-dressing or crossgender fantasy for reasons that probably are often unintentional but sometimes are clearly deliberate. Blanchard, Racansky, and Steiner (1986) measured changes in penile blood volume in 37 transvestites and nonandrophilic gender dysphoric males who listened to audio recordings describing various sexual and nonsexual scenarios, including crossdressing and solitary nonsexual activity. Participants who denied experiencing sexual arousal with cross-dressing during the past year – some of whom denied ever having experienced it – displayed significantly greater increases in penile blood volume in response to the cross-dressing scenario than to the nonsexual scenario, indicating measurable, albeit perhaps unrecognized, physiologic arousal. Moreover, Blanchard, Clemmensen, and Steiner (1985) reported that in nonandrophilic men with gender dysphoria, a tendency to describe oneself in a socially desirable way was correlated with a tendency to deny sexual arousal with cross-dressing, suggesting an explanation for the underreporting of autogynephilic arousal. More recently, Zucker et al. (2012) found that, among 96 adolescent boys referred to a gender clinic because of transvestism, 47% denied sexual arousal on every item of a 10-item scale measuring transvestic fetishism, although this was precisely the problem for which they had been referred. In this study, too, a tendency to socially desirable responding was associated with denial of sexual arousal with cross-dressing. Although denial of autogynephilic arousal may often be unintentional, sometimes it is deliberate: Walworth (1997) reported that 13% of 52 MtF transsexuals she surveyed admitted having lied to or misled their therapists about sexual arousal while wearing women’s clothing. Lawrence (2013) presented several narratives by MtF transsexuals who had concealed or lied about autogynephilic arousal, both to psychotherapists and to other transgender persons. Similarly, MtF transsexuals often inaccurately report being sexually oriented toward men (androphilic), either unintentionally or deliberately. For example, in a study by Nieder et al. (2011), of 44 males diagnosed with late-onset gender dysphoria – many of whom were plausibly autogynephilic – 52% reported that they were sexually attracted to men; but the clinicians who evaluated them believed that only 9% were actually androphilic. In some cases, autogynephilic MtF transsexuals who claim to be attracted to men may simply be experiencing attraction to the idea of having their femininity validated by men, a different phenomenon. Some nonandrophilic MtF transsexuals, however, candidly admit to having lied to their therapists about attraction to men (Blanchard, Steiner,

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& Clemmensen, 1985; Walworth, 1997). Cohen-Kettenis and Pfäfflin (2010) also drew attention to this tendency: It is likely that, depending on the criteria of access to treatment in a specific treatment facility, applicants adjust their biographical data with regard to sexuality. This makes the quality of the information, especially when given during clinical assessment, questionable. (p. 507) Cohen-Kettenis and Pfäfflin even proposed that resistance to the concept of autogynephilia might itself be responsible for some of the unreliability in the reporting of sexual orientation: The term autogynephilia, which is used for one subtype, is considered highly offensive by some. . . It is therefore likely that. . . the increased awareness regarding the sexual orientation issue has led to less reliable reports of sex reassignment applicants on their sexual orientation. (p. 508) Thus, many observed deviations from the theorized association between autogynephilia and sexual orientation in MtF transsexuals are plausibly attributable to misreporting of either autogynephilic arousal or sexual orientation (but not both) by putatively nonandrophilic MtFs. Misreporting of both autogynephilic arousal and sexual orientation by putatively nonandrophilic MtFs undoubtedly also occurs but would not result in any discrepancy from the predicted association. Yet another factor probably also contributes to observed deviations from the predictions of Blanchard’s theory: Not all cases of MtF transsexualism are clearly related to either extreme femininity in androphilic men or sexual arousal with cross-dressing or cross-gender fantasy in nonandrophilic men. Some cases of MtF transsexualism are associated with and plausibly attributable to other comorbid psychiatric disorders, especially psychotic conditions such as schizophrenia or bipolar disorder. Á Campo, Nijman, Merckelbach, and Evers (2003) reported on a large survey of Dutch psychiatrists, who had evaluated 584 patients with cross-gender identification and possible GID; in 46% of these patients, the psychiatrists interpreted cross-gender identification as an epiphenomenon of other psychiatric problems, including psychotic, mood, dissociative, and personality disorders. Brown and Jones (2016) observed that, among 5,135 persons (69% male) diagnosed with GID, transsexualism, or transvestism who had received care from the U.S. Veterans Administration, 32% had also received a diagnosis of “serious mental illness,” meaning “diagnoses associated

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with psychotic symptoms” (p. 128), including schizophrenia- and bipolar-spectrum disorders. Thus, comorbid psychotic disorders and other severe mental illnesses may account for some cases of MtF transsexualism in nonandrophilic persons who deny autogynephilia – and for some cases of MtF transsexualism in androphilic persons as well.

Autogynephilia as a Paraphilic Sexual Orientation When Blanchard first introduced the term autogynephilia, he described it as not merely an erotic propensity but as a genuine sexual orientation, theorizing that “all gender dysphoric males who are not sexually oriented toward men are instead sexually oriented toward the thought or image of themselves as women” (Blanchard, 1989a, pp. 322–323). He later elaborated: Autogynephilia might be better characterized as an orientation than as a paraphilia. The term orientation encompasses behavior, correlated with sexual behavior but distinct from it, that may ultimately have a greater impact on the life of the individual. For heterosexual and homosexual men, such correlated behavior includes courtship, love, and cohabitation with a partner of the preferred sex; for autogynephilic men, it includes the desire to achieve, with clothing, hormones, or surgery, an appearance like the preferred self-image of their erotic fantasies. (Blanchard, 1993, p. 306) Sexual orientations are characterized by feelings of attraction, idealization, and attachment in addition to feelings of erotic desire (Diamond, 2003). Autogynephilia, like other sexual orientations, can encompass all the phenomena commonly associated with the word love (Lawrence, 2007). Autogynephilic MtF transsexuals are sexually aroused by imagining themselves as female but also idealize the idea of being female, derive feelings of security and comfort from their autogynephilic fantasies and enactments, and typically want to embody their feminine identities in an enduring way (i.e., by undergoing sex reassignment). Of the elements that comprise sexual orientations, erotic desire is often the most evanescent in any particular relationship: attraction and attachment can persist long after erotic arousal has diminished. For autogynephilic MtF transsexuals, this implies the potential to feel continuing attraction to and comfort from autogynephilic fantasies and enactments that may have lost much of their initial erotic charge. Blanchard (1991) observed: In later years, however, autogynephilic sexual arousal may diminish or disappear, while the transsexual Ó 2017 Hogrefe Publishing

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wish remains or grows even stronger. . . It is therefore feasible that the continuing desire to have a female body, after the disappearance of sexual response to that thought, has some analog in the permanent love-bond that may remain between two people after their initial strong sexual attraction has largely disappeared. (p. 248) Among nonandrophilic MtF transsexuals who report that they have ceased to experience sexual arousal from autogynephilic fantasies or behaviors, it is plausible that loving the idea of being a woman, finding this comforting, and wanting to enact a woman’s role permanently may continue to be important ongoing manifestations of an autogynephilic orientation.

Autogynephilia as a Motive for Seeking Sex Reassignment In addition to describing a sexual orientation and defining a transsexual typology, autogynephilia provides an implicit theory of motivation for the pursuit of sex reassignment by autogynephilic males: It suggests that they seek sex reassignment because they love (i.e., experience attraction, sexual arousal, and comfort from) the prospect of having bodies that resemble women’s bodies and living in the world as women (Lawrence, 2007). These MtF transsexuals undergo sex reassignment to actualize their autogynephilic fantasies. This explanation is no more remarkable than the explanation that men with fetishistic transvestism crossdress because they want to actualize their transvestic fantasies. Autogynephilia appears to give rise to the desire for sex reassignment gradually and indirectly, however, through the creation of cross-gender identities that are eventually associated with gender dysphoria and then provide most of the proximate motivation for the pursuit of sex reassignment. The cross-gender identities of autogynephilic MtF transsexuals are thus theorized to be secondary phenomena that develop incrementally after years of partial and complete cross-dressing in private, cross-dressing in public, and choosing a female name. Docter (1988) observed that in the nonandrophilic cross-dressing men he studied, including those who eventually sought sex reassignment: 79% did not appear in public cross dressed prior to age 20; at that time, most of the subjects had already had several years of experience with cross dressing. The average number of years of practice with cross dressing prior to owning a full feminine outfit was 15. The average number of years of practice with cross dressing prior to adoption of a feminine name European Psychologist (2017), 22(1), 39–54


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was 21. Again, we have factual evidence indicative of the considerable time required for the development of the cross-gender identity. (p. 209) The inability to actualize one’s cross-gender identity, including the inability to inhabit a body that is congruent with that identity, is experienced as gender dysphoria. Thus, autogynephilia can result in cross-gender identification and gender dysphoria in nonandrophilic men, and these phenomena can act as the principal proximate motivation for the pursuit of sex reassignment (Lawrence, 2013).

Further Evidence Supporting a MtF Transsexual Typology Based on Sexual Orientation Blanchard’s MtF transsexual typology, which distinguishes feminine androphilic MtFs from autogynephilic nonandrophilic MtFs, is also supported by anthropometric measurements, studies of gender-related behavior, and neuroanatomic studies. The available evidence suggests that androphilic MtFs are physically, behaviorally, and neuroanatomically feminized (or demasculinized), whereas this has not been shown for nonandrophilic MtFs, albeit the latter have been less frequently studied. In a study of 422 MtF transsexuals, Blanchard, Dickey, and Jones (1995) found that androphilic MtFs were significantly shorter than nontranssexual males and significantly shorter and lighter in weight than nonandrophilic MtFs, with the latter comparisons showing small-to-medium effect sizes. In a subsequent report involving only 113 MtFs, Smith et al. (2005) could not confirm the latter findings, but Lawrence (2010a) noted that this study was underpowered to find small-to-medium effect sizes significant. Smith et al. did observe, however, that androphilic MtFs had a more feminine appearance than nonandrophilic MtFs. Androphilic MtFs also report more childhood crossgender behavior than their nonandrophilic counterparts (Blanchard, 1988; Money & Gaskin, 1970–1971; Whitam, 1987). In a comprehensive review of neuroanatomic findings in transsexualism, Guillamon, Junque, and Gómez-Gil (2016) observed that androphilic MtFs “show a distinctive brain morphology, reflecting a brain phenotype” (p. 1643) involving both feminized and demasculinized features. Limited data from nonandrophilic MtFs (Savic & Arver, 2011), in contrast, revealed neither feminization nor demasculinization of the brain, but rather “morphological peculiarities in [cortical] regions in which male and female controls do not differ” (Guillamon et al., p. 1624). Guillamon et al. concluded that neuroanatomic differences European Psychologist (2017), 22(1), 39–54

probably underlie the MtF transsexual typology suggested by Blanchard: The review of the available data seems to support two existing hypotheses: (1) a brain-restricted intersexuality in homosexual MtFs and FtMs and (2) Blanchard’s insight on the existence of two brain phenotypes that differentiate “homosexual” [androphilic] and “nonhomosexual” [nonandrophilic] MtFs. (p. 1643)

Clinical Relevance of the Theory of Autogynephilia In addition to offering descriptive value, the theory of autogynephilia and its associated MtF transsexual typology also have significant relevance for clinical care. In particular, they can help clinicians achieve an empathetic understanding of their autogynephilic clients’ behaviors, choices, and associated psychopathology. Clinicians who recognize that the gender dysphoria of autogynephilic MtFs derives from their paraphilic sexual orientation can more easily understand why these clients “are likely to feel a powerful drive to enact their paraphilic desires (e.g., by undergoing sex reassignment), sometimes with little concern for possible consequences” (Lawrence, 2009, p. 198), which can include loss of employment, family, friends, and reputation. The concept of autogynephilic interpersonal fantasy can help make sense of the otherwise puzzling fact that gynephilic MtFs sometimes develop a newfound interest in male partners late in life. Clinicians who understand the concept of autogynephilia can better interpret the sometimes ambivalent reactions of nonandrophilic MtF transsexuals to feminizing hormone therapy: Hormones can induce desired physical changes and reduce ego-dystonic autogynephilic arousal, but they can also diminish the desire to pursue sex reassignment by blunting the autogynephilic sexual excitement that partly fuels this desire (Lawrence, 2013). Realizing the paraphilic etiology of nonandrophilic MtF transsexualism can sensitize clinicians to the possible presence of other comorbid paraphilias, some of which may be of greater relevance to the lives of their clients (Lawrence, 2009). Finally, with those MtF clients who recognize the paraphilic origin of their gender dysphoria, clinicians who are familiar with the concept of autogynephilia can provide more accurate information and can reassure their clients that autogynephilic MtF transsexualism is a recognized condition – one for which hormone therapy and sex reassignment can sometimes offer significant therapeutic benefit (Lawrence, 2013). Ó 2017 Hogrefe Publishing


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The Controversy Surrounding Autogynephilia Blanchard’s concept of autogynephilia and the MtF transsexual typology associated with it received little critical attention until they were discussed in the book The Man Who Would Be Queen, a work of popular science by psychologist Bailey (2003). Bailey’s book ignited a firestorm of controversy, the history of which was reviewed by Dreger (2008). Both critics and defenders of autogynephilia have subsequently written extensively about the concept and its implications. Some criticisms of autogynephilia involve technical details that are too lengthy and complicated to address in a brief review. Many of the substantive criticisms of autogynephilia, however, can be presented and examined in a concise manner. These include: 1. Although autogynephilia exists, it is of little genuine importance, either because it is widespread and unremarkable in natal women or because it is a predictable but trivial epiphenomenon of gender dysphoria. 2. Although autogynephilia currently exists, it is a disappearing phenomenon that is likely to soon become extinct. 3. Blanchard’s autogynephilia-based typology is descriptively inadequate: There are too many observed exceptions to its predictions. 4. Although autogynephilia is theorized to be a paraphilia, it does not resemble most paraphilias, particularly because it persists despite pharmacologic treatments that reduce sex drive. 5. Autogynephilia’s sexuality-based theory of motivation inappropriately emphasizes lust and ignores the importance of gender identity. 6. Blanchard’s theory of autogynephilia contradicts the widely accepted idea that sexual orientation and gender identity are independent concepts. 7. The theory of autogynephilia disrespects the identities of MtF transsexuals and perpetuates harmful stereotypes about them.

Is Autogynephilia Ubiquitous in Natal Women or Merely an Epiphenomenon? Most critics of autogynephilia concede that the phenomenon exists (“No one disputes that autogynephilia exists or that it can explain the motivation of some MTFs; many MTFs readily admit that this construct describes their sexual interest and motivation”; Moser, 2010b, p. 791). A rare dissenter was Bettcher (2014), who appeared to take

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metaphoric descriptions of autogynephilia literally: She argued that ‘“attraction to oneself’ is literally impossible and, therefore, so is autogynephilia” (p. 606). But despite widespread agreement that autogynephilia exists, critics often dismiss it as unimportant. Many contend that natal women commonly experience autogynephilia, implying that autogynephilia therefore is a natural, nonpathological element of sexuality in women, including MtF transsexuals. Two studies (Moser, 2009; Veale, Clarke, & Lomax, 2008) have supposedly demonstrated the existence of autogynephilia in natal women; both have a superficial plausibility, especially if one does not examine their data closely. Veale et al. (2008) administered modified versions of Blanchard’s (1989b) Core Autogynephilia and Autogynephilic Interpersonal Fantasy scales to 127 natal female participants. On average, the participants endorsed several items on each scale. But interpretation of the results was complicated, because Veale et al. altered the wording of the items “to make them more applicable to biological females” (p. 589), modified the skip instructions of the original scales, and had to reclassify participants’ original ordinal responses as dichotomous because of misleading phrasing. Consequently, Veale et al. expressed significant reservations about their own results: Although a number of biological female participants endorsed items on the Core Autogynephilia and Autogynephilic Interpersonal Fantasy scales. . . it is unlikely that these biological females actually experience sexual attraction to oneself as a woman in the way that Blanchard conceptualized it. . . The scales used in this research were not sufficient for examining this. (p. 595) These reservations, however, have rarely if ever been acknowledged in scholarly critiques of Blanchard’s ideas. For example, neither Moser (2010b) nor Serano (2010) cited or referred to Veale et al.’s disclaimers. Moser (2009) reported the responses of 29 female hospital employees to his Female Autogynephilia Scale, which used items modified from scales originally devised by Blanchard (1985, 1989b) to measure autogynephilia and related traits (Lawrence, 2010b). About half of respondents reported at least occasional “autogynephilic” arousal. But Moser modified Blanchard’s original language on the advice of female colleagues and friends, to better investigate the specifics of their self-reported arousal or to provide “needed context” (Moser, 2010a, p. 694). Consequently, Moser’s modified items arguably did not adequately distinguish between being aroused by wearing sexy clothing or by imagining that a potential romantic

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partner finds one attractive – which natal women apparently do experience – and being aroused simply by the idea that one is wearing women’s clothing or has a woman’s body – which natal women probably rarely if ever experience (Lawrence, 2010b). Moser (2009) conceded that “It is possible that autogynephilia among MTFs and natal women are different phenomena and the present inventories lack the sophistication to distinguish these differences” (p. 544). Lawrence (2010b) argued that this was probable, on the grounds that Moser’s items “fail[ed] to adequately assess the essential element of autogynephilia – sexual arousal simply to the thought of being a female” (p. 3). Another basis for declaring autogynephilia in MtF transsexuals to be unimportant is the claim that it is merely a temporary mechanism for coping with incongruence between one’s gender identity and sexed body characteristics: that is, that autogynephilia is an effect rather than a cause of gender dysphoria. Serano (2010) wrote: It makes sense that pretransition transsexuals (whose gender identity is discordant with their physical sex) might imagine themselves inhabiting the “right” body in their sexual fantasies and during their sexual experiences with other people. Indeed, critics of autogynephilia theory have argued that such sex embodiment fantasies appear to be an obvious coping mechanism for pretransition transsexuals. (p. 184) This argument does not explain, however, why MtF transsexuals often experience unintended or unwanted sexual arousal while wearing women’s clothing or why autogynephilic fantasies sometimes persist for years or decades after sex reassignment has corrected much of the incongruity between gender identity and physical sex (Lawrence, 2005, 2013). Cross-dressing and cross-gender behavior are associated with sexual arousal in both sexual and nonsexual contexts for many MtF transsexuals, both before and after sex reassignment – arguably because autogynephilia is their genuine, persistent sexual orientation.

Is Autogynephilia a Disappearing Phenomenon That Will Soon Become Extinct? Nuttbrock et al. (2011) proposed an “important, albeit highly theoretical, hypothesis – that transvestic fetishism may be a historically fading phenomenon” (p. 256). Their conjecture derived from their study of transvestic fetishism – the most prevalent manifestation of autogynephilia – in a diverse group of transgender males, including a discrete subgroup of nonandrophilic cross-dressers. Because these cross-dressers, unlike most other participants, were European Psychologist (2017), 22(1), 39–54

primarily older and white (Hwahng & Nuttbrock, 2007), Nuttbrock et al. found that transvestic fetishism was correlated with older age and white ethnicity as well as nonandrophilic orientation. Accordingly, Nuttbrock et al. argued that transvestic fetishism could theoretically be primarily a generational phenomenon, because among older white MtFs, “dressing in the female role was frequently a highly secretive and exotic phenomenon. . . [which] may largely account for the[ir] higher levels of transvestic fetishism” (p. 256). Nichols (2014) made a similar argument concerning autogynephilia generally, albeit without offering either evidence or explanation: “Autogynephilia is disappearing. . . Blanchard’s theory is not a description of an essentialist phenomenon but rather of a cultural one, a presentation of gender bound by time and place” (p. 72). Reports of the impending disappearance of autogynephilia, however, appear to be premature. Erotic crossdressing and other manifestations of autogynephilia have been documented for centuries, in both Western and non-Western cultures (Lawrence, 2013). Adolescents with transvestic fetishism continue to be referred for clinical evaluation in the twenty-first century (Zucker et al., 2012). Moreover, some MtF transsexuals who have completed sex reassignment and live publicly as women report that they continue to experience autogynephilic arousal (Lawrence, 2005, 2013), suggesting that the secretive cross-dressing invoked by Nuttbrock et al. (2011) is not a prerequisite for such arousal. Concluding that autogynephilia is disappearing because it is more often reported by older MtF transgender persons makes as much sense as concluding that Alzheimer’s disease is disappearing because it is diagnosed primarily in older adults. Autogynephilia seems likely to remain a clinically important phenomenon for the foreseeable future.

Is Blanchard’s Autogynephilia-Based Transsexual Typology Descriptively Inadequate? A consistent criticism of Blanchard’s autogynephilia-based transsexual typology is that it is descriptively inadequate: In the opinion of the critics, there are simply too many deviations from the predicted relationship between autogynephilia and sexual orientation. Moser (2010b) summarized the problem: “It appears that substantial minorities of homosexual [androphilic] MTFs are autogynephilic and non-homosexual [nonandrophilic] MTFs are not” (p. 795). As noted previously, all the studies presented in Table 1 found some deviations from the predicted association between autogynephilia and sexual orientation, although the overall statistical relationship was strong. Ó 2017 Hogrefe Publishing


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The study by Veale et al. (2008), discussed previously, raised further questions about the descriptive accuracy of Blanchard’s typology. The authors divided their 169 MtF transsexual participants into “autogynephilic” and “nonautogynephilic” groups using hierarchical cluster analysis, based on participants’ responses to the same modified versions of Blanchard’s Core Autogynephilia and Autogynephilic Interpersonal Fantasy scales that the authors had used with their natal female participants, along with two other scales of less obvious relevance. Contrary to the predictions of Blanchard’s theory, Veale et al. found no significant differences in patterns of sexual orientation between the two transsexual groups. In yet another study that employed a similar methodology, Veale (2014) examined Blanchard’s two-category typology using a taxometric analysis of the responses of 308 MtF transsexuals on scales purportedly measuring aspects of autogynephilia, related elements of sexuality, and sexual orientation. Veale concluded that the structure of the data was dimensional rather than taxonic (i.e., that two distinct transsexual types could not be ascertained). Supporters of Blanchard’s typology have attributed such discrepancies from the theory’s predictions primarily to the recognized tendency of MtF transsexuals to underreport autogynephilic arousal and overreport androphilic orientation and secondarily to the probable contribution of comorbid mental illness to the etiology of gender dysphoria. They have also emphasized the limitations of Veale’s taxometric studies. Lawrence and Bailey (2009) criticized the methodology and the conclusions of Veale et al. (2008): They noted that the study’s sample size was too small for a valid taxometric analysis and that both transsexual groups displayed substantial autogynephilic arousal: “They are best described as the ‘autogynephilic’ and ‘even more autogynephilic’ groups” (p. 173). With regard to Veale's (2014) failure to confirm Blanchard’s typology, Lawrence (2014) argued that Veale had used poorly constructed measures, some of which were of dubious relevance, and had recruited too few genuinely androphilic MtF transsexuals for her study to be capable of demonstrating the taxonic structure that Blanchard’s theory predicted. Opponents of Blanchard’s theory have replied that such counterarguments effectively make Blanchard’s typology “unfalsifiable” (Winters, 2008, para. 6), because any departures from the theory’s predictions can simply be dismissed as attributable to misreporting, measurement errors, sampling problems, or psychiatric comorbidity. As Lawrence (2010a) noted, however, Blanchard’s typology is not in principle unfalsifiable: One can imagine more reliable methods of measuring sexual orientation and autogynephilic arousal (e.g., Rönspies et al., 2015) that could eliminate reliance on questionable self-report measures

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and contribute to the resolution of disputed issues. For the present, however, disagreements concerning the explanation of departures from the predictions of Blanchard’s autogynephilia-based typology remain unresolved.

If Autogynephilia Is a Paraphilia, Why Doesn’t it Resemble Other Paraphilias? Moser (2010b) claimed that autogynephilia is unlikely to be a paraphilia because in MtF transsexuals with autogynephilia, the wish for sex reassignment usually persists despite hormone treatments that reduce testosterone and male sex drive: If the impetus for gender transition is a paraphilia (autogynephilia), then reduction of the sex interest should decrease the desire for the transition. . . Estrogen acts to decrease testosterone levels. . . often to the undetectable range. The result is often decreased sexual interest, as expected, but. . . most MTFs report their drive for gender transition is unabated. (pp. 799–800) A reduction in the drive for gender transition, however, is actually not uncommon following the initiation of feminizing hormone therapy: The associated reduction in sex drive is sometimes accompanied by disappearance of the desire to pursue sex reassignment. Sometimes the cycle of starting hormones, losing the desire to transition, stopping hormones, and then experiencing a resurgence of the desire to transition occurs repeatedly in the same patient (Lawrence, 2013, pp. 150–151). Yet in many cases the desire to transition clearly does persist, just as Moser (2010b) described. As noted previously, autogynephilia is a sexual orientation, encompassing elements of attraction, idealization, and attachment as well as erotic desire; the former elements can provide continuing motivation to pursue gender transition, despite a decline in sex drive. Moreover, autogynephilic arousal in MtF transsexuals is sometimes unwanted (Blanchard & Clemmensen, 1988) and ego-dystonic (Lawrence, 2004, 2013), because autogynephilic arousal can seem inconsistent with one’s feminine gender identity. These factors help explain the persistence of the desire for sex reassignment in MtF transsexuals who experience hormone-induced reductions in sex drive. Moser expressed skepticism about parts of this explanation, suggesting (without citing evidence) that “ego-dystonic paraphilic arousal is not a common problem motivating individuals with traditional paraphilias to seek professional help” (p. 800). Even if Moser were correct, however, autogynephilia may simply be unlike

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most traditional paraphilias, in part because it has such powerful implications for identity. One piece of evidence suggesting that autogynephilia is indeed a paraphilia is the increased comorbidity of other paraphilias, especially sexual masochism, observed in MtF transsexuals who are primarily nonandrophilic (Bolin, 1988; Walworth, 1997) and in males with transvestitic fetishism (Gosselin & Wilson, 1980). Paraphilias tend to cluster or co-occur, and having one paraphilia makes it much more likely that a person will also have one or more other paraphilias (Abel & Osborn, 1992). The fact that other paraphilias often accompany autogynephilia is consistent with the idea that autogynephilia is also a paraphilia.

Does Autogynephilia’s Theory of Motivation Overemphasize Lust and Ignore Gender Identity? Critics sometimes object that the theory of autogynephilia understands the motivation of autogynephilic MtF transsexuals exclusively in terms of lust and assumes autogynephilic sexual arousal to be the sole proximate cause of the desire for sex reassignment, ignoring the importance of gender identity. Here are two examples: [Bailey, 2003, argued that autogynephilic] heterosexual men. . . changed gender so they could lust after their now female bodies. The idea that any of them were changing to seek an identity that would enable them to feel better about themselves was simply not an option. (Bancroft, 2008, p. 426) Lawrence (2004) suggests that sexual motivation (autogynephilia) explains why successful men in masculine professions choose to become women. . . Sexual motivation for SRS seems more unlikely as men age. . . Yet, older, often autogynephilic, MTFs continue to pursue SRS. (Moser, 2010b, p. 805) These descriptions are oversimplifications of Blanchard’s theory. Autogynephilia is indeed a sexual phenomenon, but it is not merely a lusty phenomenon; it encompasses other elements of sexual orientation, including attraction, admiration, and attachment (Blanchard, 1991, 1993; Lawrence, 2007, 2013). Moreover, autogynephilia in MtF transsexuals eventually gives rise to cross-gender identities and gender dysphoria, and these, not lust, provide most of the proximate motivation for the pursuit of sex reassignment in most cases (Lawrence, 2013).

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Do Blanchard’s Ideas Contradict the Independence of Sexual Orientation and Gender Identity? Some commentators have claimed that Blanchard’s theory of autogynephilia is inconsistent with the belief – supposedly widely held by both sexual scientists and members of the transgender movement – that gender identity and sexual orientation are separate and distinct concepts or dimensions: [Blanchard’s theory proposes that] autogynephilia, sexual orientation, and gender identity are interrelated and interdependent in MTFs. . . By connecting both gender identity and sexual orientation, [Blanchard’s autogynephilia theory] connects two distinct concepts in sexology usually thought of as independent. (Moser, 2010b, p. 791) [Blanchard’s] findings have sociopolitical implications far beyond scientific circles because they directly contradict basic tenets of the worldwide transgender movement: sex and gender are deemed to be separate, socially constructed dimensions of personal identity characterized by individual variation and social diversity. (Nuttbrock et al., 2011, p. 249) It may indeed be useful at times to think of gender identity and sexual orientation as distinct conceptual entities. But as measurable clinical phenomena, these entities are not statistically independent in MtF transsexuals. Rather, there is a strong statistical association between nonandrophilic sexual orientation and the autogynephilic variety of MtF transsexualism and transgenderism, with a mean effect size of .58, based on the data in Table 1. There are also plausible, albeit still controversial, explanations for the small but consistently observed deviations from Blanchard’s theorized association between sexual orientation and autogynephilia. Notwithstanding the descriptive power of Blanchard’s theory, Serano (2010) outlined a supposed alternative model that she considered more satisfactory: A more nuanced view [is] the gender variance model, which holds that gender identity, gender expression, sexual orientation, and physical sex are largely separable traits that may tend to correlate in the general population but do not all necessarily align in the same direction within any given individual. . . If autogynephilia is to be taken seriously as a theory, it should explain the observed differences in MtF transsexuals

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at least as well as (if not better than) the gender variance model. (p. 179) It is not clear, however, that Serano’s gender variance model differs much from Blanchard’s model. Blanchard, too, proposed that autogynephilia and nonandrophilic orientation tend to correlate – very highly – in MtF transsexuals, but he also acknowledged that these characteristics do not always align exactly as his theory predicts. Some observed misalignments are plausibly attributable to inaccurate reporting of autogynephilic arousal or sexual orientation; others probably reflect the influence of comorbid psychopathology. Because Serano never offered details of the correlations she alluded to or explanations for potential deviations from them, it would seem that any observed relationship between gender identity, gender expression, sexual orientation, anatomic sex, and autogynephilia – or none at all – would be consistent with her model. Serano’s gender variance model therefore has no real predictive value and is unfalsifiable.

Does the Theory of Autogynephilia Disrespect the Identities of MtF Transsexuals or Perpetuate Harmful Stereotypes About Them? These allegations constitute the most prevalent objections to Blanchard’s ideas, and they are issues about which many critics of autogynephilia are full of passionate intensity. Serano (2009) declared that “the overwhelming majority of trans women feel that autogynephilia theory is not merely ‘wrong,’ but oppressive and invalidating” (p. 13). Her claim, however, was probably overstated: A survey conducted by Veale, Clarke, and Lomax (2011) found that only a bare majority – 52% – of MtF transsexuals expressed negative opinions about Blanchard’s theory of autogynephilia, whereas 32% and 16%, respectively, expressed neutral or positive opinions. One widespread criticism of the theory of autogynephilia is that it disrespects the identities of MtF transsexuals. The terminology associated with the theory has been a particular source of contention: Many transgender activists and advocates feel that autogynephilia theory (and the terminology associated with it) is not merely incorrect, but unnecessarily stigmatizing. . . The theory conceptualizes and describes transsexual women as either homosexual or autogynephilic men, thus undermining their female gender identities and lived experiences as women. (Serano, 2010, pp. 184–185)

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Homosexual MTFs often self-identify as heterosexual females, thus, the use of the term homosexual can appear inaccurate and disrespectful (contradicting their self-identity). Similarly, non-homosexual MTFs may self-identify as lesbians; and again, the term can appear inaccurate and disrespectful. It may be more accurate and sensitive to define the sexual interests of MTFs as androphilic, gynephilic, bi-philic, [etc.]. (Moser, 2010b, pp. 792–793) Moser’s recommended terminology is both concise and unambiguous when it is applied to transsexuals of only one gender category (MtFs or FtMs), as in this article. Critics have also taken exception to the observation that MtF transsexuals sometimes lie about or deliberately misrepresent their autogynephilic interests or sexual orientations: Some proponents of [Blanchard’s theory] have asserted that non-homosexual MTFs who do not report autogynephilia are “autogynephiles in denial” and that homosexual MTFs who report autogynephilia are mistaken. Invalidating the experiences of those MTFs on the basis of our current level of knowledge is inappropriate, disrespectful, and possibly detrimental to individual [sic]. (Moser, 2010b, p. 806) There are lesbian, bisexual and asexual trans women who have never experienced crossgender arousal, and there are heterosexual [i.e., androphilic] trans women who have. In his writings, Blanchard routinely mischaracterizes the first group as autogynephiles who are lying about not having experienced crossgender arousal, and the second group as autogynephiles who are lying about their sexual orientation. (Serano, 2009, p. 14) More than a few MtF transsexuals, however, have admitted to lying about their sexual orientations or about autogynephilic arousal (Blanchard et al., 1985; Lawrence, 2013; Walworth, 1997). As noted earlier, Cohen-Kettenis and Pfäfflin (2010) argued that misrepresentation of sexual orientation by transsexuals was so prevalent that typologies based on sexual orientation had become unreliable. Because the theory of autogynephilia understands some forms of MtF transsexualism to derive from a paraphilic sexual interest, some critics contend that the theory leads to guilt by association with other paraphilic phenomenon: Blanchard and collaborators have grouped “autogynephilia” ([in] lesbian, bisexual and asexual transwomen) with pedophilia, fetishism and even

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apotemnophilia (desire for limb amputation). . . This reinforces some of the most stigmatizing and dehumanizing false stereotypes that transsexual women bear in society. (Winters, 2008, para. 7) The theory is extremely pathologizing, especially for those transsexual women who are classified as autogynephiles and, thus, lumped into a psychiatric category (paraphilia) that includes several criminal sexual offenses (e.g., pedophilia, frotteurism, and exhibitionism) as well as other. . . stigmatized sexual behaviors. (Serano, 2010, p. 185) These arguments reflect a willingness to accept rather than dispute popular misconceptions that persons who experience paraphilic sexual interests are always mentally disordered, less than fully human, or invariably guilty of criminal behavior. Paraphilic sexual interests are not considered mental disorders unless they are associated with significant distress or disability (APA, 2013), and paraphilic interests such as pedophilia, frotteurism, and exhibitionism do not constitute criminal offenses unless acted upon. It is difficult to understand why some critics of Blanchard’s ideas seem so willing to tacitly accept the stigmatization of unusual sexual interests in their attempts to discredit his theory. Going farther still, some critics contend that Blanchard’s theory delegitimizes, maligns, or humiliates MtF transsexuals: “Autogynephilia” implies that all lesbian and bi[sexual] transwomen are motivated to transition primarily by sexual paraphilia or deviance, undermining their legitimacy and dignity as women. “Autogynephilia” denies that transwomen. . . possess an inner feminine gender identity or “essence”. (Winters, 2008, para. 10) [By advancing Blanchard’s theory, Bailey, 2003] invalidate[d] the lived experiences and identities of an entire group of oppressed people about whom he [had] no first-order knowledge. . . In doing so, he maligned and humiliated an entire group of oppressed people, notwithstanding the few self-identified autogynephiles who agreed with his views. (Mathy, 2008, p. 464) The claim that the theory of autogynephilia “invalidates” (Mathy, 2008; Moser, 2010b; Serano, 2009) or “undermines” (Serano, 2010; Winters, 2008) the identities of some MtF transsexuals seems untenable. Admittedly, the theory is inconsistent with the identities of some MtF transsexuals, but it is not clear how the theory invalidates or undermines European Psychologist (2017), 22(1), 39–54

those identities in any meaningful sense: The persons in question remain free to assert whatever identities they wish. Identities that are rendered invalid if not affirmed without exception by others would seem to be tenuous at best. The notion that scholars have an ethical duty to validate or endorse the identities of all MtF transsexuals (assuming they can know what these identities are), even at the cost of rejecting a scientific theory they consider accurate and useful, seems intellectually indefensible. Veale (2015) recently made even more sweeping claims. Criticizing research on autogynephilia by Hsu, Rosenthal, and Bailey (2015), Veale asserted an “ethical obligations that researchers have when conducting research on marginalized and vulnerable groups to ensure that their findings are not misrepresented or misused in a way that can cause harm to the group being researched” (p. 1745). Ensuring that one’s findings could never be misrepresented or misused would seemingly require researchers to possess superhuman abilities to read the minds and predict the intentions of other people, including those not yet born; but that is what Veale apparently demanded. One could argue that describing autogynephilic MtF transsexuals as males who choose to undergo sex reassignment in order to effectively address their paraphilic sexual orientation portrays them as courageous and determined, not as dishonorable or morally suspect (Lawrence, 2013). Moreover, some MtF transsexuals freely admit to experiencing autogynephilia or identify as autogynephilic (Moser, 2010b); from their perspective, the idea that there is something invalidating about being described as an autogynephilic transsexual probably feels transphobic.

Implications of the Autogynephilia Controversy for Diagnosis, Treatment, and Research Arguably the most significant consequences of the controversy about autogynephilia and its associated transsexual typology have been ongoing efforts to reduce or eliminate discussion of these topics in diagnostic nosologies, clinical treatment guidelines, and research reports. For example, the term autogynephilia, which had appeared in the discussion of GID in the DSM-IV-TR (APA, 2000, p. 578), was eliminated from the discussion of Gender Dysphoria in DSM-5 (APA, 2013). Specifiers based on sexual orientation, which had been part of the diagnoses of Transsexualism and GID in every edition of the DSM since 1980, were also removed from the DSM-5. Winters, a transgender activist, had recommended that the term autogynephilia be eliminated, arguing that, “It serves no Ó 2017 Hogrefe Publishing


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constructive purpose in an evidence-based diagnostic nosology. I strongly urge the American Psychiatric Association to remove this offensive term from the supporting text of the GID diagnosis. . . in the DSM-V.” (Winters, 2008, para. 11). Her recommendation was adopted for the DSM-5 diagnosis of Gender Dysphoria. Cohen-Kettenis and Pfäfflin (2010), writing on behalf of the DSM-5 GID Subworkgroup (Zucker et al., 2013), contended that the use of specifiers based on sexual orientation in the DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000) was “largely based on the work of Blanchard and colleagues (e.g., Blanchard, 1989b; Blanchard, Clemmensen, & Steiner, 1987)” (p. 507). Their contention was historically inaccurate, given that identical specifiers had been part of the DSM since 1980. Nevertheless, this assertion gave Cohen-Kettenis and Pfäfflin additional grounds for advocating elimination of subtypes based on sexual orientation from the DSM-5: In the transgender community, there is strong resistance against subtyping on the basis of sexual orientation and activity and even against having to give this information for scientific purposes only. The term autogynephilia, which is used for one subtype, is considered highly offensive by some (e.g., Winters, 2008). (p. 508) The fact that Cohen-Kettenis and Pfäfflin cited Winters (2008) suggests that complying with the demands of transgender activists by suppressing references to Blanchard’s ideas in the DSM-5 was clearly on their minds. Similarly, when the World Professional Association for Transgender Health issued the most recent edition of its Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (Coleman et al., 2011), autogynephilia and typologies based on sexual orientation were never mentioned, even though some MtF transsexuals were known to identify as autogynephilic (e.g., Lawrence, 2009; Moser, 2010b), and typologies based on sexual orientation were recognized as having significant descriptive, predictive, and heuristic value (Lawrence, 2010a; Zucker et al., 2013). As Zucker, Lawrence, and Kreukels (2016) subsequently observed: In the seventh revision to the Standards of Care. . . terms such as sexual orientation, transvestic fetishism, and autogynephilia are never mentioned. We would argue that this reflects a kind of intellectual erasure in the discourse on phenomenology, which may inadvertently (or, perhaps, intentionally) obscure the importance of these parameters with regard to

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theoretical issues, empirical research on causal mechanisms, and therapeutic care. (p. 221) A similar pattern of erasure of information about sexual orientation in MtF transsexuals and other gender dysphoric males has occurred in recent publications from the European Network for the Investigation of Gender Incongruence (ENIGI; Kreukels et al., 2012). In an early ENIGI article discussed previously, Nieder et al. (2011) compared MtF transsexuals’ self-reported sexual orientation data with ratings by treating clinicians, observing that “self-report and clinician’s report data appeared to be quite incongruent. With a negative Cohen’s kappa (κ = 0.39), the [MtF] participants’ and clinicians’ ratings. . . largely disagreed” (p. 787). There would seem to be obvious value in continuing to report clinicians’ ratings of sexual orientation, including the possibility of comparing correlations between clinical variables of interest and clinician-rated (versus self-reported) sexual orientation. However, subsequent ENIGI publications that have addressed sexual orientation in gender dysphoric males (e.g., Becker et al., 2016; Cerwenka et al., 2014; van de Grift et al., 2016) have presented no detailed clinician-rated sexual orientation data, although van de Grift et al. reported the correlation between clinician-rated and self-reported sexual orientation for their combined group of MtF and FtM participants (pp. 577–578), suggesting that clinicians’ ratings were still being collected as of 2012. If analyzed and published, clinician-rated sexual orientation data might confirm Lawrence’s (2010a) conclusion that transsexual typologies based on sexual orientation are superior to the age of onset-based typologies that many ENIGI researchers seem to favor. Perhaps this partly explains why the ENIGI clinician-rated data remain unpublished. Meanwhile, the ENIGI researchers have sometimes concluded that typologies based on sexual orientation have superior predictive value (e.g., van de Grift et al., 2016, p. 581), even when these rely on potentially inaccurate self-report data.

The Future of a Controversial Theory and Typology Notwithstanding the controversy surrounding the theory of autogynephilia and recent attempts to deemphasize or eliminate discussion of autogynephilia and its associated transsexual typology in diagnostic nomenclatures, clinical guidelines, and research reports, some scholarly discourse and scientific investigation concerning these topics has continued. A few researchers (e.g., Hsu et al., 2015) have persisted in studying autogynephilia, albeit not in the

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clinical populations where their findings would be of greatest relevance. Meanwhile, the descriptive and clinical value of Blanchard’s theory remains undiminished by the controversy: Like Darwin’s theory of evolution and similar disputed ideas, the theory of autogynephilia continues to be useful to researchers and clinicians despite its failure to achieve universal acceptance. Perhaps the future development of innovative methodologies for accurately assessing autogynephilic arousal and sexual orientation will eventually resolve many current disagreements. Until that time, autogynephilia and its associated sexual orientation-based typology of MtF transsexualism are likely to remain important but controversial topics.

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Blanchard, R. (1989b). The concept of autogynephilia and the typology of male gender dysphoria. The Journal of Nervous and Mental Disease, 177, 616–623. Blanchard, R. (1991). Clinical observations and systematic studies of autogynephilia. Journal of Sex & Marital Therapy, 17, 235–251. Blanchard, R. (1993). Partial versus complete autogynephilia and gender dysphoria. Journal of Sex & Marital Therapy, 19, 301–307. Blanchard, R. (2005). Early history of the concept of autogynephilia. Archives of Sexual Behavior, 34, 439–446. doi: 10.1007/ s10508-005-4343-8 Blanchard, R., & Clemmensen, L. H. (1988). A test of the DSM-III-R’s implicit assumption that fetishistic arousal and gender dysphoria are mutually exclusive. Journal of Sex Research, 25, 426–432. Blanchard, R., Clemmensen, L. H., & Steiner, B. W. (1985). Social desirability response set and systematic distortion in the selfreport of adult male gender patients. Archives of Sexual Behavior, 14, 505–516. Blanchard, R., Clemmensen, L. H., & Steiner, B. W. (1987). Heterosexual and homosexual gender dysphoria. Archives of Sexual Behavior, 16, 139–152. Blanchard, R., Dickey, R., & Jones, C. L. (1995). Comparison of height and weight in homosexual vs. nonhomosexual male gender dysphorics. Archives of Sexual Behavior, 24, 543–554. Blanchard, R., Racansky, I. G., & Steiner, B. W. (1986). Phallometric detection of fetishistic arousal in heterosexual male cross-dressers. Journal of Sex Research, 22, 452–462. Blanchard, R., Steiner, B. W., & Clemmensen, L. H. (1985). Gender dysphoria, gender reorientation, and the clinical management of transsexualism. Journal of Consulting and Clinical Psychology, 53, 295–304. Bolin, A. (1988). In search of Eve: Transsexual rites of passage. New York, NY: Bergin & Garvey. Brown, G. R., & Jones, K. T. (2016). Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: A casecontrol study. LGBT Health, 3, 122–131. doi: 10.1089/lgbt. 2015.0058 Cerwenka, S., Nieder, T. O., Briken, P., Cohen-Kettenis, P. T., De Cuypere, G., Haraldsen, I. R. H., . . . Richter-Appelt, H. (2014). Intimate partnerships and sexual health in gender-dysphoric individuals before the start of medical treatment. International Journal of Sexual Health, 26, 52–65. doi: 10.1080/19317611. 2013.829153 Cohen-Kettenis, P. T., & Pfäfflin, F. (2010). The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior, 39, 499–513. doi: 10.1007/s10508009-9562-y Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., De Cuypere, G., Feldman, J., . . . Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gendernonconforming people, version 7. International Journal of Transgenderism, 13, 165–232. doi: 10.1080/15532739.2011. 700873 Diamond, L. M. (2003). What does sexual orientation orient? A biobehavioral model distinguishing romantic love and sexual desire. Psychological Review, 110, 173–192. doi: 10.1037/0033295X.110.1.173 Docter, R. F. (1988). Transvestites and transsexuals: Toward a theory of cross-gender behavior. New York, NY: Plenum Press. Dreger, A. (2008). The controversy surrounding The Man Who Would Be Queen: A case history of the politics of science, identity, and sex in the Internet age. Archives of Sexual Behavior, 37, 366–421. doi: 10.1007/s10508-007-9301-1

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Freund, K., Steiner, B. W., & Chan, S. (1982). Two types of crossgender identity. Archives of Sexual Behavior, 11, 47–63. Gosselin, C., & Wilson, G. (1980). Sexual variations: Fetishism, sadomasochism, transvestism. New York, NY: Simon and Schuster. Guillamon, A., Junque, C., & Gómez-Gil, E. (2016). A review of the status of brain structure research in transsexualism. Archives of Sexual Behavior, 45, 1615–1648. doi: 10.1007/s10508-0160768-5 Hsu, K. J., Rosenthal, A. M., & Bailey, J. M. (2015). The psychometric structure of items assessing autogynephilia. Archives of Sexual Behavior, 44, 1301–1312. doi: 10.1007/ s10508-014-0397-9 Hwahng, S. J., & Nuttbrock, L. (2007). Sex workers, fem queens, and cross-dressers: Differential marginalizations and HIV vulnerabilities among three ethnocultural male-to-female transgender communities in New York City. Sex Research & Social Policy, 4, 36–59. Kreukels, B. P., Haraldsen, I. R., De Cuypere, G., Richter-Appelt, H., Gijs, L., & Cohen-Kettenis, P. T. (2012). A European network for the investigation of gender incongruence: The ENIGI initiative. European Psychiatry, 27, 445–450. doi: 10.1016/j.eurpsy. 2010.04.009 Lawrence, A. A. (2004). Autogynephilia: A paraphilic model of gender identity disorder. Journal of Gay & Lesbian Psychotherapy, 8(1/2), 69–87. doi: 10.1300/J236v08n01_06 Lawrence, A. A. (2005). Sexuality before and after male-to-female sex reassignment surgery. Archives of Sexual Behavior, 34, 147–166. doi: 10.1007/s10508-005-1793-y Lawrence, A. A. (2007). Becoming what we love: Autogynephilic transsexualism conceptualized as an expression of romantic love. Perspectives in Biology and Medicine, 50, 506–520. Lawrence, A. A. (2009). Transgenderism in nonhomosexual males as a paraphilic phenomenon: Implications for case conceptualization and treatment. Sexual and Relationship Therapy, 24, 188–206. doi: 10.1080/14681990902937340 Lawrence, A. A. (2010a). Sexual orientation versus age of onset as bases for typologies (subtypes) of gender identity disorder in adolescents and adults. Archives of Sexual Behavior, 39, 514–545. doi: 10.1007/s10508-009-9594-3 Lawrence, A. A. (2010b). Something resembling autogynephilia in women: Comment on Moser (2009) [Letter to the Editor]. Journal of Homosexuality, 57, 1–4. doi: 10.1080/ 00918360903445749 Lawrence, A. A. (2011). Autogynephilia: An underappreciated paraphilia. Advances in Psychosomatic Medicine, 31, 135–148. Lawrence, A. A. (2013). Men trapped in men’s bodies: Narratives of autogynephilic transsexualism. New York, NY: Springer. Lawrence, A. A. (2014). Veale’s (2014) critique of Blanchard’s typology was invalid [Commentary]. Archives of Sexual Behavior, 43, 1679–1683. doi: 10.1007/s10508-014-0383-2 Lawrence, A. A., & Bailey, J. M. (2009). Transsexual groups in Veale et al. (2008) are “autogynephilic” and “even more autogynephilic” [Letter to the editor]. Archives of Sexual Behavior, 38, 173–175. doi: 10.1007/s10508-008-9431-0 Lukianowicz, N. (1959). Survey of various aspects of transvestism in the light of our present knowledge. The Journal of Nervous and Mental Disease, 128, 36–64. Mathy, R. M. (2008). Cowboys, sheepherders, and The Man Who Would Be Queen: “I know” vs. first-order lived experience [Commentary]. Archives of Sexual Behavior, 37, 462–465. doi: 10.1007/s10508-008-9335-z Money, J., & Gaskin, R. J. (1970–1971). Sex reassignment. International Journal of Psychiatry, 9, 249–269. Moser, C. (2009). Autogynephilia in women. Journal of Homosexuality, 56, 539–547. doi: 10.1080/00918360903005212

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Moser, C. (2010a). A rejoinder to Lawrence (2010): It helps if you compare the correct items [Letter to the editor]. Journal of Homosexuality, 57, 693–696. doi: 10.1080/00918369.2010. 485859 Moser, C. (2010b). Blanchard’s autogynephilia theory: A critique. Journal of Homosexuality, 57, 790–809. doi: 10.1080/00918369. 2010.486241 Nichols, M. (2014). Men trapped in men’s bodies: Narratives of autogynephilic transsexualism, by Anne Lawrence [Book review]. Journal of Sex & Marital Therapy, 40, 71–73. doi: 10.1080/0092623X.2013.854559 Nieder, T. O., Herff, M., Cerwenka, S., Preuss, W. F., Cohen-Kettenis, P. T., De Cuypere, G., . . . Richter-Appelt, H. (2011). Age of onset and sexual orientation in transsexual males and females. The Journal of Sexual Medicine, 8, 783–791. doi: 10.1111/j.1743-6109.2010.02142.x Nuttbrock, L., Bockting, W., Mason, M., Hwahng, S., Rosenblum, A., Macri, M., & Becker, J. (2011). A further assessment of Blanchard’s typology of homosexual versus non-homosexual or autogynephilic gender dysphoria. Archives of Sexual Behavior, 40, 247–257. doi: 10.1007/s10508-009-9579-2 Ovesey, L., & Person, E. (1976). Transvestism: A disorder of the sense of self. International Journal of Psychoanalytic Psychotherapy, 5, 219–236. Rönspies, J., Schmidt, A. F., Melnikova, A., Krumova, R., Zolfagari, A., & Banse, R. (2015). Indirect measurement of sexual orientation: Comparison of the implicit relational assessment procedure, viewing time, and choice reaction time tasks. Archives of Sexual Behavior, 44, 1483–1492. doi: 10.1007/s10508-014-0473-1 Savic, I., & Arver, S. (2011). Sex dimorphism of the brain in male-to-female transsexuals. Cerebral Cortex, 21, 2525–2533. doi: 10.1093/cercor/bhr032 Serano, J. M. (2009, June). Psychology, sexualization and transinvalidations . Paper presented at the 8th Annual Philadelphia Trans-Health Conference, Philadelphia, PA. Retrieved from http://www.juliaserano.com/av/Serano-TransInvalidations.pdf Serano, J. M. (2010). The case against autogynephilia. International Journal of Transgenderism, 12, 176–187. doi: 10.1080/ 15532739.2010.514223 Smith, Y. L. S., van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. T. (2005). Transsexual subtypes: Clinical and theoretical significance. Psychiatry Research, 137, 151–160. doi: 10.1016/j.psychres.2005.01.008 Stoller, R. J. (1968). Sex and gender: On the development of masculinity and femininity. New York, NY: Science House. van de Grift, T. C., Cohen-Kettenis, P. T., Steensma, T. D., De Cuypere, G., Richter-Appelt, H., Haraldsen, I. R., . . . Kreukels, B. P. (2016). Body satisfaction and physical appearance in gender dysphoria. Archives of Sexual Behavior, 45, 575–585. doi: 10.1007/s10508-015-0614-1 Veale, J. F. (2014). Evidence against a typology: A taxometric analysis of the sexuality of male-to-female transsexuals. Archives of Sexual Behavior, 43, 1177–1186. doi: 10.1007/ s10508-014-0275-5 Veale, J. F. (2015). Comments on ethical reporting and interpretations of findings in Hsu, Rosenthal, and Bailey’s (2014) “The psychometric structure of items assessing autogynephilia” [Letter to the editor]. Archives of Sexual Behavior, 44, 1743–1746. doi: 10.1007/s10508-015-0552-y Veale, J. F., Clarke, D. E., & Lomax, T. C. (2008). Sexuality of maleto-female transsexuals. Archives of Sexual Behavior, 37, 586–597. doi: 10.1007/s10508-007-9306-9 Veale, J. F., Clarke, D. E., & Lomax, T. C. (2011). Male-to-female transsexuals’ impressions of Blanchard’s autogynephilia theory. International Journal of Transgenderism, 13, 131–139. doi: 10.1080/15532739.2011.669659

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Walworth, J. R. (1997). Sex-reassignment surgery in male-tofemale transsexuals: Client satisfaction in relation to selection criteria. In B. Bullough, V. L. Bullough, & J. Elias (Eds.), Gender blending (pp. 352–369). Amherst, NY: Prometheus Books. Whitam, F. L. (1987). A cross-cultural perspective on homosexuality, transvestism, and transsexualism. In G. D. Wilson (Ed.), Variant sexuality: Research and theory (pp. 176–201). Baltimore, MD: Johns Hopkins University Press. Winters, K. (2008). Autogynephilia: The infallible derogatory hypothesis, part 2. Retrieved from http://gidreform.wordpress.com/ 2008/11/19/autogynephilia-the-infallible-derogatory-hypothesispart-2/ World Health Organization. (1992). International statistical classification of diseases and related health problems (Vol. 1). Geneva, Switzerland Author. Zucker, K. J., Bradley, S., Owen-Anderson, A., Kibblewhite, S. J., Wood, H., Singh, D., & Choi, K. (2012). Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. Journal of Sex & Marital Therapy, 38, 151–189. doi: 10.1080/ 0092623X.2011.611219 Zucker, K. J., Cohen-Kettenis, P. T., Drescher, J., Meyer-Bahlburg, H. F., Pfäfflin, F., & Womack, W. M. (2013). Memo outlining evidence for change for Gender Identity Disorder in the DSM-5. Archives of Sexual Behavior, 42, 901–914. doi: 10.1007/s10508013-0139-4 Zucker, K. J., Lawrence, A. A., & Kreukels, B. P. C. (2016). Gender dysphoria in adults. Annual Review of Clinical Psychology, 12, 217–247. doi: 10.1146/annurev-clinpsy-021815-093034

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Received March 6, 2016 Revision received July 9, 2016 Accepted September 8, 2016 Published online March 23, 2017 Anne A. Lawrence 6801 28th Ave NE Seattle, WA 98115 USA alawrence@mindspring.com

Anne A. Lawrence, MD, PhD, is an Adjunct Associate Professor in the Department of Psychology at the University of Lethbridge, AB, Canada. She is the author of Men Trapped in Men’s Bodies: Narratives of Autogynephilic Transsexualism (Springer, 2013) and over 50 book chapters, research studies, review articles, and commentaries concerning gender identity disorders and paraphilias.

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Special Issue: Controversial Issues in Human Sexuality Research: The State of the Science Original Articles and Reviews

Unique and Shared Relationship Benefits of Consensually Non-Monogamous and Monogamous Relationships A Review and Insights for Moving Forward Amy C. Moors,1,2 Jes L. Matsick,3 and Heath A. Schechinger4 1

Social Science Research and Evaluation, College of Engineering, Purdue University, West Lafayette, IN, USA

2

National Center for Institutional Diversity and Department of Women’s Studies, University of Michigan, Ann Arbor, MI, USA

3

Departments of Psychology and Women’s, Gender, and Sexuality Studies, Pennsylvania State University, University Park, PA, USA

4

Counseling and Psychological Services, University of California, Berkeley, CA, USA

Abstract: The increased media and public curiosity on the topic of consensual non-monogamy (CNM) presents an interesting case, given that these types of relationships are highly stigmatized. In the present review piece, we first situate common themes of benefits that people believe are afforded to them by their CNM relationships within the current state of the literature to provide insight into unique and shared (with monogamy) relationship benefits. This approach helps uncover relationship benefits and theoretical advances for research on CNM by highlighting some of the key features of CNM relationships that people find rewarding, including need fulfillment, variety of activities, and personal growth and development. Second, we discuss common misconceptions about CNM and stigma toward CNM. Finally, we conclude with future directions and recommendations for scholars interested in pursuing research on CNM. Keywords: consensual non-monogamy, relationship qualities, relationship benefits, stigma

A quick Internet search uncovers numerous media headlines touting the benefits as well as pitfalls of consensual non-monogamy (CNM) – relationships where people involved consensually agree to have more than one concurrent sexual and/or romantic partner. From blogs to landmark outlets (e.g., New York Times, Telegraph, Scientific American), there is an online market of information to fulfill the public’s curiosity about departures from coupledom. In fact, Google searches related to polyamory and open relationships have markedly increased over the past decade in the United States (Moors, 2016). Coinciding with the general public’s interest in seeking more information about CNM, dozens of “how to” guides and scientific books on the topic have emerged within the last few years (Anapol, 2010; Beckett, 2015; Minx, 2014; Ryan & Jethå, 2010; Sheff, 2015; Veaux & Rickert, 2014). It seems safe to assume that people want to know more. Arguably, research interest in CNM has dwindled since the 1980s Ó 2017 Hogrefe Publishing

(Cole & Spanier, 1973; Jenks, 1985); however, there has recently been a resurgence of empirical pursuit (see Conley, Ziegler, Moors, Matsick, & Valentine, 2013; Rubel & Bogaert, 2015, for reviews). This increased curiosity, especially by the public, is interesting given the robust stigma that surrounds CNM relationships (e.g., Conley, Moors, Matsick, & Ziegler, 2013). For example, a recent survey indicated that over one-quarter of people in polyamorous relationships have experienced discrimination based on their relationship status in the past 10 years (Cox, Fleckenstein, & Bergstrand, 2013). For this reason and many others, people in CNM relationships strategically manage to whom they disclose their relationship styles (Nearing, 2000; Pallotta-Chiarolli, 2010) and, further, some communities who openly practice CNM purposefully remain geographically isolated (Aguilar, 2013). Overall, these experiences reflect a fear of being “out” with one’s relationship style European Psychologist (2017), 22(1), 55–71 DOI: 10.1027/1016-9040/a000278


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and, unfortunately, research on relationship stigma suggests that these fears are not irrational. In the present review of the CNM literature, we draw on elements of feminist practice and qualitative methodology (Braun & Clarke, 2006; Fitzgerald, 2004; Stewart, 1998) to situate the voices of people engaged in CNM within extant research on CNM, with the goal of identifying trends in the literature and directions for future research. Thus, we asked people engaged in CNM “What are the benefits of consensual non-monogamy?”1 and use these benefits of CNM as a guide to reappraise the growing body of academic inquiry in Western cultures on consensual departures from monogamy. We conceptually mapped relationship benefits that people engaged in CNM believe are afforded to them which provides insight into: (1) unique relationship benefits – features of CNM relationships that are not characteristic of monogamy and vice versa, and (2) shared relationship benefits – common features of both CNM and monogamous relationships. With this approach, we structure the current review in three parts. First, we review research and theory related to three relationship benefits that were uniquely mentioned by people engaged in CNM: diversified need fulfillment, variety of nonsexual activities, and individual growth and development. In other words, these relationship benefits did not spontaneously emerge in previous research when people in monogamous relationships were asked about the benefits of monogamy (see Conley, Moors, Matsick, et al., 2013). Second, we take a closer look at two relationship benefits, health and morality, that were uniquely mentioned as benefits by people in monogamous relationships. Finally, after synthesizing research on CNM, we provide recommendations and future directions for moving forward with scholarly pursuits in this area. To provide additional context on the framing of this review and to help generate future research directions, Table 1 describes relationship benefits associated with CNM relationships. Of note, the research reviewed in this piece predominantly focuses on scholarship from Western countries (e.g., the United States and the United Kingdom).

1

A. C. Moors et al., Consensual Non-Monogamy

What Is Consensual Non-Monogamy? Romantic and/or sexual relationships can be thought of as agreements or “rules” that all partners decide upon, whether they be explicitly discussed or assumed. Some relationships might be built on the rule that people can have only one sexual and romantic partner – the foundation of contemporary monogamous relationships (see Ziegler, Conley, Moors, Matsick, & Rubin, 2015, for an overview of social and sexual monogamy). However, many variations of rules exist to create other relationship configurations. In CNM relationships, all partners involved make consensual agreements to engage (or not) in concurrent romantic and/or sexual relationships (Conley, Ziegler, et al., 2013). CNM can take a variety of forms; for instance, some relationship agreements are characterized by some, but not all, partners engaging in concurrent relationships. Another agreement might involve partners engaging in multiple romantic, but not sexual relationships (or having “rules” that permit which types of sex are permitted with various partners). Regardless of the exact relational configuration, these types of non-monogamy are consensual, whereas sexual infidelity (having more than one partner without consent) is nonconsensual non-monogamy. CNM relationships include (but are not limited to) polyamory, swinging, open relationships, and “monogamish” relationships, and these types of CNM embody different relationship agreements. Polyamory typically refers to romantic and/or sexual involvement with multiple partners. Emotionally intimate relationships, but not sexual, also fall into this practice (Klesse, 2006; Scherrer, 2010). Although not exhaustive, some common ways polyamorous relationships are configured include one or two “primary” partners (often the focal or longest relationship partner) and other “secondary” partner(s), triads (three people involved with each other), or quads (four involved with each other; Barker, 2005; Munson & Stelboum, 1999; Sheff & Tesene, 2015). Moreover, some polyamorous relationships are not open for everyone, per se, as “polyfidelity” refers to remaining

To assist in the framing of the present literature review, we asked 175 people currently engaged in CNM to list up to five benefits of their relationship type (for further details see Conley, Moors, Matsick, et al., 2013). Thematic coding (Braun & Clarke, 2006) was utilized to identify the major and minor benefit themes. The responses were independently coded into nine major themes (and minor themes within each major theme) by the last author and a trained research assistant with an inter-rater reliability of 91%. Major themes that emerged for CNM were compared to themes that emerged for monogamy in Conley, Moors, and colleagues’ (2013) research to identify relationship benefits that were unique to either type of relationship and shared between relationship styles. Of those who provided benefits of CNM, 43% identified as part of a polyamorous relationship, 30% identified as part of an open relationship, 16% identified as part of a swinging relationship, and 11% identified as part of CNM relationships (i.e., without a specific label). On average, participants were 35.41 years old (SD = 10.39) and indicated they were currently romantically and/or sexually involved with 2.49 partners (SD = 1.27). Fifty-eight percent of participants identified as female, 35% identified as male, and 7% identified as trans, nonbinary, or gender queer. Nearly half of the sample identified as bisexual (46%), followed by 32% heterosexual/straight, 18% pansexual/omnisexual/queer, and 5% gay or lesbian.

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Table 1. What are the benefits of consensual non-monogamy? Percentages of major and minor themes that emerged Major themes

% of major themes mentioned

Example responses

Minor themes

% of minor theme mentioned

“Getting different mental/ emotional/physical needs met” “Spreading the burden of having my and my partners’ needs met” Not expecting one partner to be ‘everything’ to me” “More satisfied because of multiple people meeting many needs” “Variety of everyday activities” “Having partners for various non-sexual activities that a primary partner might not enjoy” “Always something fun to do with partners, like date nights and movies”

More people to meet needs (and more of own needs met) Decreased pressure to meet all needs (of partner) Satisfaction (because of multiple partners)

55

More activities and variety Fun

51 28

“Freedom from restrictions” “Self-growth” “I can express my full range of sexuality - not possible when monogamous”

Autonomy/freedom Introspection

50 36

Ability to explore connections with same-gender/queer partners

14

“Being part of a big, happy, close-knit chosen family” “Strong friendship network”

Large social network (family and friendship) Increased/shared financial resources

61

“Improved financial stability for all partners if all contribute to the household” “Co-parenting”

Shared household/parenting responsibilities

14

“Complete trust. (I know my partner isn’t going to cheat on me because if he calls me first I’ll say its ok)” “True honesty” “Encourages greater openness” “Compersion (joy of seeing partners fall in love with someone else)” “More variety to sex”

Honesty/no deception

56

Openness

15

Compersion (conceptualized as opposite of jealousy) Increased variety of sex/experimentation

10 41

“Better sex”

Better/great sex

17

“More sex”

High frequency of sex

15

“Grown closer to my partner and love him more because of our [consensual non-monogamous] relationship” “More love”

Experience greater amounts/depth of love

31

Able to love multiple people/not having to “choose”

16

Benefits Unique to Consensual Non-monogamy: DIVERSIFIED NEED FULFILLMENT

42

ACTIVITY VARIETY (NONSEXUAL)

40

PERSONAL GROWTH/ DEVELOPMENT

32

23 11

Benefits shared with monogamy: FAMILY/COMMUNITY BENEFITS

TRUST

SEX

LOVE

COMMUNICATION

COMMITMENT

45

42

39

28

28

23

“Not having to break up with someone when you fall in love with someone else” “Open communication” Open/honest communication

19

43

“Relationships must be more conscious and well-communicated, which makes them stronger” “Different perspectives are valuable when you need someone to talk to” “Develop better communication skills”

More opinions/perspectives

35

Enhances communication skills

18

“Web of emotional support”

Emotional support

43

“A strong and secure relationship not marred by fears of infidelity” “Not relying solely on one person, committed to many”

Security/stability

30

Can depend on multiple people

13

Notes. The major themes are ordered by percentage mentioned by participants, beginning with the item that was most frequently mentioned by participants, separated by benefits that were unique to consensual non-monogamy and shared with monogamy.

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faithful to a specific multi-person relationship. Co-marital sex, popularly known as swinging, refers to couples exchanging partners or engaging in group sex (Buunk & van Driel, 1989; Jenks, 1985). This type of relationship typically involves sexual (not emotional) activities outside a primary relationship; although, long-term friendships and, sometimes, romantic relationships with other couples are formed (Kimberly & Hans, 2015). Open relationships are often presented in the literature as the overarching term for non-monogamy (e.g., Kurdek & Schmitt, 1986). However, the meaning of this relationship appears to be flexible (although the focus is typically on independent sexual, not romantic relationships, as opposed to swinging relationships which involve partners mutually seeking out other relationships together). Similarly, the term “monogamish” was more recently made popular by sex columnist, Dan Savage, to refer to people who are mostly monogamous (adhering to social monogamy), but have permeable sexual relationship boundaries (e.g., engagement in threesomes; Savage, 2012). Thus, there is a great diversity of relationship agreements among partners who consensually depart from monogamy.2 Throughout this review, we tend to focus on CNM relationships collectively; however, we note when we discuss a specific type of relationship agreement. Engagement in CNM relationships appears to be relatively common. Utilizing two separate national samples of single adults in the US (a total of 8,718 people), Haupert, Gesselman, Moors, Fisher, and Garcia (2016) found that approximately one in five Americans has previously been a part of a CNM relationship at some point during their lifetime. In terms of current engagement, Rubin, Moors, Matsick, Ziegler, and Conley (2014) used convenience sampling techniques to ask 2,876 people in North America to report on either behavior-related or identity-related relationship status items. Averaging across both samples, 5.3% of participants indicated they were currently part of a CNM relationship (Rubin et al., 2014). Importantly, both of these large-scale studies did not recruit people on the basis of previous or current engagement in CNM (i.e., participants were unaware of the research questions at hand). Men and sexual minorities were more likely to report previous and current engagement in CNM (compared to women and heterosexual individuals, respectively; Haupert et al., 2016; Rubin et al., 2014). Moreover, no differences in previous engagement in CNM emerged based on race/ethnicity, age, education level, income, religion, geographic region, or political affiliation (Haupert et al., 2016). Thus, not only is CNM commonly practiced but is practiced by a variety

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of people. At the same time, other researchers (albeit small samples sizes often acquired with targeted CNM recruitment techniques) have noted that people engaged in CNM (in particular, polyamory) tend to be upper-class, white, and highly educated (e.g., Klesse, 2014; Sheff & Hammers, 2011; Wosick-Correa, 2010).

Are Relationship Benefits Uniquely Mentioned by People Engaged in CNM? Inquiries about the benefits of relationship type tap into which features of relationships are most salient and desirable and, perhaps, fuel people’s motivation for engaging in particular types of relationships. It is not to say that benefits mentioned by people engaged in CNM about their particular romantic and/or sexual arrangement are only experienced in CNM (and the same logic for the perceived benefits of monogamy). But, answers to this question provide insight into important and common benefits that people believe are afforded by being a part of a CNM relationship. In this section, we discuss three relationship benefits that uniquely characterize CNM: need fulfillment, variety of nonsexual activities, and personal growth and development. That is, these common relationship benefits were spontaneously mentioned by people who are currently in a CNM relationship (i.e., major themes that did not emerge in previous research on benefits of monogamy; Conley, Moors, Matsick, et al., 2013) and acts as a framework for understanding features of CNM.

Need Fulfillment People in CNM relationships see their relationship structure as allowing them to meet a wide variety of their needs – a benefit that was one of the most commonly mentioned. Thus, people engaged in CNM see multiple romantic and/or sexual partners as a way to help displace needs that would typically be met (or not met) by one person in a monogamous relationship; often, directly relating this benefit to increased relationship satisfaction. The importance of the fulfillment of interpersonal needs from close relationships is central to numerous psychological frameworks, including attachment theory, Maslow’s hierarchy of needs, self-determination theory, and interdependence theory. These frameworks identify a diverse set of human needs (many are overlapping), such as belonging, security,

Drawing clear definitional boundaries between types of CNM relationship is challenging for researchers because not all relationships are practiced in the exact same way (e.g., within swinging relationships, people may engage in different relationship rules); however, the definitions of each relationship style we describe reflect the most comprehensive and commonly used perspectives in the literature.

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self-worth, autonomy, intimacy, and competence – and fulfillment of these needs is linked with well-being and relationship quality (e.g., Drigotas & Rusbult, 1992; La Guardia, Ryan, Couchman, & Deci, 2000). Despite the centrality of need fulfillment in interpersonal psychological theories, few studies have applied these frameworks to people who reject the cultural ideal of having one romantic partner meet their needs. Hence, understanding relationship processes among people engaged in CNM is an interesting and underexplored theoretical endeavor. Need fulfillment may be particularly salient for people engaged in CNM because Western cultural norms perpetuate the lofty expectation that one romantic partner should meet most of an individual’s needs (DePaulo & Morris, 2005; Finkel, Hui, Carswell, & Larson, 2014). Drawing on Maslow’s hierarchy of needs, Finkel and colleagues (2014) argue that people in contemporary American (monogamous) marriages are asking too much of their partners – to fulfill physiological, safety, belonging, esteem, and self-actualization needs – and, in turn, metaphorically suffocating them. Finkel and colleagues make a compelling argument that there has been a shift away from helping partners meet lower level needs (physiological and safety) to an emphasis on higher altitude needs (esteem and self-actualization). However, Americans appear to be investing less time and effort in their relationships than in previous eras, thus are not able to meet these higher level needs (Finkel et al., 2014). Finkel and colleagues suggest that, while controversial, CNM may be one avenue to achieve need fulfillment and help alleviate this suffocation dilemma. Extending their proposal, Conley and Moors (2014) suggest ways in which adopting tenets of CNM could improve monogamous relationships over time, including increasing social capital, household organization, communication, and management of attraction to others. Overall, the dispersion of needs across various people in one’s life may help alleviate the suffocation that can occur in monogamous relationships. But, how does having needs fulfilled by multiple partners impact relationship quality? Mitchell, Bartholomew, and Cobb (2014) proposed three ways in which having needs fulfilled by two partners could impact relational quality in relationships with multiple partners. First, having multiple partners can help people achieve greater need fulfillment and, in turn, enhance relationship quality in all relationships (an additive effect). Second, people could compare how well their partners are meeting their needs; thus, if one partner is meeting their needs and another is not to the same extent, then the higher need fulfillment in the one relationship could be linked with lower relational quality in the other relationship (a contrast effect). Finally, if needs are not being met by one partner then another partner can meet those needs, ultimately compensating for presumably low relationship Ó 2017 Hogrefe Publishing

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satisfaction and commitment with the partner who is not meeting the desired needs (a compensation effect). In a study of 1,093 people in polyamorous relationships, Mitchell and colleagues (2014) tested how having needs met by two concurrent partners affects relational quality. Drawing on interpersonal relationship frameworks, they investigated a multitude of needs – autonomy, closeness, emotional support, security, self-esteem, self-expansion, and sexual fulfillment – and how meeting these needs with a given partner impacts relationship satisfaction and commitment in both romantic relationships. Interestingly, there was no support for an additive or compensation effect of partners: the extent to which one partner met someone’s needs was unrelated to satisfaction or commitment with another partner (inconsistent with an additive effect) and need fulfillment across the seven needs assessed were consistently high with both partners of the participant (compensation was not taking place because people were fulfilled by both partners). Mitchell and colleagues found some evidence to support a contrast effect; specifically, need fulfillment in one partner was linked with lower relationship satisfaction (but unrelated to commitment) with the other partner (this only accounted for 1% of the variance; thus, this support for a contrast effect is not particularly meaningful). These findings suggest that a relationship with one partner tends to function relatively independently of a relationship with another partner, as both relationships were considered fulfilling as well as satisfying (essentially without influencing each other). That is, it does not appear that people engage in polyamory because of low need fulfillment with their primary partners, as a given relationship did not have a strong positive or negative effect on the other relationship. Taken together, people engaged in CNM perceive their relationship arrangement as affording them the ability to have a variety of their needs met. Contrary to stereotypes about CNM, it does not appear that people engage in polyamory because of low need fulfillment with their primary partners (Mitchell et al., 2014). Although need fulfillment is central to many contemporary psychological theories, understanding how CNM operates within these frameworks is relatively unexplored. Another area for research is translating core principles of CNM (e.g., jealousy management, communication) to understand whether they help people in monogamous relationships experiencing relational issues reorganize how (and from who) people can meet their needs (see Conley & Moors, 2014).

Variety of Non-Sexual Activities People who engage in CNM are often stereotyped as sexually promiscuous and hedonistic (e.g., Conley, Moors, Matsick, et al., 2013). However, these depictions run European Psychologist (2017), 22(1), 55–71


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contrary to the notion that CNM affords people a variety of nonsexual activities with their partners, a relationship benefit that was far more commonly mentioned than sexualrelated benefits. Thus, people see CNM as providing ample opportunities for social interactions, new experiences, fun, and engagement in a wide variety of activities. Whether CNM provides greater opportunities for social bonding and enjoyment than monogamy remains an empirical question; however, recent research supports the idea that those engaged in CNM embrace the nonsexual activities that are involved in their relationships. Perhaps, this benefit is particularly salient for people engaged in CNM because they may not be experiencing dyadic withdrawal. For instance, research on people in monogamous relationships has shown that as a couple progresses toward living together (and becoming more committed), they tend to withdraw from their social networks (M. P. Johnson & Leslie, 1982; Kalmijn, 2003). It is unclear whether this phenomenon also happens among people who engage in CNM (this remains an empirical question). However, given the priority placed on multiple sexual and/or romantic partners, those engaged in CNM may experience a greater variety of activities (as usually found in one’s social network), especially when one partner does not share a particular hobby or interest, but another partner does. While this can happen with friends in monogamous relationship, CNM relationships may experience greater flexibility regarding whom a partner can spend time with and the type of activities they can engage in. Having multiple partners also affords people with many opportunities to be physical with one another, even in nonsexual ways. For example, members of egalitarian communal living spaces (many of whom engage in CNM) report that they enjoy physical (but not explicitly sexual) touch and other displays of belongingness, such as hugging or signs of affection (Aguilar, 2013). In fact, Aguilar (2013) suggested that this physical closeness involved in nonsexual activities might be one of many reasons why people pursue polyamorous relationships over monogamous relationships. Considering nonsexual elements of fun or satisfaction with life provides an interesting context to think about romantic relationships. We are unaware of research related to CNM that specifically addresses these benefits, although, previous research suggests that, at least for swingers, greater perceived excitement may be the case. When asked “is life exciting or dull?,” over three-quarters of people engaged in swinging indicated their life was “exciting” compared to fewer than half of people in a national survey sample (in the US) who were presumably monogamous (Bergstrand & Sinski, 2010). This finding coincides with how people generally perceive swingers (i.e., compared to other forms of CNM, swingers are perceived as more European Psychologist (2017), 22(1), 55–71

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adventurous and more open to new experiences; Matsick, Conley, Ziegler, Moors, & Rubin, 2014), suggesting that people’s perceptions of CNM, or of swingers more specifically, acknowledge that these relationships provide fun for those involved. The emergence of this unique benefit offers a new way of thinking about the advantages of CNM in nonsexual terms. As we will discuss in another section of this review, there are sexual benefits associated with CNM and monogamy; however, the emphasis on nonsexual activities and intimacy only emerged in perceptions of CNM. Future researchers should address this aspect of CNM relationship to understand how the nonsexual intimacy of these relationships may be linked to relationship quality. That is, does engaging in nonsexual touch with more than one partner provide psychological and/or relationship benefits? How does this benefit contribute to people’s preference for and well-being in CNM relationships?

Individual Growth and Development Another relationship benefit unique to CNM that emerged was individual growth and development. This resonates with conceptual arguments made decades ago in the relationship literature (e.g., O’Neill & O’Neill, 1972; Peabody, 1982). Peabody (1982) posited that the building blocks of CNM relationships, including privacy, honest communication, equality of power, trust, and separate identities, promote both personal and interpersonal growth than possible in monogamous relationships. Early qualitative research on open marriages found that people perceive their relationship as affording them a feeling of freedom combined with security – a benefit that they could not achieve with monogamy (Knapp, 1976). In recent ethnographic research, individual growth and development continue to emerge as reasons people desire to engage in CNM as well as outcomes of this relationship arrangement (Aguilar, 2013; Sheff, 2015). Similar to the concept of need fulfillment, personal growth and autonomy (also commonly mentioned as a benefit of CNM) are defining features of developmental as well as interpersonal psychological frameworks, including implicit theories of relationships, self-expansion theory, and self-determination theory. Together, these frameworks underscore the importance of personal growth and autonomy as motivators to expand, adopt coping strategies, and engage in honest communication within close relationships. However, research in theoretical application to CNM is scant. The psychological construct of autonomy in close relationship contexts is intertwined with need fulfillment (autonomy can be viewed as a need to be fulfilled). As mentioned previously, people who practice polyamory Ó 2017 Hogrefe Publishing


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reported high levels of autonomy with their primary partner and other significant partner (means of 8.27 and 8.26 on a 9-point scale, respectively; Mitchell et al., 2014). Thus, indicating that those who practice polyamory have partners who support and respect their independence and autonomy (and this is linked with relational quality). When asked to compare whether personal freedom is more important in marriage than companionship, relatively few people in swinging and monogamous relationships in the US strongly endorsed this sentiment (Bergstrand & Sinski, 2010). Thus, it does not appear that people in swinging relationships desire personal freedom over companionship any more than people in monogamous relationships. But, how is personal growth, including freedom and autonomy, developed within a broader mononormative culture? Entering a CNM relationship does not simply absolve people of their beliefs about how to have a relationship. Instead, reconciling newly adopted beliefs of CNM with beliefs about monogamy takes a great deal of processing and ideological work. For instance, members of communal living spaces (that promote the practice of CNM) have regular support meetings to discuss overcoming possessiveness and jealousy (referred to as the “dominate culture hangover”; Aguilar, 2013). Members willingly engage in these discussions, believing that “personal growth” is rewarding (Aguilar, 2013). Related, scholars have mapped distinct stages of adjustment for people who practice swinging, indicating that personal growth and developing autonomy is an important component throughout this developmental trajectory (Bergstrand & Sinski, 2010; Butler, 1979). People who are new to swinging often go through a curiosity stage, where breaking the boundaries of monogamy elicits feelings of adventure as well as personal and sexual freedom. Moving into the individuation stage, people begin to view themselves and others as unique individuals and reignite appreciation for each other’s individuality. Moreover, in this stage, noticeable personal and interpersonal change happens, including deconstructing and resolving shame regarding sex and sex role stereotypes (Bergstrand & Sinski, 2010). Promoting freedom and autonomy is also evident from the ways in which people discuss their CNM agreements. When asked about their relationship negotiations, over one-third (39%) of people engaged in polyamorous relationships indicated resistance to terms, such as “allow,” “restrict,” or “rules,” that signified that they might have control over their partners (Wosick-Correa, 2010). In a similar vein, research on CNM that draws feminist and queer scholarship unearths the importance of personal growth as well as a resistance to cultural ideals of (compulsory) heterosexual monogamous marriage (e.g., Barker, 2005; Cascais & Cardoso, 2012; Jackson & Scott, 2004; Ó 2017 Hogrefe Publishing

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Klesse, 2006; Moors & Schechinger, 2014; Rosa, 1994; Wilkinson, 2010; Ziegler, Matsick, Moors, Rubin, & Conley, 2014). People who practice CNM are actively engaging with and resisting gender, sexuality, and relationship normative standards. In a critical review of how endorsement of monogamy may negatively impact women, Ziegler and colleagues (2014) argue that the broader culture entangles women’s selfhood with being part of a monogamous relationship, and this conflation justifies supporting jealous behaviors toward women as well as restricting women’s autonomy. That is, jealousy has been socially constructed to represent sexual ownership, which serves to maintain women’s emotional (and even financial) dependence on men (Rosa, 1994). Thus, the structure of monogamy may make it difficult for women to question normative scripts (reinforcing a patriarchal system), whereas the lack of traditional relationship scripts within CNM may be conducive to challenging of gender norms embedded within relationships (Rosa, 1994; Ziegler et al., 2014). Similarly, Robinson (1997) argues that the institution of monogamy has not served the best interests of women; specifically, “it privileges the interests of both men and capitalism, operating as it does through the mechanisms of exclusivity, possessiveness and jealousy, all filtered through the rose-tinted lens of romance” (p. 144; also see Ritchie & Barker, 2007). Cultural ideals of heterosexual monogamous marriage also influence the ways in which gay men form romantic relationships, as some men (especially younger men) conform to these ideals that may not best fit their or their partner’s preferences (van EedenMoorefield, Malloy, & Benson, 2016). Although CNM relationships can provide a space for resistance, Cascais and Cardoso (2012) found that during the initial stages of moving from monogamy to CNM (particularly polyamory), patriarchal reasoning (e.g., words marking ownership or power differentials) is often still present when people are describing their new relationship(s). Finally, the notion that CNM provides people with the ability to explore emotional and/or sexual connection with same-gender/queer partners is an important benefit to highlight. CNM relationships appear to provide a space for some people to move beyond polarizing dichotomies of sexuality and gender through creating a relationship context that promotes fluid sexual expression (Pallotta-Chiarolli, 1995). This benefit is also reflected by the finding that sexual minorities are more likely to have engaged in CNM than heterosexuals (Haupert et al., 2016). In sum, there are relationship characteristics that uniquely emerged as benefits of CNM, including need fulfillment, variety of nonsexual activities, and personal growth. These benefits reflect recent findings and empirical pursuits in the literature on various aspects of CNM relationships (e.g., interrogating how needs are met and evaluated by individuals who have more than European Psychologist (2017), 22(1), 55–71


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one relationship partner). Next, we discuss two themes that uniquely emerge in research as perceived benefits of monogamy.

Are There Relationship Benefits That Uniquely Emerged for Monogamy? Two themes, health and morality, emerged in previous research as benefits of monogamy (see Table 1 in Conley, Moors, Matsick, et al., 2013) that were not associated with CNM. In this section, we highlight misconceptions about how specific relationship styles relate to health – including the notion that monogamy is a safe haven for sexual health while CNM harms sexual health. Further, because monogamy is believed to afford morality, we review research that indicates that the absence of a monogamous agreement is deemed immoral. The research on morality is then used as a backdrop for reviewing research on stigma toward CNM, including the ways in which individuals may differ in their perceptions and desire to engage in CNM.

Are People in CNM or Monogamous Relationships Sexually “Healthier”? On the one hand, people tend to view monogamy as a safe haven for sexual health, specifically 69% mention that monogamy affords protection from sexually transmitted infections (STIs; Conley, Moors, Matsick, et al., 2013). People also believe that those who practice CNM are more likely to spread STIs (compared to people in monogamous relationships; Conley, Moors, Matsick, et al., 2013; Moors, Matsick, Ziegler, Rubin, & Conley, 2013). On the other hand, one-quarter (or more) of adults report having been sexually unfaithful to their monogamous partner (Lehmiller, 2015; Owen, Rhoades, Stanley, & Fincham, 2010; Swan & Thompson, 2016). Thus, it appears that the sexual fidelity ideals of monogamy are challenging for many people to live up to. Monogamy can be conceptualized as a safer sex strategy; however, this approach is effective insofar as both partners test negative for STIs at the start of the relationship and remain sexually faithful. In fact, a content analysis of state-level public health websites found that the messages these websites convey overwhelming focus on sexual exclusivity (often second to abstinence) with one partner as an effective strategy to prevent the spread of HIV/STIs (Conley, Moors, Matsick, & Ziegler, 2015). In contrast to having sexual contact with only one person (when monogamy agreements are upheld), CNM could add an additional layer European Psychologist (2017), 22(1), 55–71

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of sexual risk, given that people in these relationships often have multiple concurrent sexual partners. However, safer sex practices seem to be a priority for people in CNM relationships. Among people who practice polyamory, the overwhelming majority (91%) reported explicit rules regarding safer sex, including routine testing for all involved (especially prior to a new partner) and consistently using barrier methods (Wosick-Correa, 2010). Whereas the common trajectory for partners in monogamous relationships includes the eventual stopping of condom use as the relationship progresses, which is a signal of relationship commitment and intimacy (Corbett, Dickson-Gómez, Hilario, & Weeks, 2009; Manlove et al., 2011). When looking at the safer sex practices among sexually unfaithful individuals in monogamous relationships and individuals in CNM relationships a clear pattern emerges: those who practice CNM engage in safer sex practices than people who are sexually unfaithful in monogamous relationships (Conley, Moors, Ziegler, & Karathanasis, 2012; Conley, Moors, Ziegler, Matsick, & Rubin, 2013; Swan & Thompson, 2016). Specifically, individuals engaged in CNM were more likely than sexually unfaithful individuals to use condoms (for anal and vaginal sex) and implement other barriers (e.g., cover sex toys) with their primary partner and with their most recent extra-dyadic partner (Conley et al., 2012). In sexual encounters with extra-dyadic partners, individuals in CNM relationships were also more likely than sexually unfaithful individuals to discuss STI testing history and tell their primary partner about the sexual encounter (Conley et al., 2012). Drawing on the Centers for Disease Control’s recommendations for correct condom use, research has also found that people engaged in CNM relationships were less likely to make condom use mistakes (e.g., putting the condom on the wrong way) than sexually unfaithful individuals in monogamous relationships (Conley, Moors, Ziegler, et al., 2013). Moreover, despite reporting a greater lifetime number of sexual partners, people in CNM relationships reported similar rates of STI diagnoses (e.g., chlamydia, gonorrhea, herpes, HIV) as people in monogamous relationships (Lehmiller, 2015). Taken together, beliefs that monogamy minimizes sexual risk appear to jeopardize people’s sexual health. People who practice monogamy but are sexually unfaithful to their partners (and those who remain sexually faithful) use protection less often and less appropriately. People tend to label a relationship as monogamous – even when sexual infidelity is present – because they associate monogamy with emotional attachment rather than a sexual fidelity attachment (Swan & Thompson, 2016). That is, the way in which people perceive and practice monogamy is a protective fallacy, as this type of relationship does not shield the risk of STIs (Swan & Thompson, 2016). Ó 2017 Hogrefe Publishing


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Promoting monogamy as an effective safer sex strategy does not appear to curb the spread of STIs as intended by public health officials; instead, this strategy may be an irresponsible public health message (see Conley, Matsick, Moors, Ziegler, & Rubin, 2015; for further discussion). It is not to say that CNM relationships are the solution to halting the spread of STIs, but principles of explicit negotiation and transparent conversations about sexual health (key components of CNM) are avenues future researchers should further explore.

What Do People Think of Consensual Non-Monogamy? Normative behaviors, especially in the context of sexuality, often reflect what people deem morally appropriate (and, intertwined with religious views). Morality in psychology is popularly thought of as five aspects that drive moral cognition, including care, fairness, loyalty, authority, and purity (Moral Foundations Theory; Graham et al., 2013). Perceptions of purity (religious notions of living in a noble way) are strongly associated with moral attitudes toward nonnormative sexual behaviors (e.g., same-sex sexuality; Koleva, Graham, Iyer, Ditto, & Haidt, 2012). Although this framework has not been applied to understand moral reasoning that drives stigma toward CNM, people’s responses regarding morality as a benefit of monogamy seem to illustrate this point (e.g., “maintaining a higher moral standard. . .” and “fulfilling God’s design for the world”; Conley, Moors, Matsick, et al., 2013, p. 10). Moreover, recent experimental research uncovered that the cultural priority placed on monogamy is part of an ideology structure – the committed relationship ideology – in which many are motivated to defend (Day, 2016; Day, Kay, Holmes, & Napier, 2011; DePaulo & Morris, 2005). This ideology consists of beliefs that monogamous relationships are enduring, most people wish to couple, and that the committed relationship is the most important relationship (also see Rich, 1980; G. Rubin, 1984, for feminist and queer theoretical advances). Endorsement of monogamy reinforces the committed relationship ideology and serves to promote order and stability within a larger sociopolitical system. Taken together, it seems reasonable that people’s perceptions of monogamy as providing a moral way of having a relationship will simultaneously deem departures from monogamy as immoral. In the first series of experimental studies to understand whether people perceive a specific type of relationship as optimal, Conley, Moors, Matsick, and colleagues (2013) asked people to rate their perceptions of (hypothetical) people engaged in a monogamous or CNM relationship. A halo effect was captured: people in monogamous relationships Ó 2017 Hogrefe Publishing

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were perceived as better (with notably large effect sizes) on over 20 traits related to relationship quality, interpersonal skills, health, morality, and arbitrary dimensions (i.e., characteristics unrelated to romantic relationships) than people in CNM relationships. In other words, monogamy and the people who practice it are perceived positively (as if a halo was surrounding them) and the reverse occurred for CNM and its practitioners (known as the devil effect). This cognitive bias was even found among people engaged in CNM, illustrating an effect of system justification (i.e., people hold favorable attitudes toward large social systems, such as monogamy, even when they do not directly benefit from the system; Jost, Banaji, & Nosek, 2004). Even in circumstances when people in CNM were portrayed as happy and satisfied with their relationship, they were still stigmatized (Moors et al., 2013). This stigma was also unilaterally placed upon people regardless of their sexual orientation or gender (Moors et al., 2013), indicating that people believe CNM is a less acceptable practice than monogamy. People also have an implicit hierarchy for which type of CNM is “the best.” Relationships where the focus is on love (polyamory) were perceived as more moral and family-oriented than relationships where the focus tends to be on sex (swinging and open relationships; Matsick et al., 2014). Specifically, people engaged in swinging received the brunt of the stigma (as compared to people in polyamorous and open relationships), suggesting that sex should not occur in the absence of any emotional attachment (as in the case of swinging). Subsequent research on perceptions of relationship arrangements paints a similarly grim profile of people who practice CNM. People in monogamous relationships are perceived as possessing greater relationship satisfaction, morality, and cognitive abilities (akin to arbitrary traits) than those in polyamorous, open, and swinging relationships (Grunt-Mejer & Campbell, 2016). However, when people are asked to compare practitioners of polyamory in relation to those of monogamy, some positive findings emerged (Hutzler, Giuliano, Herselman, & Johnson, 2016). People engaged in polyamory were perceived as better communicators, more extraverted, and higher in physical attractiveness (when the scale was anchored in comparison to people engaged in monogamy; Hutzler et al., 2016). Despite the few positive perceptions that emerged, stigma toward people engaged in polyamory on dimensions of relationship quality, morality, trustworthiness, and unsafe sexual practices was replicated (Hutzler et al., 2016). In addition to comparing perceptions of CNM to monogamy, some research has examined how CNM relationships compare to sexually unfaithful relationships. When examining how people perceive someone in a European Psychologist (2017), 22(1), 55–71


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monogamous relationship who wants to pursue a polyamorous relationship, love affair, or casual sexual fling with another person – all three scenarios were met with stigma (Burris, 2014). However, when people were asked to take the perspective of the person trying to make sense of their feelings for someone else, people viewed the target who wanted to pursue a pure sexual fling (compared to a polyamorous relationship or love affair) more leniently (Burris, 2014). This finding suggests that people may be more able to relate to those thinking about brief sexual infidelity than those thinking about pursuing polyamory. In contrast, Grunt-Mejer and Campbell (2016) found that sexually unfaithful individuals (a cheating couple) were rated the lowest on relationship quality and arbitrary dimensions (cognition and morality) than those in monogamous and CNM relationships. Thus, in this case, the consensual aspect of CNM relationships (as opposed to nonconsensual non-monogamy) appears to buffer some stigma. How Do Individual Differences Affect Attitudes and Behavior? If someone endorses monogamy as the “natural” or “moral” way to have a relationship (mononormativity3) or if someone is politically conservative, are these beliefs linked with prejudice toward CNM? Researchers recently developed a scale, Attitudes towards Polyamory, to examine the extent to which people endorsed popular misconceptions of polyamory (e.g., “polyamory is harmful to children” and “people use polyamorous relationships as a way to cheat on their partners without consequence”; S. M. Johnson, Giuliano, Herselman, & Hutzler, 2016, p. 329). People who endorsed traditional values (mononormativity, religious fundamentalism, political conservatism, and right-wing authoritarianism) and those with greater jealousy held more negative attitudes toward polyamory. Conversely, people who endorsed sensation-seeking and sex positivity (adventure seeking and erotophilia) as well as those with a greater desire for sex held positive attitudes toward polyamory (S. M. Johnson et al., 2015). Related, personal interest in pursuing polyamory (agreeing with statements like “I would consider initiating a discussion of polyamory with my relationship partner”) is linked with positive attitudes toward polyamory (Hutzler et al., 2016). Thus, traditional values and jealousy may be underlying mechanisms that motivate individuals to stigmatize CNM relationships. In terms of popular constructs of personality (i.e., the “Big Five”), research has found links between two of the dimensions and attitudes toward, as well as willingness to 3

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engage in, CNM among sexual minorities (a group that, regardless of a specific identity, expresses positive attitudes toward CNM; Moors, Rubin, Matsick, Ziegler, & Conley, 2014). Among sexual minorities, those who have active imaginations, a preference for variety, and proclivity for new experiences (high in openness), tended to hold positive attitudes toward and greater desire to engage in CNM (Moors, Selterman, & Conley, 2016). Moreover, those who tended to be highly organized, careful, and success-driven (high in conscientiousness) perceived CNM negatively and expressed less willingness to engage in CNM (Moors et al., 2016). Given that openness to experience is associated with enjoying abstractions and ambiguities (McCrae & Costa, 2008), people who possess this trait may be intrigued by “rewriting” traditional relationships rules. Highly conscientiousness individuals tend to deliberate and are less inclined for sensation-seeking (Zuckerman, Kuhlman, Joireman, Teta, & Kraft, 1993); thus, these individuals may have carefully considered what these relationships embody before expressing their attitudes and desire. Interestingly, extraversion was inversely related to sexual minorities’ attitudes toward CNM (and unrelated to desire), a trait which people tend to ascribe to practitioners of CNM (Hutzler et al., 2016). Drawing on another popular theory of personality, researchers have gained a better understanding of attachment in the context of CNM (Moors, Conley, Edelstein, & Chopik, 2015). Attachment theory posits that close bonds with other people, especially romantic partners, are important sources of support, stability, and safety (Hazan & Shaver, 1987). Perhaps, some people are better equipped to manage multiple partners’ sources of support and stability than others. For instance, someone who tends to experience discomfort with closeness to a partner (attachment-related avoidance) or someone who tends to experience insecurity about a partner’s availability and jealousy (anxious attachment) may not have orientations that are best suited for having their needs fulfilled by their partner (e.g., Cassidy, 2000). Looking at attachment across a range of close relationships (with a mother, romantic partner, best friend), fulfillment of autonomy, competence, and belonging needs were linked with secure attachment (i.e., low levels of avoidance and anxiety; La Guardia et al., 2000). Secure attachment is perceived as the optimal orientation, as it reflects comfort with intimacy and is linked with a host of positive outcomes (Feeney, 2008). Adult-attachment researchers often conceptualize romantic love and security as intertwined with sexual exclusivity, suggesting that monogamous relationships are the most natural and healthiest partnerships. However, Moors and colleagues

The term mononormativity was coined by researchers Robin Bauer and Marianne Pieper (and organizers of) at the first International Conference on Polyamory and Mononormativity at the University of Hamburg (November 4th–6th, 2005).

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(2015) posited that people engaged in CNM may be particularly skilled at managing multiple emotional bonds and likely exhibit secure attachment. Moors and colleagues (2015) examined how attachment orientations relate to three facets of sexuality pertaining to CNM: attitudes, desire, and behavior. In one study, people (who had never engaged in CNM) were asked to report their avoidance and anxiety in romantic relationships, attitudes toward CNM (e.g., “If people want to be in an open/consensually non-monogamous relationship, they have every right to do so”), and willingness to engage in different types of CNM (e.g., “You and your partner may form outside romantic relationships, but they must always be less important than the relationship between the two of you”; Moors et al., 2015, p. 228). Highly avoidant individuals endorsed more positive attitudes and greater willingness to engage in CNM. Highly anxious people, on the other hand, tended to hold negative attitudes toward CNM (anxiety was unrelated to desire). Thus, highly avoidant individuals may see CNM relationships as a way to remain psychologically and physically distant from romantic partners, whereas anxious individuals may see these relationships as exacerbating their jealousy (also see Deri, 2015). Given that people in CNM relationships express similar relationship qualities possessed by securely attached individuals (e.g., high satisfaction, emotional closeness, and low jealousy; Conley, Matsick, Moors, & Ziegler, in press; Ritchie & Barker, 2006; Visser & McDonald, 2007), it seems that avoidance may not be related to actual engagement in CNM. In a second study, Moors and colleagues (2015) found that people engaged in CNM reported lower levels of avoidance compared to people in monogamous relationships (anxiety levels were similar in both groups). Thus, avoidant individuals desire CNM in the abstract, but ultimately, people in CNM relationships exhibit aspects of attachment security. In sum, people believe that those who practice monogamy have higher quality relationships, more desired personality characteristics, greater intelligence, and a better quality of life compared to those engaged in CNM. Even those in CNM relationships tend to endorse the status quo and perceive monogamy as affording greater relationship benefits (Conley, Moors, Matsick, et al., 2013). This halo extends to traits and skills unrelated to romantic relationships, as people engaged in monogamy are perceived as being more skilled at paying taxes on time, flossing teeth daily, and taking care of pets (compared to those in CNM relationships; Moors et al., 2013). There is compelling evidence that people in CNM relationships are met with great stigma – and perceived as morally inferior. Some individual difference factors, such as sensationseeking, sex positivity, and openness to new experiences, Ó 2017 Hogrefe Publishing

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buffer stigma toward people engaged in CNM and predict personal desire to engage in these types of relationships. Moreover, contrary to stereotypes about CNM (Conley, Moors, Matsick, et al., 2013; Moors et al., 2013), recent work has shown that those involved in CNM relationships exhibit aspects of attachment security without sexual exclusivity (Moors et al., 2015). Arguably, this influences how people manage having needs met by multiple partners without extreme jealousy (also see Deri, 2015).

What Relationship Benefits Are Shared Between Monogamy and CNM? Before we conclude, it is important to highlight that while a few relationship benefits were uniquely attributed to CNM or monogamy, the majority of themes that emerged were shared across both types of relationships. That is, regardless of relationship structure, people perceived their romantic relationship(s) to provide benefits regarding family, sex, trust, love, communication (meaningfulness), and commitment (also see Table 1 in Conley, Moors, Matsick, et al., 2013). There is a growing body of research that investigates whether these benefits are differentially experienced by people in CNM and monogamous relationships. Given monogamy is commonly practiced and believed to be the golden standard of relationships, research has examined whether these glowing perceptions hold up under empirical scrutiny. Here, we identify conclusions about relationship functioning across both relationship styles. In their examinations of relationship quality outcomes, Conley, Ziegler, and colleagues (2013) found that, in many cases, monogamy does not afford people a greater degree of these benefits than CNM. For example, when looking at relational quality across both types of relationships, people engaged in CNM experience greater trust and lower jealousy as well as similar levels of satisfaction, commitment, and passionate love compared to people engaged in monogamy (Conley et al., in press). Related, Rubel and Bogaert (2015) found that relationship style was not a particularly powerful predictor of psychological (e.g., depression, happiness) and relational well-being (e.g., satisfaction, longevity, jealousy). Research regarding family benefits is sparse with the notable exception of Sheff and colleagues’ work (e.g., Goldfeder & Sheff, 2013; Sheff, 2011, 2015). Spanning years of ethnographic work, Sheff finds that polyamorous families benefit in terms of shared financial and household responsibilities. Drawing on open-ended responses regarding benefits of both relationships, it is clear that people tend European Psychologist (2017), 22(1), 55–71


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to talk about family benefits in different ways (despite this benefit being characteristic of both monogamy and CNM). People in CNM relationships discussed how CNM promotes close-knit communities of friends and partners as well as shared household responsibilities, whereas responses about monogamy focused on being an ideal structure for raising children (also see Table 1 in Conley, Moors, Matsick, et al., 2013). However, the notion that monogamy better serves children is inconsistent with research showing that children enjoy having multiple role models (e.g., for help with homework and variety of hobbies) and do not necessarily experience stigma for their parents’ CNM relationships (see Conley, Ziegler, et al., 2013; Sheff, 2015, for further discussion). The public as well as relationship researchers may attribute benefits of family, sex, trust, love, communication, and commitment as foundational to monogamous relationships (Conley, Ziegler, et al., 2013; Moors & Schechinger, 2014), but, here we illustrate that these benefits are not exclusive to one relationship style. Instead, people engaged in monogamy and CNM experience these six benefits, though, perhaps, in different ways. In the future, researchers should consider why people engage in a certain type of romantic relationship and continue to examine how these shared benefits are experienced. Moreover, understanding that one can receive these benefits in either type of relationship can influence one’s awareness of options for romance (e.g., engagement in CNM can cater to having a family and monogamy can provide social inclusion).

Where Do We Go From Here? Moving Forward With CNM Research Despite the increased scientific pursuit of CNM relationships, there remains new empirical territory to cover to understand the complexity of CNM as well as how these relationships can broaden the fields of relationship and sexuality psychology. Within the previous sections we recommended ways in which future research could be helpful; in this section, we cover additional challenges that researchers may face as well as future directions regarding CNM in the legal context.

Challenges and Strategies Embarking on CNM research presents new and exciting directions, yet posing many challenges. CNM relationships

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are a context in which researchers can understand how people ensure commitment between multiple partners while concurrently integrating emotional and sexual needs within a monogamy-focused culture. However, research and statistical designs that prove helpful in studying monogamous relationships may not be the best fit for people with multiple partners. Thus, we should strive to redevelop existing frameworks and measures and to create inclusive models for thinking about relationships. For instance, our conceptualizations of relationship concepts and frameworks may need to be expanded as we gain a better understanding of CNM. Feelings of jealousy appear to be easy for people in monogamous relationships to identify (e.g., Hart & Legerstee, 2010). However, people in CNM relationships often avoid such loaded terminology because they may not experience jealousy to the same extent. Instead, people engaged in CNM commonly use different terms (e.g., wobble, shaky, jelly moments) to articulate feeling uncomfortable or anxious – lesser degrees of jealously (Easton & Liszt, 1997; Ritchie & Barker, 2006). Conversely, terms like “compersion” or “frubble” reflect feeling positively about seeing one’s partner with another partner (conceptualized by some as the opposite of jealousy; Ritchie & Barker, 2006). In cases of not meeting relationship expectations, understanding the extent to which people remain loyal to the process of establishing agreements and rules (i.e., agentic fidelity; Wosick-Correa, 2010) may be a useful direction for research – whether that research be focused on people in monogamous or CNM relationships. Moving forward, we suggest being mindful of (accidentally) prioritizing one type of CNM and carefully considering whether comparing relational functioning between monogamy and CNM is appropriate. Barker, Heckert, and Wilkinson (2013) explain how polyamory in popular press is regularly presented as superior to monogamy (and to other types of CNM). This prioritizing of polyamory – where the focus is on multiple loving relationships – lends itself to a “polynormativity”4 perspective, which positions polyamory as the “right way” to engage in CNM and, importantly, leaves the practice of prioritizing romantic relationships over other relationships unchallenged (Barker et al., 2013; Wilkinson, 2010). People who practice polyamory may be easier to identify for research, as numerous online communities are visible (unlike communities for open relationships). However, accessibility should not dictate research questions, as this would also perpetuate “polynormativity” rhetoric in empirical work. Related, research does not necessarily need to compare the relationship quality

The term polynormativity was coined by writer Andrea Zanin in a 2013 article “The Problem with Polynormativity” on her blog, sex geek; see: https://sexgeek.wordpress.com/2013/01/24/theproblemwithpolynormativity/

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between people who engage in monogamy and CNM to deem CNM an acceptable relationship practice. Our goal as researchers should not be to strive for the answer to an unobtainable question: which type of relationship is superior? Instead, we should employ methods and theory to understand the uniqueness of CNM relationships, for what they are, without an arbitrary baseline (i.e., using monogamy as a “control” group). When it comes to people’s personal lives, choosing any type of consenting adult arrangement should be a viable option.

CNM and the Law Given many nationwide rulings regarding same-sex marriages (e.g., the US, Portugal, Ireland, South Africa, England), it is plausible that public discussions surrounding multiple-person marriages and unions are on the horizon. Polyamorist activists in the US have tended to abstain from pursing legal avenues, fearing potential harm to same-sex marriage equality efforts (Aviram, 2008). While some polyamory activists have deliberately refrained from legal efforts, others have been purposely excluded from larger LGBT movements (e.g., Portugal’s Pride parade) due to organizers’ fear of being publically associated with polyamory (Cardoso, 2014). Aside from these tensions, the implications of campaigns for same-sex marriage equality can produce a legal “spillover” for people engaged in CNM. On one hand, same-sex marriage rulings may have opened the door for multi-person marriages. For instance, the Netherlands and Brazil have set precedent by legally recognizing multi-person unions (BBC News, 2012; Belien, 2005; Martín, 2015). In response to backlash regarding Brazil’s first multi-person union, public notary Claudia do Nascimento Domingues stated, “We are only recognizing what has always existed. We have not invent [ed] anything. . .what we considered a family before isn’t necessarily what we would consider a family today” (BBC News, 2012). These cases suggest changes in same-sex marital legalization may create momentum for further expanding the institution of marriage. On the other hand, the strategic plans of many same-sex marriage advocates have clearly differentiated the agenda from multi-person marriage. A differentiation strategy has, in part, been made to address “slippery slope” arguments – claims that expanding marriage to include same-sex couples would spawn further expansions for bigamy, incest, and polygamy (see Aviram & Leachman, 2015; Cardoso, 2014; Sheff, 2011, for further discussion). For example, in the US, Ted Olson (the attorney who represented same-sex couples in Hollingsworth v. Perry) reassured the court that same-sex marriage would not lead to multi-person marriage (Aviram & Leachman, 2015). Thus, a potential consequence of this

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rhetoric is that it can undercut future legal case for multiperson marriages. In moving psychological research on CNM forward, we encourage researchers to consider how research questions are relevant to social justice and legal contexts. For instance, Aviram and Leachman (2015) provide a legal “road map” for how multi-person marriages may be presented in US courts (e.g., discrimination based on sex not sexual orientation) as well as potential legal counterarguments (e.g., impact of multi-person marriages on children, regulative challenges regarding taxation). At the same time, it is important to consider that political action for multi-person marriage is not unified or desired by everyone who practices CNM, as some approach CNM with a “relationship anarchy” or non-assimilation political perspectives (e.g., Barker & Langdridge, 2010; PortwoodStacer, 2010). Moreover, psychological work on prejudice and discrimination in employment and educational contexts regarding CNM is also an important endeavor, as ample research has shown the deleterious effects that bullying, harassment, and discrimination can have on physical and mental health (Gruber & Fineran, 2008; Meyer, 2003; Schmitt, Branscombe, Postmes, & Garcia, 2014). Drawing on international comparisons and legal efforts of LGBT movements may prove to be a useful method for understanding the similarities (and differences) that people in CNM relationship may face in achieving equity (see Aviram & Leachman, 2015; Emens, 2004; Gates, 2015; McReynolds, 2005; Powell, Quadlin, & Pizmony-Levy, 2015). Given the extent to which research has documented stigma against CNM relationships, we believe it is only a matter of time until these issues are involved in calls for marriage reform and discrimination protection.

Concluding Remarks Our goal of this review was not only to synthesize research in light of unique and shared benefits of CNM, but also to identify avenues for future research. We encourage scientists and clinicians to recognize that consensually engaging in sex or intimacy with multiple people does not need to be viewed as controversial – it is merely another way of having a relationship. For some, CNM affords wider possibilities for relationships than exists within conventions of monogamy. However, for others, monogamy fits their ideals, desires, and goals perfectly. Both relationship styles have their “pros” and “cons”; thus, it will be helpful to better understand how adopting principles and strategies of one type of relationship could benefit the other.

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La Guardia, J. G., Ryan, R. M., Couchman, C. E., & Deci, E. L. (2000). Within-person variation in security of attachment: A self-determination theory perspective on attachment, need fulfillment, and well-being. Journal of Personality and Social Psychology, 79, 367. Lehmiller, J. J. (2015). A comparison of sexual health history and practices among monogamous and consensually nonmonogamous sexual partners. The Journal of Sexual Medicine, 12, 2022–2028. doi: 10.1111/jsm.12987 Manlove, J., Welti, K., Barry, M., Peterson, K., Schelar, E., & Wildsmith, E. (2011). Relationship characteristics and contraceptive use among young adults. Perspectives on Sexual and Reproductive Health, 43, 119–128. Martín, M. (2015, October). The three Brazilian brides who are challenging the traditional family unit. Sao Paulo, Brazil: El Paìs. Retrieved from http://elpais.com/elpais/2015/10/27/inenglish/ 1445948093_804967.html Matsick, J. L., Conley, T. D., Ziegler, A., Moors, A. C., & Rubin, J. D. (2014). Love and sex: Polyamorous relationships are perceived more favourably than swinging and open relationships. Psychology & Sexuality, 5, 339–348. McCrae, R. R., & Costa, P. T. (2008). The five-factor theory of personality. In O. P. John, R. W. Robins, & L. A. Pervin (Eds.), Handbook of personality: Theory and research (pp. 159–181). New York, NY: Guilford Press. McReynolds, A. W. (2005). What international experience can tell U.S. courts about same-sex marriage. UCLA Law Review, 53, 1073–1105. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. Minx, C. (2014). Eight things I wish I’d known about polyamory: Before I tried it and frakked it up. Seattle, WA: CreateSpace Independent Publishing Platform. Mitchell, M. E., Bartholomew, K., & Cobb, R. J. (2014). Need fulfillment in polyamorous relationships. Journal of Sex Research, 51, 329–339. Moors, A. C. (2016). Has the American public’s interest in information related to relationships beyond “the couple” increased over time? Journal of Sex Research. Advance online publication. doi: 10.1080/00224499.2016.1178208 Moors, A. C., Conley, T. D., Edelstein, R. S., & Chopik, W. J. (2015). Attached to monogamy? Avoidance predicts willingness to engage (but not actual engagement) in consensual non-monogamy. Journal of Social and Personal Relationships, 32, 222–240. Moors, A. C., Matsick, J. L., Ziegler, A., Rubin, J., & Conley, T. D. (2013). Stigma toward individuals engaged in consensual nonmonogamy: Robust and worthy of additional research. Analyses of Social Issues and Public Policy, 13, 52–69. Moors, A. C., Rubin, J. D., Matsick, J. L., Ziegler, A., & Conley, T. D. (2014). It’s not just a gay male thing: Sexual minority women and men are equally attracted to consensual non-monogamy. Journal für Psychologie, 22, 38–51. Moors, A. C., & Schechinger, H. (2014). Understanding sexuality: Implications of Rubin for relationship research and clinical practice. Sexual and Relationship Therapy, 29, 476–482. Moors, A. C., Selterman, D., & Conley, T. D. (2016). Personality correlates of attitudes and desire to engage in consensual nonmonogamy among sexual minorities, Unpublished manuscript. Munson, M., & Stelboum, J. P. (1999). The lesbian polyamory reader: Open relationships, non-monogamy, and casual sex. Binghamton, NY: Haworth Press. Nearing, R. (2000). Polyamory demography – the “Loving More Magazine” study. Bloomington, IN: Kinsey Institute, Indiana University. Retrieved from www.kinseyinstitute.org/ resources/Nearing.html

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Sheff, E. (2015). Polyamorists Next Door: Inside Multiple-Partner Relationships and Families. Lanham, MD: Rowman & Littlefield. Sheff, E., & Hammers, C. (2011). The privilege of perversities: Race, class and education among polyamorists and kinksters. Psychology & Sexuality, 2, 198–223. Sheff, E., & Tesene, M. M. (2015). Consensual non-monogamies in industrialized nations. In J. DeLamater & R. F. Plante (Eds.), Handbook of the Sociology of Sexualities (pp. 223–242). Cham, Switzerland: Springer International Publishing. Stewart, A. J. (1998). Doing personality research: How can feminist theories help? In B. McVicker Clinchy & J. K. Norem (Eds.), The gender and psychology reader (pp. 54–68). New York, NY: New York University Press. Swan, D. J., & Thompson, S. C. (2016). Monogamy, the protective fallacy: Sexual versus emotional exclusivity and the implication for sexual health risk. Journal of Sex Research, 53, 64–73. van Eeden-Moorefield, B., Malloy, K., & Benson, K. (2016). Gay men’s (non) monogamy ideals and lived experience. Sex Roles, 75, 43–55. Veaux, F., & Rickert, E. (2014). More than two: A practical guide to ethical polyamory. Portland, OR: Thorntree Press, LLC. Visser, R., & McDonald, D. (2007). Swings and roundabouts: Management of jealousy in heterosexual “swinging” couples. British Journal of Social Psychology, 46, 459–476. Wilkinson, E. (2010). What’s queer about non-monogamy now. In M. Barker & D. Langdridge (Eds.), Understanding nonmonogamies (pp. 243–254). New York, NY: Taylor & Francis. Wosick-Correa, K. (2010). Agreements, rules and agentic fidelity in polyamorous relationships. Psychology & Sexuality, 1, 44–61. Ziegler, A., Conley, T. D., Moors, A. C., Matsick, J., & Rubin, J. (2015). Monogamy. In C. Richards & M. Barker (Eds.), Psychology of sexuality and relationships handbook (pp. 219–235). Basingstoke, UK: Palgrave Macmillan. Ziegler, A., Matsick, J., Moors, A. C., Rubin, J., & Conley, T. D. (2014). Does monogamy harm women? Deconstructing monogamy with a feminist lens. Journal für Psychologie, 22, 1–18. Zuckerman, M., Kuhlman, D. M., Joireman, J., Teta, P., & Kraft, M. (1993). A comparison of three structural models for personality: The Big Three, the Big Five, and the Alternative Five. Journal of Personality and Social Psychology, 65, 757–768. Received February 28, 2016 Revision received July 31, 2016 Accepted October 16, 2016 Published online March 23, 2017 Amy C. Moors Social Science Research and Evaluation Armstrong Hall of Engineering Purdue University 701 West Stadium Avenue West Lafayette, IN 47907-2045 USA amoors@purdue.edu

Amy C. Moors, PhD, is the Director of Social Science Research and Evaluation at Purdue University, West Lafayette, IN. Her research focuses on the ways in which social-contextual processes (bias, stigma, societal ideals) impact people’s intimate and professional lives.

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A. C. Moors et al., Consensual Non-Monogamy

Jes L. Matsick, PhD, is an Assistant Professor of Psychology and Women’s, Gender, & Sexuality Studies at The Pennsylvania State University, University Park, PA. Her research focuses on how people with stigmatized sexual and gender identities experience intergroup relations, relationships, and health.

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Heath A. Schechinger, PhD, is a postdoctoral fellow at the University of California, Berkeley’s Counseling and Psychological Services, Berkeley, CA. His research interests primarily revolve around the clinical treatment of relational, sexual, and gender minorities.

European Psychologist (2017), 22(1), 55–71


EFPA News and Views Meeting Calendar April 6–8, 2017 Biennial Meeting of the Society for Research in Child Development, Austin, TX, USA Contact: www.srcd.org/meetings/ biennial-meeting

July 5–8, 2017 General Meeting of the European Association of Social Psychology, Granada, Spain Contact: http://www.easp.eu/events/ general-meeting/

April 20–22, 2017 4th International Conference Aging & Cognition 2017 Zurich, Switzerland Contact: http://eucas.org/conference/ a-c-2017/

July 10–14, 2017 International Society of Sport Psychology (ISSP) 14th World Congress Seville, Spain Contact: http://www.issp2017.com/

April 27–29, 2017 1st Middle East Psychological Association Conference Dubai, United Arab Emirates Contact: http://www.mepa2017.com/ May 17–20, 2017 18th Congress of the European Association of Work and Organizational Psychology, Dublin, Ireland Contact: www.eawop2017.org May 25–28, 2017 29th Annual Convention of the Association for Psychological Science, Boston, MA Contact: http://www.psychological science.org/index.php/convention June 29–July 2, 2017 2017 Annual Meeting, International Society of Political Psychology Edinburgh, Scotland, United Kingdom Contact: http://www.ispp.org/ meetings/

European Psychologist (2017), 22(1), 72 DOI: 10.1027/1016-9040/a000287

July 10–14, 2017 27th Congress of the International Association of Individual Psychology Minnesota, USA Contact: http://www.iaipwebsite.org/ July 11–14, 2017 15th European Congress of Psychology Amsterdam, The Netherlands Contact: https://psychologycongress. eu/2017/

August 30–September 1, 2017 18th European Conference on Developmental Psychology, Utrecht, The Netherlands Contact: http://www.ecdp2017.nl/ June 25–30, 2018 29th International Congress of Applied Psychology Montreal, Canada Contact: www.icap2018.com August 9–12, 2018 126th Annual Convention of the American Psychological Association San Francisco, CA, USA Contact: http://www.apa.org/ convention August 8–11, 2019 127th Annual Convention of the American Psychological Association Chicago, IL, USA Contact: http://www.apa.org/convention

July 23–27, 2017 36th Interamerican Congress of Psychology Mérida, Yucatán, Mexico Contact: http://www.sip2017merida. com/home August 3–6, 2017 125th Annual Convention of the American Psychological Association, Washington, DC, USA Contact: www.apa.org/convention

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Instructions to Authors - European Psychologist European Psychologist is a multidisciplinary journal that serves as the voice of psychology in Europe, seeking to integrate across all specializations in psychology and to provide a general platform for communication and cooperation among psychologists throughout Europe and worldwide. European Psychologist publishes the following types of articles: Original Articles and Reviews, EFPA News and Views. Manuscript Submission: Original Articles and Reviews manuscripts should be submitted online at http://www.editorial manager.com/EP. Items for inclusion in the EFPA New and Views section should be submitted by email to the EFPA News and Views editor Eleni Karayianni (eleni.karayianni@efpa.eu). Detailed instructions to authors are provided at http://www. hogrefe.com/j/ep Copyright Agreement: By submitting an article, the author confirms and guarantees on behalf of him-/herself and any coauthors that he or she holds all copyright in and titles to the submitted contribution, including any figures, photographs, line drawings, plans, maps, sketches and tables, and that the article and its contents do not infringe in any way on the rights of third parties. The author indemnifies and holds harmless the publisher from any third-party claims. The author agrees, upon acceptance of the article for publication, to transfer to the publisher on behalf of him-/herself and any coauthors the exclusive right to reproduce and distribute the article and its contents, both physically and in nonphysical, electronic, and other form, in the journal to which it has been submitted and in other independent publications, with no limits on the number of copies or on the form or the extent of the distribution. These rights are transferred for the duration of copyright as defined by international law. Furthermore, the author transfers to the publisher the following exclusive rights to the article and its contents:

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November 2016

European Psychologist (2017), 22(1)


Concise guide to the multidisciplinary treatment of sexual disorders “If you have time to read one book about female sexual dysfunction, this should be the one.” Irving Binik, Professor of Psychology, McGill University, Director of the Sex and Couple Therapy Service, McGill University Health Center, Montreal, Canada

Marta Meana

Sexual Dysfunction in Women (Series: Advances in Psychotherapy – Evidence-Based Practice – Vol. 25) 2012, x + 100 pp. US $29.80 / € 24.95 ISBN 978-0-88937-400-3 Also available as eBook Sexual Dysfunction in Women is a concise yet detailed clinical guide to the treatment of sexual difficulties in women. Written with the general psychologist and therapist in mind and being published with the companion volume Sexual Dysfunction in Men, it takes the novel position that most clinicians interested and willing to help female clients with sexual concerns can do so effectively, even if they do not primarily consider themselves sex therapists. Many women will experience difficulties with desire, arousal, orgasm, or pain with intercourse at

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some point in their lives, yet most clinicians feel less equipped to treat sexual dysfunction than far less prevalent disorders. This book empowers general psychologists, therapists, and other practitioners to actively engage in the multidisciplinary treatment of sexual disorders and broaden their knowledge base about sexuality, an important component of most clients’ quality of life. It is both a go-to guide for professional clinicians in their daily work and an ideal resource for students and practice-oriented continuing education.


Evidence-based guidance on the diagnosis and treatment of the most common male sexual disorders “Simply put, this is by far the best professional book ever published about understanding, assessing, and treating male sexual dysfunction.” Barry McCarthy, Professor of Psychology, American University, Washington DC; certified marriage and sex therapist; coauthor of Men’s Sexual Health and Sexual Awareness, (5th ed.)

David L. Rowland

Sexual Dysfunction in Men (Series: Advances in Psychotherapy – Evidence-Based Practice – Vol. 26) 2012, viii + 108 pp. US $29.80 / € 24.95 ISBN 978-0-88937-402-7 Also available as eBook Sexual dysfunctions in men, such as erectile dysfunction, ejaculatory disorders, and low sexual desire, are typically sources of significant distress for men. This book provides general therapists with practical, yet succinct evidence-based guidance on the diagnosis and treatment of the most common male sexual disorders encountered in clinical practice. It assumes that mental health professionals and other clinicians without expertise in the field of sex therapy have much to offer these men by

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combining a multidisciplinary understanding of issues surrounding sexual problems with their general clinical knowledge and expertise. With tables and marginal notes to assist orientation, the book is designed for quick and easy reference while at the same time providing more in-depth understanding for those desiring it. The book can serve as a go-to guide for professional clinicians in their daily work and is an ideal educational resource for students and for practiceoriented continuing education.


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Zeitschrift für Psychologie

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Editor-in-Chief Edgar Erdfelder University of Mannheim, Germany Associate Editors Michael Bošnjak, Mannheim, Germany Herta Flor, Mannheim, Germany Dieter Frey, Munich, Germany Friedrich W. Hesse, Tübingen, Germany

ISSN-Print 2190-8370 ISSN-Online 2151-2604 ISSN-L 2151-2604 4 issues per annum (= 1 volume)

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About the Journal The Zeitschrift für Psychologie publishes high-quality research from all branches of empirical psychology that is clearly of international interest and relevance, and does so in four topical issues per year. Each topical issue is carefully compiled by guest editors and generally features one broad Review Article accompanied by Original Articles from leading researchers as well as additional shorter contributions such as Research Spotlights (presenting details of individual studies or summaries of particularly interesting work in progress), Horizons (summarizing important recent or future meetings or outlining future directions of work), and Opinion pieces that provide a platform for both established and alternative views on aspects of the issue’s topic. The guest editors and the editorial team are assisted by an experienced international editorial board and external reviewers to ensure that the journal’s strict peer-review process is in keeping with its long and honorable tradition of publishing only the best of psychological science. The subjects being covered are determined by the editorial team after consultation within the scientific community, thus ensuring topicality.

Benjamin E. Hilbig, Landau, Germany Heinz Holling, Muenster, Germany Bernd Leplow, Halle, Germany Christiane Spiel, Vienna, Austria

The Zeitschrift für Psychologie thus brings convenient, cutting-edge compilations of the best of modern psychological science, each covering an area of current interest.

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Sex and gender differences: new perspectives and new findings within a psychobiosocial approach Topics covered include • Conceptualizations of “sex” and “gender” • The interrelation of gender stereotyping and performance in various cognitive tasks, such as multi-digit number processing, mental rotation, and verbal fluency • Sex differences in competition-based attentional selection • Sex and gender effects in school contexts • Gender-specific effects in leadership issues as well as academic evaluation

Markus Hausmann / Barbara Schober (Editors)

Sex and Gender Differences Revisited New Perspectives and New Findings

(Series: Zeitschrift für Psychologie – Vol. 220) 2012, iv + 88 pp., large format US $49.00 / € 34.95 ISBN 978-0-88937-429-4 Sex and gender are among the most heavily investigated interindividual factors in all areas of psychology. Although sex and gender have been studied for more than a hundred years, there has been an explosion of theories and research in this field in the past several years. Whether psychological differences between men and women truly exist, and where they originate, is still under debate. Although the

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majority of experts would agree that sex and gender differences in mind and behavior are neither purely biological nor purely social in origin, it seems that the proportions attributable to nature and nurture are still being negotiated. New research takes into account biological and social factors as well as the interaction between them and addresses “the small difference” within a psychobiosocial approach.

Epp 2017 22 issue 1  
Epp 2017 22 issue 1