What is the best approach to diagnose and treat disorders of arousal, particularly in relation to sexual function?

Disorders of Arousal: Diagnosis and Treatment

Critical Diagnostic Distinction

The most critical first step is distinguishing between sexual arousal disorders and Sexual Orientation OCD (SO-OCD), as approximately 84.6% of SO-OCD cases are misdiagnosed and require fundamentally different treatment approaches. 1

Key Differentiating Features

Sexual Arousal Disorders are characterized by:

• Decreased genital response (reduced lubrication, vasocongestion) or absent subjective pleasure during sexual activity 2, 3
• Distress related to inability to become aroused or maintain arousal 4
• Often multifactorial etiology involving physiologic, psychologic, and interpersonal factors 5

Sexual Orientation OCD (SO-OCD) presents distinctly as:

• Pornography use serving as a checking compulsion to test arousal patterns, not for gratification 1
• Compulsive body scanning for signs of physical arousal when encountering same-sex individuals 1
• Anxiety sensations misinterpreted as sexual arousal, creating false confirmation loops 1
• Characteristic confused reasoning cycle: relief from reassurance is short-lived, with doubts perpetually restarting 1
• Affects 10-12% of individuals with lifetime OCD, with 91% reporting high distress 1

Assessment Protocol for Sexual Arousal Disorders

History Components

Identify underlying etiologies systematically:

• Hormonal factors: Assess for menopause-related symptoms (vaginal dryness, discomfort, pain), decreased estrogen or testosterone levels 5, 4
• Medication review: Antidepressants, antipsychotics, and antihypertensives commonly cause arousal dysfunction 6
• Vascular insufficiency: Atherosclerosis, diabetes-related vascular changes 4
• Neurologic disease: Diabetic neuropathy, other peripheral neuropathies 4
• Psychological factors: Depression, anxiety, past trauma, body image distress, fatigue 5
• Interpersonal context: Relationship quality, partner factors 5

Physical and Laboratory Evaluation

Perform targeted assessments:

• Morning testosterone testing for suspected androgen deficiency 6
• Estrogen levels if menopausal symptoms present 4
• Gynecologic examination for vaginal mucosal changes, atrophy 4
• Assessment of comorbid erectile dysfunction in male partners (affects female arousal) 6

Treatment Algorithm for Sexual Arousal Disorders

First-Line Interventions

Implement multidimensional treatment addressing identified underlying issues: 5

For menopause-related arousal problems:

• Menopausal hormone therapy improves sexual function when vaginal dryness, discomfort, or pain are present 5
• Vaginal DHEA (prasterone) shows significant improvements in desire, arousal, and pain specifically in gynecologic cancer survivors 7
• Vaginal moisturizers, gels, and oils for vaginal dryness (though data are limited) 5
• Topical lidocaine to vulvar vestibule before penetration for dyspareunia 5

For medication-induced dysfunction:

• Adjust or discontinue offending medications when possible 6
• Consider bupropion if antidepressant needed, as it may help hypoactive desire rather than worsening it 7

For testosterone deficiency:

• Testosterone replacement therapy for confirmed deficiency affecting arousal 6
• Androgens primarily affect desire, arousal, orgasm, and overall well-being 4

Behavioral and Psychological Interventions

Cognitive Behavioral Therapy (CBT) is effective for arousal disorders: 5, 7

• Addresses anxiety, depression, and cognitive factors inhibiting arousal 8
• Focuses on improving arousal and sexual satisfaction 8
• Explicit attention to relational context 8

Integrative therapies:

• Yoga and meditation help alleviate anxiety that impacts arousal 5

Pelvic physical therapy for pelvic floor dysfunction contributing to arousal problems 5

Specialist Referrals

Refer when appropriate: 5

• Psychotherapy or sexual/couples counseling for psychological or interpersonal factors
• Gynecologic care for hormonal management
• Sexual health specialist for complex cases

Treatment Protocol for Sexual Orientation OCD

If SO-OCD is identified, treatment differs fundamentally from arousal disorders:

Gold-Standard Psychotherapy

Exposure and Response Prevention (Ex/RP) therapy is the gold-standard approach: 1

• Deliver 10-20 sessions of CBT with ERP, in-person or internet-delivered 1
• Implement controlled graded exposure to sexual imagery while intentionally resisting checking rituals 1
• Include three critical components: (a) psychoeducation regarding LGBTQ+ identities, (b) neutral or positive exposures avoiding harmful stereotypes, (c) exposures to uncertainty and core fears 1
• Target contamination-based disgust and responsibility/threat overestimation beliefs 1

Pharmacotherapy for SO-OCD

Initiate SSRI therapy concurrently with psychotherapy for moderate to severe symptoms: 1

• Fluoxetine is the preferred SSRI 1
• Titrate to maximum recommended or tolerated dose for at least 8 weeks 1
• If inadequate response after 8 weeks, switch to a second SSRI or consider clomipramine 1
• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse 1

Special Populations

Cancer Survivors

All adult cancer survivors should be asked about sexual function at regular intervals, regardless of gender identity or sexual orientation. 5

• Cervical cancer survivors treated with radiotherapy have significantly worse arousal, lubrication, orgasm, pain, and satisfaction compared to surgery-treated patients 5
• Chemotherapy is linked to sexual dysfunction in breast cancer survivors, related to chemotherapy-induced menopause 5
• Body image changes after cancer treatment affect sexual health 5

Cardiovascular Disease Patients

For patients with cardiac disease concerned about arousal and sexual activity:

• Sexual activity is safe when patients can achieve 3-5 METs without ischemia during exercise testing 5
• Patients with mild, stable angina are at low risk; those with unstable or refractory angina should defer sexual activity until stabilized 5
• Nitroglycerine (if prescribed) can be used for chest pain with sexual activity 5

Common Pitfalls to Avoid

Do not misdiagnose SO-OCD as compulsive sexual behavior disorder or arousal disorder - the 84.6% misdiagnosis rate leads to inappropriate treatment that can worsen symptoms 1

Do not overlook medication-induced arousal dysfunction - systematically review all medications, particularly antidepressants and antihypertensives 6

Do not assume arousal disorders are purely psychological - vascular and neurologic etiologies are common and require specific treatment 4

Do not neglect partner factors and relational context - arousal is strongly influenced by interpersonal dynamics 5, 8

Do not discontinue SO-OCD treatment prematurely - maintain treatment for minimum 9-12 months after symptom resolution to prevent relapse 1