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The aim of this paper is to explore the state of the art about the connection between anger and sexual behavior in eterosexual couples. After a description of anger in psychiatric and psychological literature, the Authors review the available studies about anger-sexuality relationship from theorethical, clinical and experimental point of view. They conclude that there is, till now, a ificant confusion about the question. Therefore, Authors suggest a new approach to this problem, due to the possible relevance of the topic in clinical practice. Despite the complexity of this research area, there is a need of clarification regarding methodological trends and clinical perspectives. Authors suggest the relevance of such a research for the understanding of sexual behavior, sexual couples problems and the finding of treatment strategies for anger problems connected to sexual behavior.

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Try out PMC Labs and tell us what you think. Learn More. Psychological therapies are effective treatments for hypoactive sexual desire dysfunction HSDD; formerly hypoactive sexual desire disordera common sexual dysfunction among women. Access to evidence-based treatments, however, remains difficult. Internet-based interventions are effective for a variety of psychological disorders and may be a promising means to close the treatment gap for HSDD. This article describes the treatment protocol and study de of a randomized controlled trial, aiming to study the efficacy of cognitive behavioral and mindfulness-based interventions delivered via the internet for women with HSDD to a waitlist control group.

Outcomes are sexual desire primary and sexual distress secondary. Additional variables eg, depression, mindfulness, rumination will be assessed as potential moderators or mediators of treatment success. A cognitive behavioral and a mindfulness-based self-help intervention for HSDD will be provided online.

Overall, women with HSDD will be recruited and ased either to one of the intervention groups, or to a waitlist control group Outcome data will be assessed at baseline, at 12 weeks, and at 6 and 12 months after randomization. Intention-to-treat and completer analyses will be conducted. We expect improvements in sexual desire and sexuality-related distress in both intervention groups compared to the waitlist control.

Recruitment has begun in January and is expected to be completed in August will be published in One of the most common sexual dysfunctions among women is a lack of sexual desire which, according to the eleventh edition of the International Classification of Diseases ICDcan manifest as reduced or absent spontaneous desire sexual thoughts or fantasiesreduced or absent responsive desire to erotic cues and stimulation, or an inability to sustain desire or interest in sexual activity once initiated [ 2 ].

If a pattern of low sexual desire is present over a period of at least several months and is associated with clinically ificant distress, a hypoactive sexual desire dysfunction HSDD; formerly hypoactive sexual desire disorder can be diagnosed.


A UK study found that among sexually active women, Individuals with sexual dysfunctions including low desire are more likely to report higher rates of sexually transmitted infections, unwanted sex, unemployment, relationship breakdown, and difficulties discussing sexuality [ 3 ].

In addition, low sexual desire is often comorbid to mental health problems such as depression and anxiety [ 67 ]. To date, flibanserin is the only drug that has received approval for treatment of low sexual desire in women in the United States and Canada. Furthermore, such treatments lead to medium to large increases in sexual satisfaction.

Psychological interventions for low desire often comprise a variety of components such as psychological and sexual education, couples exercises, guided masturbation, communication training, cognitive behavioral as well as mindfulness-based techniques [ 15 ].

Many interventions aim to educate women about their genital anatomy, psychological and physiological aspects of sexual arousal, and sexual difficulties eg, symptoms, prevalence. Other common treatment elements are self-exploration and sensate focus. Self-exploration may include exploration of genital anatomy using a handheld mirror.

Self-touch exercises aim to provide knowledge about how to elicit pleasurable sexual feelings and arousal Brotto, Paterson, Basson, Driscoll, and Grabovac, unpublished manual, and unpublished manuscript, Exercises start with a couple taking turns at providing nonsexual touch and end with sexual intercourse. Even supposedly specialized treatments often include a broad range of psychological methods [ 9 ]. Four modules of mindfulness-based treatment, for example, included not only mindfulness exercises but also information on sexual dysfunctions, sexual response, and female genital anatomy, supplemented by self-exploration, cognitive restructuring, and sensate focus exercises [ 17 ].

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Among the most common treatments for low desire are cognitive behavioral therapy CBT and mindfulness-based therapy MBT [ 15 ]. CBT is change oriented and is one of the most researched forms of psychotherapy. It is effective for a variety of mental health problems such as depression, anxiety disorders, and posttraumatic stress disorder [ 18 ], as well as sexual dysfunctions such as HSDD [ 15 ].

MBT has been found effective for the treatment of depression, anxiety, and stress [ 20 ]. Although many women are distressed by their lack of desire, the of those who receive qualified, evidence-based treatment remains low [ 23 ]. Sexual dysfunctions are connected to stigma and reluctance in seeking professional help [ 2425 ].

Furthermore, a lack of information on the treatment options prevails as well as structural barriers, such as limited access to qualified therapists. This issue could be addressed by developing and disseminating treatments that require less direct forms of contact, namely internet-based interventions. A growing body of literature suggests that interventions delivered via internet or mobile technology are feasible and effective to improve depression, anxiety [ 26 ], and even psychosis [ 27 ].

These interventions offer varying degrees of guidance ranging from self-help, user-led interventions, to regular to contact with a trained clinician.

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Interventions involving at least some kind of guidance or coaching have been proven to be more effective than unguided interventions [ 28 ]. Concerning internet-based interventions for sexual dysfunctions in women, van Lankveld [ 29 ] reviewed 5 studies and found that these interventions were effective in improving sexual functioning and emotional intimacy in couples.

The aim of this study is to present the protocol of a randomized controlled trial RCT comparing 2 internet-based interventions for low sexual desire in women with HSDD to a waitlist. Hypotheses 1 and 2 are that at posttreatment 12 weeks after randomizationwomen receiving I-CBT or I-MBT report ificantly more sexual desire primary outcome; H1 and less sexuality-related distress secondary outcome; H2 compared to a waitlist control condition.

It is also proposed that these differences are maintained at the 6- and month follow-up assessments. It is also explored whether improvements from pretreatment to posttreatment are dependent on treatment dosage eg, completed modules, time spent with at-home exercises and whether changes in proximal variables such as mindfulness or rumination mediate improvement in symptoms in either one of the treatments.

Recommendations for the reporting of psychological and eHealth interventions will be considered [ 3132 ].

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This 3-arm superiority trial with allocation ratio will demonstrate whether the benefit from I-CBT or I-MBT is superior to natural remission of low desire symptoms. Outcomes will be assessed at baseline T1at midtreatment T2, 5 weeks after randomization, only in active conditionsat posttreatment T3, 12 weeks after randomizationand at 6 months T4 and 12 months T5 after randomization. Two computerized reaction-time paradigms will be administered at T1 and T3.

Participants will receive up to 3 reminders for each assessment after 7, 14, and 21 days.

Qualitative telephone interviews with active participants will be conducted at T3. For an overview of participant flow, see Figure 1. Inclusion criteria are being 18 years or older; completion of the informed consent form; female gender; being able to read, write, and speak German; and meeting ICD criteria for HSDD. Exclusion criteria are being pregnant, ongoing treatment for any sexual dysfunction or plans to enter such treatment, symptoms of a physical condition that might interfere with study participation eg, cancer, multiple sclerosiscurrent substance use disorder, current or lifetime schizophrenia spectrum or other psychotic disorders, and ificant relationship discord or violence.

As sexual dysfunctions show high rates of comorbidity with other mental health issues such as anxiety or affective disorders [ 733 ], women experiencing mild to moderate symptoms of other mental disorders are not excluded automatically. Rather, symptoms of a mental disorder eg, eating disorders, obsessive-compulsive disorder, posttraumatic stress disorder, major depression, bipolar disorder that might interfere with participation ie, might make it too burdensome for individuals to participate in data assessments are assessed during screening.

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Women whose low desire may be fully attributable to pain during sexual intercourse are also not included. Inclusion and exclusion criteria will be assessed in a 2-step process consisting of an online screening followed by an in-depth telephone interview with a clinical psychologist. In order to recruit a diverse sample of women of different ages, sexual orientations, and ethnicities, a variety of recruitment strategies will be employed.

Recruitment and study enrollment will follow a stepwise procedure. Potential participants will be invited to complete an online questionnaire assessing inclusion and exclusion criteria. Individuals not meeting the study criteria eg, male gender, no sexual concerns, or minors will be informed and, if needed, be referred to other resources eg, their physician, counseling services.

For all other individuals, an in-depth telephone interview with a clinical psychologist will be scheduled to evaluate eligibility. If an individual is eligible, she will receive an invitation to an internet-based questionnaire.

Women who complete this baseline assessment and who provide informed consent electronically will be enrolled. Enrolled participants will be randomly ased to 1 of the 3 conditions. A stratification procedure will be applied to balance relationship status partner vs no partner and age younger than 30 years vs 31 years and older.

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These variables were selected based on their known effect on sexual desire [ 34 - 36 ]. An internet-based randomization tool will be used by a trained research assistant not involved in the recruitment, screening, or treatment of participants [ 37 ]. The clinical psychologist conducting the diagnostic interviews will not be involved in the randomization process but will be informed about the ased condition after its completion. Block randomization with varying block-sizes will be applied. Participants will be informed about their ased condition. Participants in the active conditions will gain immediate access to the respective program.

Sample size was determined based on an a priori power analysis and practical considerations. Although this study is not sufficiently powered to detect smaller differences in efficacy between I-CBT and I-MBT, it will still provide first estimates that may be useful for future studies.

Based on these considerations, a total of women will be enrolled in the study. The study introduces 2 internet-based, guided, self-help interventions for low sexual desire in women.

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Four weeks after completion of Module 8, participants will gain access to an additional booster module. For a more detailed overview of the modules, see Table 1. Modules are deed to be completed by most participants within minutes. Participants are free to take additional time for completion, if needed. As an optional feature, participants are invited to keep an internet-based daily diary of their mood, level of sexual desire, and the time spent with at-home exercises each day.

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This diary can be accessed via a corresponding smartphone app. If participants fail to log in to the platform for 7 consecutive days, they will receive up to 4 reminders after 7, 14, 21, and approximately 30 days by their eCoach and the study coordinator.

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In each module, participants receive new information and are introduced to new at-home exercises to be completed between modules. Self-exploration Modules and sensate focus exercises Modules as well as information on the prevalence of sexual dysfunctions, genital anatomy, and sexual response Modules are included in both COPE and MIND.

In Module 2, participants will be introduced to the circular sexual response model as proposed by Basson [ 39 ] and in each of the following modules, different parts of the cycle will be presented.

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This model proposes that women with low desire tend to enter sexual situations from a state of neutrality and, if context and stimulation are adequate, may develop sexual arousal and responsive sexual desire during the course of a pleasing sexual encounter. For more information, see Basson [ 40 ]. Participants are given the opportunity to work with their sexual response cycle, to reflect on their own situation eg, to identify contexts they find sexually arousing, to explore reasons for sexual activityand to develop strategies to improve their sexual experiences.