In this two part article, Dr Sofra Weiss introduces two studies that assessed what female sexual aging and sexual satisfaction mean to women from their point of view.

A Comprehensive Model Of Female Sexual Anti-aging

Female aging is associated with sexual decline and well-documented symptoms of decreased metabolism increased visceral fat deposits, decreased mobility increased incidence of body aches and impaired self-confidence, which can lead to depression, marital dissatisfaction, conflicts or apathy. Research has consistently discussed the adverse effects of obesity on female sexuality.

The sexual decline becomes more prominent with diabetic females suffering from neuropathy that is usually a challenge since traditional methods usually offer temporary pain relief. Neuropathy is the dysfunction of one or more peripheral nerves, typically causing numbness, tingling, sharp pain, poor mobility and weakness that have an additional adverse effect on female sexuality. Clinically, diabetic neuropathy has always been a challenge, because traditional treatments result in temporary symptoms’ relief.

Hormone replacement interventions treat only part of the systemic hormonal imbalance problem, ignoring the fact that disruption in the hormonal network signifies a disruption in the entire micro-cosmos of cellular communications leading to bio-disorganization and health deterioration. New vaginal rejuvenation methods aspire to resolve a complex psychophysiological issue by merely improving vaginal laxity and dyspareunia, via invasive or minimally invasive methods that often reduce sexual sensation for women, while increasing male satisfaction during intercourse. An extensive review paper from Barbara et al (2017) strongly recommends that psychological and counseling is offered to all women who seek genital cosmetic surgery, firstly to help identify untreated psychiatric conditions, and secondly to help some women identify the true origin of their sexual dysfunction problems that may be interpersonal in nature. Earlier research has also underlined the association between body dysmorphic disorder, a psychiatric condition, and the request for cosmetic surgery (Barbara et al, 2015).

Energy-based vaginal rejuvenation methods assess their results with the FSFI, without considering that the transparency of the FSFI items may lead to false results that may range from inadequate self-insight to deliberate faking. Measures are needed that comprise objective items and have no readily discernible connection with the items being measured since content validity is no guarantee of validity. Women may be embarrassed to admit to problems with their sexual function, and many will deny that the problem remains, despite the expensive procedure, because such admittance would place liability on their partners and put their relationship at risk. Others will not complain unless something has gone extremely wrong.

Additionally, FSFI has been validated on women with a clinical diagnosis, such as female sexual arousal disorder or female orgasmic disorder, by basically verifying the accuracy of the diagnosis (Rosen et al, 2000; Meston, 2003). Only three of the women in Meston’s study (2003) met the criteria for dyspareunia, one of the main issues studied and reported by vaginal rejuvenation studies. Overall, different laser and RF methods touting female satisfaction from successful vaginal rejuvenation stand against the strict comments from a number of federal agencies and medical associations. The American College of Obstetricians and Gynecologists (2007) stated that ‘women should be informed about the lack of data supporting the efficacy of these procedures and their potential complications, including infection, altered sensation, adhesions, and scarring’.

The US FDA has not approved vaginal laser treatments for what is known as vulvovaginal atrophy, a condition that often accompanies menopause and can include symptoms like vaginal dryness, painful intercourse, and urinary incontinence, emphasizing that the safety and effectiveness of these treatments are unproven. A recent study by Gordon et al (2019) reported four cases that demonstrated complications after completion of three consecutive laser treatments for vaginal rejuvenation. Complications included fibrosis, scarring, agglutination, and penetration injury, including vaginal tearing, bleeding, and scar tissue formation, ultimately causing obstructions. Overall, intercourse became more painful after laser treatments than it was before. However, this sample is too small to draw any reliable conclusions. In the absence of a lie scale and further exploration of hormonal imbalance or other contributing psychological factors, self-report questionnaires or clinical interviews posing straight forward questions may be simply collecting inaccurate data rendering the study’s validity and reliability questionable at best without a full diagnostic profile including both psychological and physiological data. it is unclear how many women are really satisfied with vaginal rejuvenation interventions performed by energy-based devices.

A systematic review and meta-analysis of randomized controlled trials found a positive correlation between hormone therapy (estrogen alone or in combination with other hormones) and improvement in sexual function in women with menopausal symptoms or in early menopause (Nastri et al, 2013). However, the results of these studies suggest that hormone therapy is primarily beneficial in alleviating pain during intercourse, whereas evidence specific to increased sexual desire and female satisfaction is lacking (Santoro et al, 2016). The most important criticism of hormone therapy is its narrow focusing on the symptom without considering the possibility that female sexual behavior, self-confidence, and satisfaction may be intrinsically related to hormonal balance, a complex constellation of over 200 hormones that have been discovered in the human body that depends on both optimum concentration levels of individual hormones and their interactions at different ages.

Weight gain, especially an increase in visceral fat, can often be the centerpiece of female insecurity. Obesity predicts the incidence of several major chronic diseases, including diabetes, cardiovascular disease and certain types of cancer, especially for women facing the menopause transition (Nappi and Kokot-Kierepa, 2012; Ippoliti et al, 2013). Numerous laser and RF studies report successful results in reducing subcutaneous but not visceral fat, and several of these studies do not appear to produce statistically significant results or be well controlled. For example, a study Chang et al (2014) aimed to assess the efficacy, safety, pain and satisfaction levels of the combination therapy of focused ultrasound and RF for improving body contours. They report a mean reduction in circumference of 3.91 ± 1.8 cm (p ≤ 0.001). Fat thickness reduction was 21.4 and 25% on the upper and lower abdomen, respectively, in MRI measurements; however, only two out of their 32 subjects underwent MRIs. Their satisfaction survey based on a single short questionnaire (normally more than one questionnaire should be adopted for cross-reference and study validity and reliability) showed a 71.9% satisfaction, a result that is not statistically significant.

We conducted two studies. Study 1 found a discrepancy between high scores on the FSFI and the true feelings of women who had previously undergone vaginal rejuvenation procedures with energy-based technologies. Study 1 also explored a new method of vaginal rejuvenation on women who had previously received vaginal rejuvenation interventions with energy-based technologies. This novel intervention offers a pleasant soothing experience despite being imperceptible. The technology is represented by a device that emits four complex signals at a variety of discrete specific times that range from four to 24 seconds. Signals are comprised of sine and square waveforms, with frequencies ranging from 0.25 – 10,000 Hz. The four signals are combined into their resultant, and they are transmitted simultaneously via a pair of tour-grade ultra-silver-plated microphone cables with stainless surgical steel leads attached to their ends. The leads must make contact with the patient’s skin. In this case, the long round lead was inserted into the patient’s vagina and the other lead was placed on the vulva. Leads were sanitized prior to each usage. During treatment, the device’s voltage output ranges from 0.003 μV to 0.5 μV (μV = 0.000001 volts) depending on the frequency. The device’s current output ranges from 50 na to 150 na (na = 0.0000000001 Amps). A total of 69% of the subjects reported a significant increase in sexual sensation, while 31% of them reported a minor increase in sexual sensation or no change. These results may have been compromised by the possibility of scar tissue formed in the vaginal canal following the usage of energy-based technologies, posing a difficulty in reinstating sexual sensation.

Seven of these females obtained their own blood tests measuring Free T3 and Triglycerides. They also made available their MRIs which they had financed on their own, before and after receiving 10 treatments, over the course of 4 weeks, with a novel effortless exercise technology originally invented at London University. This technology has clinically and experimentally shown a decrease in visceral fat and VLDL and an increase in skeletal muscle mass and FreeT3 (Sofra-Weiss, 2019). A one-tailed t-test for dependent variables was used to analyze the data.

The device offers a voltage-driven signal that results in an 8-second full body contraction every 2-second rest time. Maximum voltage is 25 V at 500 Ω and 100 V at 10,000 Ω with a net charge of 0.001 Amps at 500 Ω, 0.004 Amps at 2000 Ω and 0.00025 Amps at 1000 Ω and leakage of 0.007µa (10^-6 Amps). The signal is emitted via 16 channels isolated by separate transformers via silver-plated tour-grade microphone cables that are connected to gel pads, which are attached to the body. The two waveform controls each have 12 square complex waveforms, each composed out of 4000 sine frequencies added onto each other on the basis of the original London University formula. The 12 waveforms on the left are manually combined with the 12 waveforms on the right to form 144 combinations that give different types of 8-second contractions every 2 seconds, depending on the waveform combination. All waveforms are rectangular in shape and have their own specific resultant frequencies that vary from 55 Hz to 888 Hz. This was a double-blind study; the operator was trained on how to operate the device but had no other knowledge related to the device. Both the operators and subjects were unaware of the results they were going to get and had no bias or direct knowledge of the device.

During treatment, both the operator and the subjects observed a series of 8-second visible contractions that were repeated every 2 seconds, 1000 times during the procedure. Contractions were involuntary, involving the entire body’s coordinated musculature contracting simultaneously in a rhythmical manner as during physical exercise. The contractions were experienced by the subjects as vigorous, yet painless and effortless. Subjects did not receive any specific instructions on adding exercise to their lifestyle or reducing their alcohol and food intake.

Results were statistically significant on all four variables tested: skeletal muscle mass (p<0.05),visceral adipose tissue: p<0.01; Free T3: p<0.05; and triglycerides: p<0.05. The Free T3 increase was within the normal range, spiking from the lower end to the higher end of the normal range. This consistent elevation in T3 among all subjects suggested that, while hormonal secretion remains within the normal limits, a woman will function at her metabolic peak in terms of Free T3 after undergoing 10 treatments of effortless exercise. Study 2 explores methods to improve neuropathy in ten diabetes patients. Neuropathy is also experienced by a large number of individuals that have not been diagnosed with diabetes.

Musculoskeletal pain (MP) is generally addressed by physiatrists, orthopedists, and rheumatologists who are not traditionally trained in psychology or sexual medicine, therefore, the sexual or psychological concerns of women with MP often go unaddressed. A review article by Rosenbaum (2010) reported that lack of mobility and MP can restrict intercourse and limit sexual activity. The authors recommended sexual and relationship counseling in addition to rehabilitative treatment. A one-tailed t-test for dependent variables was used to analyze the data. Results revealed a statistically significant improvement before and after treatment where p-value was 0.0015 (p<0.01) indicating that over 100% (985%) of individuals subjected to this treatment experience relief in their neuropathy after two treatments.

Difference score calculations are given below:
Mean: -6.5
μ = 0
S2 = SS/df = 236.5/(10-1) = 26.28 S2M = S2/N = 26.28/10 = 2.63
SM = √S2M = √2.63 = 1.62
T-value Calculation t = (M - μ)/SM = (-6.5 – 0)/1.62 = -4.01

Results on all subjective variables assessed by the treating physician (numbness, pain, sharpness, burning sensation, tingling sensation, sensitivity to touch and muscle weakness) went from positive prior to treatment, to negative after the second treatment. All subjects reported neuropathic pain relief and increased mobility. Seven out of 10 of these subjects reported permanent neuropathic pain relief that was sustained for at least 1 year following the two treatments. Three subjects re-experienced neuropathic symptoms after three months and returned for follow-up treatments. Empowering women means first understanding both the physiological and psychological female dynamics, and then devising or adopting methods and interventions that can safely and genuinely help women improve their psychophysiological health, sexuality, and interpersonal relationships. The female dynamic profile should be based on a comprehensive assessment of overall health status, hormonal balance, optimum weight, emotional organization, and psychological stability.

This article lists some new safe and effective technologies to be taken into consideration in treating women. Psychotherapy is a crucial addition to successfully treating women. Some of the most commonly important psychotherapy targets are given below:

1. Introduce individuals to themselves for a realistic self-appraisal and appreciation of strengths and weaknesses.
2. Be designed to increase degrees of freedom by freeing the patient from the stickiness of past failures, abandonment in relationships, resentments, and losses. Welcome to new beginnings and opportunities.
3. Educate individuals on how to turn adversity into an advantage. Learn how to utilize both character advantages and character flaws in a productive manner.
4. Help patients abandon self-deprecating attitudes, self-blame, pathological dependence, and eternal pessimism. Enhance self-driven motivation, self-reliance, self-confidence, and persistence in completing tasks.
5.Gear patients towards a realistic appraisal and acceptance of others that renders realistic expectations, thus avoiding the repetition of unresolved conflicts in interpersonal relationships.
6. Help patients realistically evaluate life events and situations and develop a strategy that brings solutions, avoiding teleological explanations and attitudes that give the distorted perspective of self-punishment or predetermined destiny.

Evaluating Sexual Satisfaction from Her Point of View

Sexual dysfunction among all women is between 25% to 63%. This number dramatically increases in postmenopausal women to 68% or even higher 86.5%. Recent research indicates that only 56% of married women older than 60 (compared to 75% of men) are sexually active. Overall, estrogen decline in aging women, leads to loss of subcutaneous tissue from the pubis, atrophy of labia and shortening and loss of elasticity of the vaginal barrel. The pelvis that supports the anterior vagina shows a decreased ratio of collagen I, III and V. This decreased ratio is apparently the result of a 75% decrease in collagen I in postmenopausal women that disturbs the balance between collagen I and the other collagens. The reduction of vaginal thickness of the epithelium from 8-10 layers to 3-4 leads to bleeding and burning sensations during intercourse. Lactic acid and increased vaginal pH affect the microbial population leading to increased bacterial infections. Women aspire to solve the problems generated by hormonal and collagen structural changes by altering their genital anatomy to gain greater self-esteem and diminish functional discomfort.

The field of vaginal rejuvenation surgical procedures has been expanded by laser and RF technologies in the absence of a robust qualitative body of data on the therapeutic advantages of these technologies. One of the issues that appears to be quite pervasive is the method of assessing female satisfaction following vaginal rejuvenation. For example, Alinsod’s research on 25 women receiving RF vaginal rejuvenation, assessed female sexual satisfaction by an 8 items self-made questionnaire with no established validity or reliability asking straight forward questions such as “did you achieve orgasms after the treatments?” to which 23 out of 25 subjects answered “yes”. This question was followed by the question “were your orgasms more or less intense after treatments?” to which 16 out of 25 subjects answered: “no change” and 9 out of 25 subjects answered: “more intense.”

Provided that all subjects were truthful rather than tailoring their responses to please their doctor or partners, the fact that the technology was clearly effective in increasing orgasms in only 9 of the subjects sets the significance level of this study below chance since only 36% of the subjects experienced an improvement in sexual satisfaction and 64% of the subjects reported no change. The only question that appeared to be statistically significant was the RF effect on vaginal tightening that pertains to increasing male satisfaction. Additionally, it is impossible to assess the long-term effects of this treatment since this research was not longitudinal.

Another study studied 30 “premenopausal” women (21-52 years) treated with a single session of RF therapy. This study was longitudinal and used a battery of tests such as the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale-Revised (FSDS-R) and the Vaginal Laxity and Sexual Satisfaction Questionnaires. The authors reported a significant improvement in sexual functioning and a decreased distress related to sexual activity at the 6-month follow-up. Women also reported decreased vaginal laxity within the first months after the RF treatment.

Unfortunately, there are many problems with self-report questionnaires like the FSFI, and FSDS-R or the Vaginal Laxity and Sexual Satisfactions questionnaire. The problems primarily concern the transparency of items, none of which controls for distortion that could range all the way from inadequate self-insight to deliberate faking. Such questionnaires merely collect evidence that confirms the hypothesis of female satisfaction following vaginal rejuvenation intervention. Searching only for confirmation instances leads to phenomenological confirmation bias. Only the absence of falsification instances that makes it impossible to refute the hypothesis can lead to scientific proof based on truth rather than subjective phenomenology.

Data from 14 females, aged 45-59, was collected over a period of six years (2012-2018) on the basis of their testing battery records and specifically the FSFI, the K scale, assessing normality, the Code scores of the MMPI-2, the Lie (L), Depression (D) and Hysteria (Hy) scales of the MMPI-2, the Differential Emotions Scale (DES), and psychotherapy notes. The main inclusion factors were: a) All females had previously received at least one vaginal rejuvenation procedure with energy-based technologies like laser and RF; b) The battery of tests, MMPI-2, and DES were administered at least one month following the vaginal rejuvenation procedure; c) The FSFI was administered by the doctor who had performed the vaginal rejuvenation procedure; d) All patients had relatively low scores on the K validity scale of the MMPI-2, yet not low enough to indicate normal functioning, basically, suggesting some degree of psychopathology in the absence of a severe mental illness. The “d” factor of inclusion intended to eliminate females with a serious mental disorder and only involve those with less severe psychological problems.

All females included in the study gave their consent to the anonymous release of their clinical records, including the relevant clinical notes from their sessions. The clinical records included a battery of tests such as the Minnesota Multiphasic Personality Inventory (MMPI-2), the Female Sexual Function Index (FSFI) questionnaire and Izard’s Differential Emotions Scale (DES) of basic emotions. The MMPI-2 is a 567-item standardizes psychometric test of adult personality and psychopathology based on a large number of reliability and validity studies. The FSFI is female sexual functioning brief questionnaire measure assessing domains of sexual functioning (e.g. sexual arousal, orgasm, satisfaction, pain). According to its developers “The FSFI may be useful for evaluation of treatment outcome in a clinical trial situation, but this remains to be demonstrated.” The DES is a validated 30 item self-report inventory, with each item scored on a 5-point Likert system. DES items are sensitive indicators of innate facial expressions postulating 10 basic emotions, universally discernible in the human facial expression: Interest, Joy, Surprise, Sadness, Anger, Disgust, Contempt, Fear, Shame and Guilt. The reason for choosing a discrete emotions instrument was to investigate the subjects’ unexpressed feelings on the premise that emotions are often experienced and described as a visceral event, like for example when we describe disappointment as a sinking heart and nervousness as butterflies in the stomach.

Subjects results on the FSFI were correlated with the L(Lie) validity scale of the MMPI which consists of 15 items and is intended to identify individuals who are deliberately trying to present themselves under a positive light, basically distorting reality. FSFI was also correlated with the Hy (Hysteria) subscales that reveal a tendency to repress feelings and the need for other’s approval, specifically the Hy2 (need for affection), H3 (lassitude malaise assessing a general feeling of unhappiness in the home environment) and Hy (inhibition of aggression) subscales of the MMPI-2, and the D (Depression) subscales indicating a general dissatisfaction with one’s life, specifically the D1 (subjective depression) and D4 (mental dullness), D5 (brooding / worrying) subscales scores of the MMPI-2. These subscales also reflected the subjects highest scores, once again confirming the absence of severe psychopathology in these women.

Results of the 14 women’s high scores on the FSFI indicated that the subjects perceived sexual satisfaction following their vaginal rejuvenation procedure with either a laser or RF technology. Both technologies produced high scores on the FSFI. The average mean score of all subjects on the FSFI was 29.92. Most subjects gave high scores on the satisfaction and orgasms subscales, and lower scores on the arousal, subscale which appeared interesting. According to the psychotherapy notes, when a distinction was drawn between personal sexual satisfaction and that of sexually fulfilling their partners, 99% of women admitted that although it was a relief not experiencing pain during intercourse, some of the sexual sensation they had prior to the vaginal rejuvenation had either dissipated or was mostly muffled. They also admitted that their orgasms were less frequent than before the procedure. All of these women had reported improved orgasms in their FSFI questionnaires given to them after their vaginal rejuvenation, so it is not clear if they had simply been untruthful or whereas they were referring to their partners’ orgasms rather than their own.

Correlation between the MMPI-2 scales and the FSFI scores:
FSFI scores were plotted against the MMPI-2 L, D and Hy scales of the MMPI-2. The L-scale scores range from 1-9 with scores higher than 5 revealing dishonesty. The D-scale scores that fall within the 55-64 range reveal a general sense of dissatisfaction with life situation and lacking self-confidence. The Hy-scale scores that fall within the 55-64 range reveal denial, immaturity, need for approval, being suggestible and attention seeking.

Results were analyzed both with the Pearson Correlation Coefficient and the Spearman’s Rho statistical tests.

Correlation between FSFI and MMPI-2 Lie Scale:

R = 0.8027 R2 = 0.6443
The P-value is 0.000549
The result is significant at p<0.01
rs = 0.85864, p (2-tailed) = 8E-05

Spearman’s Rho revealed that the association between the two variables is statistically significant. Results showed a strong positive correlation between the high FSFI scores of sexual satisfaction and the L-scale of the MMPI-2, confirming the statistically significant results obtained by the Pearson Correlation Coefficient. This significantly positive correlation between the two variables suggests that either these women were untruthful in their FSFI responses of they had a tendency to deny or deliberately distort reality.

Correlation between FSFI and MMPI-2 D:
R = 0.8378 R2 =0.7019
The p-value is 0.000184
The result is significant at 0<0.01
rs = 0.86086, p (2-tailed) = 8E-05

Spearman’s Rho correlation revealed that the association between the two variables is statistically significant. Results showed a strong positive correlation between FSFI scores and the D-scale of the MMPI-2 in both the Pearson correlation coefficient and the Spearman’s Rho tests, suggesting that the reports of sexual fulfilment and interpersonal satisfaction on the FSFI were based on a superficial positive outlook shielding an underlying general feeling of unhappiness in their home environment.

Correlation between FSFI and MMPI-2 Hy-Scale:
R = 0.6368 R2 = 0.4055
The P-value is 0.014326
The result is significant at p<0.05
rs = 0.64193, p (2-tailed) = 0.01332

Spearman Rho correlation revealed that the association between the two variables is statistically significant. Results showed a strong positive correlation between FSFI scores and the Hy-scale of the MMPI-2 in both the Pearson Correlation Coefficient and the Spearman’s Rho tests, suggesting that the reports of sexual satisfaction on the FSFI did not reflect these women’s true feelings but was merely driven by their need for approval and affection and perhaps the unrealistic optimism that the pretense of happiness will make everything alright.

The scores of the 14 female subjects on the DES reached the highest scores on the discrete emotions of shame, sadness and joy reflecting an almost surrealistic juxtaposition of contradictory layers, the covert front layer of sexual satisfaction and contentment shielding the hidden layer of unspoken discontent. All women reported physical symptoms, mostly related to the incidence of body aches and indigestion. It is not clear whether the reported physical symptoms were an aspect of the subjects’ personality constellation that was characterized by hysterical features as seen in the MMPI-2 or whether there was a significant correlation between the three dominant discrete emotions in our study group (shame, sadness and reported joy) and physical illness.

The success of interpersonal relationships is largely dependent on understanding and improving quality of life in the female, who is usually in charge of maintaining the foundation, continuity and integrity of a relationship. This is not a simple matter but a multi-faced, psycho-physiological composite that cannot be modified without altering both its physiological and psychological components. The results we obtained on the DES should be re-examined for further reliability and validity. However, it is somewhat alarming that our sample of women who reported a positive outcome on the FSFI accompanied by a high Lie score and depressive / hysterical traits were organized around the emotions of shame, sadness and joy along with higher than average reports of physical illness. This multidimensional landscape reflected a multilayered overtly positive and covertly negative emotional configuration. A person organized around shame, prone to hide feelings behind the pleasant façade of joy (according to the DES results) may underlie the emotional organization of the type C personality that is vulnerable to cancer. Without a full diagnostic profile including a Lie scale in their assessment procedures in addition to both psychological and physiological data, it is unclear how many women are really satisfied by vaginal rejuvenation interventions performed by energy-based devices like lasers and RF.

References coming soon…