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Proceedings of the

The International 20th World


Federation of Congress
Automatic Control
Proceedings
The of the
International
Toulouse, France, 20th9-14,
World
Federation
July of Congress
Automatic Control
2017
The International
Available online at www.sciencedirect.com
Toulouse, France,Federation of Automatic Control
July 9-14, 2017
Toulouse, France, July 9-14, 2017
ScienceDirect
Qualitative modeling of pressure vs. pain
IFAC PapersOnLine 50-1 (2017) 2043–2050
Qualitative modeling of pressure vs. pain
Qualitative
relationsmodeling
in womenofsuffering pressure from
vs. pain
relations in women suffering from
relations indyspareunia
women suffering from
dyspareunia
dyspareunia
Damiano Varagnolo ∗ , Steffi Knorn ∗∗ , Reinhilde Melles ∗∗∗ and
∗ ∗∗ ∗∗∗
Damiano Varagnolo ∗Marieke , Steffi Knorn Dewitte , Reinhilde
∗∗∗ Melles and
Damiano Varagnolo Marieke , Steffi Knorn Dewitte , Reinhilde Melles ∗∗∗ and
∗∗ ∗∗∗

Marieke Dewitte ∗∗∗



Department of Computer Science, Electrical and Space Engineering,
∗ Department of Computer Science, Electrical and Space Engineering,
Luleå University of Technology, Luleå, Sweden
∗∗Department ofofComputer Science, Electrical andUniversity,
Space Engineering,

Department Luleå University
Engineering ofSciences,
Technology, Luleå,
Uppsala Sweden Uppsala,
∗∗ Department Luleåof University
Engineering of Technology,
Sciences,
Sweden Luleå,
Uppsala Sweden
University, Uppsala,
∗∗∗ Department of Engineering Sciences, Uppsala Clinical
University, Uppsala,
∗∗
Department of Psychology and Sweden
Neuroscience, Psychological
∗∗∗ Department of Psychology and Sweden
Neuroscience, Clinical Psychological
∗∗∗ Science, Behavioural Medicine, Maastricht Universitair Medisch
Department
Science, of Psychology
Behavioural
Centrum, and Neuroscience,
Medicine,
Maastricht, Maastricht Clinical Psychological
Universitair
The Netherlands Medisch
Science, Behavioural
Centrum,Medicine,
Maastricht, Maastricht Universitair Medisch
The Netherlands
Centrum, Maastricht, The Netherlands
Abstract: Genital pain / penetration disorders affect a significant portion of the female
Abstract: and
population Genital
diminishpainsignificantly
/ penetration the disorders
quality of affect
life of athesignificant portion of the
subjects. Treatments, thatfemale
often
Abstract:
population Genital
and diminishpain / penetration
significantly the disorders
quality of affect
consist in stretching opportunely the vaginal duct by means of opportune vaginalthat
life of a
the significant
subjects. portion
Treatments, of the female
often
dilators,
population
consist
are known andbediminish
in stretching
to invasive, significantly
opportunely
lengthy and thethe quality
vaginal of life
duct
uncomfortable. of the subjects.
byDesigning
means ofbetter Treatments,
opportune
treatmentsvaginal that often
dilators,
(e.g., more
consist
are known
efficient in stretching
to be invasive,
locations opportunely
and levels lengthy the vaginal
and uncomfortable.
of pressures) duct by means
nonetheless Designing of opportune
better treatments
requires understanding vaginal
better dilators,
(e.g.,
howmore the
are known
efficient
pressure to be invasive,
locations
developed and
in the lengthy
levels
vaginal and uncomfortable.
of pressures)
channel nonetheless
affects Designing
requires
the patient bettertotreatments
andunderstanding
leads better
subjective (e.g.,
howmore
pain. the
Here
we take a control-oriented approach to the problem, and aim at describing the dynamics of the
efficient
pressure locations
developed and
in levels
the of
vaginal pressures)
channel nonetheless
affects the requires
patient and understanding
leads to better
subjective how
pain. Here
the
pressure
we take avs.
pressure developed in the vaginal
control-oriented
pain mechanisms approach channel
by means to theof affects
problem,
opportunethe and
patient
state aim and
space leads to subjective
at describing the dynamics
representations. pain.ofHere
In particular, the
we
we take
first acollect
pressure control-oriented
vs. painand discussapproach
mechanisms by medical
the meansto the problem, that
ofliterature,
opportune and
state aim
spaceat describing
describes how thethe
representations. dynamics of the
In particular,
variables that are
pressure
we first collect
involved vs.
in pain
the and mechanisms
discussofthe
treatment by meanspain
medical
genital ofliterature,
opportune statedescribes
that
/ penetration space representations.
disorders how
withthe In
variables
vaginal particular,
that are
dilators, are
we first collect
involved
logically in the and
related. Afterdiscuss
treatment thisofthe
we medical
genital pain
translate literature, that describes
/ penetration
(and complete) this set how
disorders with
of the variables
vaginal
logical that
dilators,
relations intoare
area
involved
logically in
qualitative the treatment
related.
model After thisofwe
that allows genital
control pain
translateoriented/ penetration
(and complete)
analyses ofdisorders
this set ofwith
the dynamics. vaginal
logical dilators,
Therelations
obtained into are
state a
logically
qualitative
space modelrelated.
model
is then After
that thistoweboth
allows
proved translate
controlmimic (and
oriented complete)
whatofisthis
analyses
correctly the set offrom
dynamics.
expected logical
The relations
logicalobtained into
perspectivesstatea
qualitative
and modelmodel
spacereproduce thenthat
is behaviors allows
proved control
to both
measured mimic
in oriented analyses
correctly
clinical settings.whatofis the dynamics.
expected from The logicalobtained
perspectivesstate
space model is behaviors
and reproduce then proved to both in
measured mimic correctly
clinical settings.what is expected from logical perspectives
and
© 2017, reproduce behaviors measured
IFAC (International Federation in clinical settings.
of Automatic Control) Hosting by Elsevier Ltd. All rights reserved.
Keywords: genital pain / penetration disorders, state space models
Keywords: genital pain / penetration disorders, state space models
Keywords: genital pain / penetration disorders, state space models
1. INTRODUCTION floor) (Binik et al., 2006; Bergeron et al., 2008; Goldstein
1. INTRODUCTION floor)
et al., (Binik
2011).etThese al., 2006; Bergeron
therapies are et al., 2008; known
nonetheless Goldstein to
1. INTRODUCTION
Female genital pain / penetration disorders affect a floor) et
be al., (Binik
2011).et
invasive, al., 2006;
These
lengthy, Bergeron
therapies
intimate andet
are al., 2008;
nonetheless
scarce Goldstein
known
at the to
point
Femalenumber
great genitalof painpersons / penetration
(being estimated disorders 30-40%a et
that affect be
that al., 2011).patients
invasive,
several These therapies
lengthy, intimate
rather are
andnonetheless
prefer scarce
to known
at the
go untreated to
point
and
Female
great genital
number of pain
persons / penetration
(being disorders
estimated that affect
30-40% a be
that invasive,
several
of women suffer from painful experiences during sexual live with these debilitating disorders. The societal needlengthy,
patients intimate
rather and
prefer scarce
to go at the
untreated point
and
great number of from
persons et (being estimated thatand 30-40%
arise that live several
with patients rather disorders.
prefer to Thegotountreated and
of women
intercourses suffer
(Goldstein painful experiences
al., 2009, Chap. during
2)), sexual is thus to these
adapt debilitating
the treatments in order societal their
increase need
of women
intercourses suffer
from a great(Goldstein from
variety of et painful experiences
al., 2009,
causes during sexual
2)), and arise is
Chap. psychological,
(biological, live with these debilitating disorders.
thus to adapt the treatments in order to increase their The societal need
appealingness.
intercourses
social great(Goldstein
from areasons, variety
and the of et al., 2009,
causes
union Chap.
of(biological,
these 2)), andetarise
psychological,
(Goldstein al., is thus to adapt the treatments in order to increase their
appealingness.
from
social a great
reasons, variety
and of
the causes
union (biological,
of these psychological,
2009, Chap. 3), with interpersonal and relational factors Towards this
(Goldstein et al., Towards
appealingness. goal, here we focus on the specific and
social reasons, and the union of these (Goldstein et al., common this goal, here
physiological we focus
treatment on the specific
of stretching and
the vaginal
2009,
such asChap. 3), partner
hostile with interpersonal
responses and andotherrelational factors Towards this goal, here
psychosocial wepressure
focus on the specific and
2009, Chap. 3), with interpersonal and relational factors common
duct by physiological
applying a treatment
certain of stretching
by means the
of vaginal
oppor-
such as contributing
factors hostile partner to responses
maintenance, and other psychosocial
exacerbation and common physiological treatment of stretching the vaginal
such as contributing
hostileofpartner duct by applying a certain pressure by means of oppor-
factors
chronicization genital to responses
maintenance,
pain). and other
Affected persons psychosocial
exacerbationare known and tune duct
vaginal dilators. This strategy is indeed commonly
by
factors contributing
chronicization of genital to maintenance,
pain). Affected exacerbation
persons
to be likely to develop comorbid sexual difficulties, neg- tune are and
known
tune
used for applying
vaginaltreating adisorders
dilators. certain pressure
This strategy byindeed
is
with components means commonly
ofthat
oppor-
are
chronicization of genital pain). Affected persons are known used
both vaginal dilators.
for treating disorders
psychosomatic This
(e.g., strategy
vaginismus) is
with components indeed
and commonly
that are
physiological
to be affect,
ative likely toanddevelop comorbid
relationship sexual(Goldstein
concerns difficulties,etneg- al., both
used psychosomatic
for treating disorders with cancer
components thatvagi-
are
to be affect,
likely to (e.g., vaginismus) and physiological
ative
2009, Chap. anddevelop
3), factors comorbid
allrelationship sexual(Goldstein
thatconcerns
diminish difficulties,
significantly etneg-
al., (e.g.,
the both
complications
psychosomatic
after cervix
(e.g., vaginismus) and
surgeries,
physiological
ative affect, andallrelationship (e.g., complications after cervix cancer surgeries, vagi-
2009,
qualityChap.
of life.3), factors thatconcerns diminish(Goldstein
significantly et the
al., nal radiotherapies, Mayer-Rokitansky-Küster-Hauser syn-
(e.g., complications after gender
cervix reassignment
cancer surgeries, vagi-
2009, Chap. nal radiotherapies, Mayer-Rokitansky-Küster-Hauser syn-
quality of life.3), all factors that diminish significantly the dromes, nal
or male-to-female
radiotherapies, Mayer-Rokitansky-Küster-Hauser
surgeries).
syn-
Treatments
quality of life.of genital pain / penetration disorders follow dromes, or male-to-female gender reassignment surgeries).
combinations of psychological perspectives (e.g., Cogni- We thus develop qualitative and quantitative models of the
Treatments of genital pain / penetration disorders follow We thus
dromes, develop
or qualitative
male-to-female and
gender quantitative
reassignment models of
surgeries).
the
Treatments
combinations
tive Behavioral of of
genital pain(CBTs)
psychological
Therapies / penetration
such asdisorders
perspectives follow
mod- dynamics
(e.g., Cogni-
exposure, of the quantities involved in the treatment, i.e.,
combinations of psychological perspectives (e.g., Cogni- We
how thus
dynamicsthe develop
of the qualitative
pressure quantities
developed and
in quantitative
involved
the vaginal models of
in the treatment,
channel the
i.e.,
(plus
tive Behavioral
ifying, Therapies
hypervigilance and (CBTs) such as strategies)
catastrophizing exposure, mod- and dynamics of the quantities involved in the treatment, i.e.,
tive Behavioral Therapies and (CBTs) how the pressure developed in the vaginal channel (plus
ifying, hypervigilance
physiological perspectives assuch
catastrophizing
(such as strategies)
stretching exposure,
the vaginal and some
mod-
how
ancillary variables) transform into subjective pain.
the pressure
ifying, hypervigilance
physiological perspectives and catastrophizing
(such as stretching
duct, desensitizing the vestibulum, and relaxing the pelvic some strategies)
the and
vaginal
some
Our ancillary
aim todeveloped
is thusvariables) ainmathematical
providetransform the vaginal channel
tool that(plus
into subjective pain.
can
physiological perspectives (such as stretching the vaginal Our
be usedancillary
aimtoisdesign variables)
thus to provide
novel transform
vaginal pressure into
a mathematical subjective
patterns thatpain.
tool(location,can
duct, desensitizing the vestibulum, and relaxing the pelvic Our aim isdesign
thus to provide a mathematical tool(location,
thatwith
can
duct, desensitizing the vestibulum, and relaxing
 The research leading to these results has received funding from the
the pelvic be
levelusedof to
pressure, novel
way vaginal
of pressure
building up patterns
the pressure)
 The research leading to these results has received funding from the
Swedish research council Norrbottens Forskningsråd. Corresponding be
levelusedof to design
pressure, novel
way vaginal
of pressure
building
higher effectiveness than the current practice. up patterns
the (location,
pressure) with
 The research leading to these results has received funding from the
Swedish
author: D.research council
Varagnolo, Norrbottens Forskningsråd. Corresponding
damiano.varagnolo@ltu.se level
higherofeffectiveness
pressure, way than of the
building
current uppractice.
the pressure) with
Swedish research council Norrbottens
author: D. Varagnolo, damiano.varagnolo@ltu.se Forskningsråd. Corresponding higher effectiveness than the current practice.
author: D. Varagnolo, damiano.varagnolo@ltu.se
Copyright © 2017 IFAC 2079
2405-8963 ©
Copyright © 2017, IFAC (International Federation of Automatic Control)
2017 IFAC 2079Hosting by Elsevier Ltd. All rights reserved.
Peer review under responsibility
Copyright © 2017 IFAC of International Federation of Automatic
2079Control.
10.1016/j.ifacol.2017.08.207
Proceedings of the 20th IFAC World Congress
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Toulouse, France, July 9-14, 2017 Damiano Varagnolo et al. / IFAC PapersOnLine 50-1 (2017) 2043–2050

Delaying the discussion on the relevant literature to Sec- xpleasure := perceived and subjective level of pleasure, that
tion 3, our contributions consist in collecting the existing for convenience is measured with the same measurement
medical literature on the subject, translating and complet- units with which xpain is measures;
ing it into a state-space description of the dynamics of the
relevant variables, and eventually analyzing the dynamics xsubj.arousal := subjectively perceived sexual arousal levels,
from mathematical perspectives (e.g., the positivity of the corresponding to the perceived current interest in sexual
system, its equilibria and their stability properties). activity, and measured through opportune questionnaires
(notice that in our settings we ignore the type of sexual ac-
The paper is structured as follows: Section 2 lists and tivity the subject is interested into) or by means of oppor-
discusses the variables involved in the treatment of genital tune Visual Analogue Scale (VAS). Notice that xsubj.arousal
pain / penetration disorders. Section 3 reviews the med- is different from the physiological arousal level xphys.arousal
ical literature that describes qualitative relations among defined below, that instead corresponds to the physiologi-
the variables listed in Section 2. Section 4 defines which cal genital arousal (that translates into lubrication levels,
variables above should be included and which ones should blood congestion levels, etc.). Importantly, women may be
be excluded in a state-space representation of the system physiologically aroused but not subjectively aroused; this
under investigation. Section 5 drafts the co-implications implies that there may be low concordance between the
among the variables in our state-space representations, two signals xsubj.arousal and xphys.arousal ;
and Section 6 completes our translation efforts by pre-
senting our final state-space model plus a mathematical xphys.arousal := physiological genital arousal level, a quan-
analysis of it in Section 7. Section 8 concludes the paper tity that merges different and distinct physiological signals
with some remarks and indications for future research such as xlubrication (the vaginal lubrication levels) and
directions. xvasocongestion (the vaginal vasocongestion levels, that can
be measured through thermography, by Doppler consider-
ations on ultrasounds, or using Magnetic Resonance Imag-
2. INVOLVED QUANTITIES
ings (MRIs) techniques). In this manuscript we lump the
various signals together for simplicity, assuming implicitly
The following list contains the variables that are usually
that they have large concordance;
involved in the treatment of genital pain / penetration
disorders by means of vaginal dilators. Note that this xmuscles := pelvic muscles tension / activity, known to
paper focusses on a qualitative model without considering be influenced by the intravaginal pressure upressure but
exact mathematical values. Hence, the typical order of currently still not understood how;
magnitude or dimension of the variables are not of interest.
xfear := subjective fear level status, a situation-related
upressure := intravaginal pressure, physically correspond- quantity that is in principle measurable through opportune
ing to an actuation pressure signal. It can be measured questionnaires or a VAS;
numerically by means of opportune pressure sensors, but
it is still unknown how a measured vaginal pressure relates xtouch := perceived and subjective touch intensity, as-
to the muscular tension in the pelvic floor; suming that the intensity of the stimulus is beyond the
threshold for which the stimulus is perceived, and also that
uvibration := vibration levels of the vaginal dilator, physi- the stimulus is neither associated to pain nor pleasure.
cally corresponding to an actuation signal. As for upressure ,
it is numerically known but it is still unknown how it The following list instead contains some other ancillary
relates to the muscular tension in the pelvic floor; mathematical quantities that are useful to define the
ustimulus := visual sexual stimuli, physically correspond- logical relations among the variables listed above.
ing to erotic movies with different arousal-level contents, T touch := touch perception threshold, which measurement
and corresponding to an actuation signal measured sub- unit depends on the type of stimulus applied to the patient
jectively through questionnaires; (e.g., Pascal or mmHg if it is a pressure);
xpain := affective-motivational dimension of the perceived T pain := pain perception threshold, which measurement
level of pain, a subjective state that is measured subjec- unit depends on the type of stimulus applied to the patient
tively 1 ; (e.g., Pascal or mmHg if it is a pressure);
1 Importantly, pain is not a mono-dimensional feeling; one may S pain := pain sensitivity, i.e., the function that maps a
indeed distinguish the following two dimensions:
certain stimulus (considered as a time-dependent signal)
sensory-discriminative dimension of pain: dimension of pain into a subjective pain level (considered again as a time-
relative to the sense of the intensity, location, quality and duration dependent signal);
of the pain;
affective-motivational dimension of pain: dimension of pain S touch := touch sensitivity, for which the same consider-
relative to the unpleasantness and urge to escape the unpleas- ations for the pain sensitivity Spain also apply.
antness.
For example, placebos may modulate the affective-motivational
dimension while leaving the sensory-discriminative one un-
changed (Melzack and Casey, 1968). Intensity and unpleasantness 3. LITERATURE REVIEW
of a painful stimulus should thus be measured and treated inde-
pendently; in this paper nonetheless we consider only the affective-
motivational dimension since it is the unique one dimension usually We now describe the known qualitative relationships
measured in tests through dedicated devices called algometers. among the variables introduced in Section 2.

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3.1 Mechanisms leading to painful penetrative intercourses that xsubj.arousal is highly influenced by the cognitive ap-
praisal of the stimuli. Indeed the Basson’s model assumes
xphys.arousal > 0 =⇒ (xlubrication > 0, xvasocongestion > overlapping phases of physiological and subjective arousal
0), which reads xphys.arousal greater than 0 implies that in a variable and circular temporal sequence, plus considers
xlubrication greater than 0 and xvasocongestion greater than relational factors and needs for emotional closeness as
0; more precisely, when xphys.arousal starts increasing then important motivators of sex, and focuses also on non-
this initiates genital blood flow leading to vasoconges- sexual outcomes instead of focusing on sexual urges and
tion of the vestibular bulbs (Puppo, 2013) and vagi- orgasmic release. In other words, in the Basson’s model the
nal lubrication (Levin, 2002). Indeed non-null xlubrication goal of sexual activity for women is not necessarily orgasm,
and xvasocongestion are indirect measures of a non null but rather personal and relational satisfaction/intimacy,
xphys.arousal ; which can manifest itself as physical satisfaction (orgasm
and/or satisfactory sexual intercourse) and/or emotional
uvibration ∈ "suitable range" may =⇒ xpleasure > 0; satisfaction (e.g., a feeling of intimacy and connection with
more precisely, stimulation of the inner labia together a partner) and self esteem.
with the vestibular bulbs (summarizable in uvibration ) can
facilitate and intensify orgasms (Puppo, 2011); Thus, concerning the relationship between xsubj.arousal and
xphys.arousal , some psychological factors (e.g., memories,
xfear > 0 =⇒ xmuscles > 0, i.e., fear induces activity of thoughts, desire for increased emotional closeness and in-
the pelvic floor muscles (van der Velde et al., 2001; Both timacy, a particular overture from a partner in a long-
et al., 2012); term relationship, etc.) may trigger a predisposition to
(if happening before or at the beginning of the pen- participate in sexual activity, i.e., leading to further in-
etrative act) xmuscles > 0 =⇒ (xlubrication ↓ crease of sexual arousal and desire conditions. At the same
0, xvasocongestion ↓ 0), where x ↓ 0 denotes that x de- time, and concurrently, the physiological sexual arousal
creases till 0; more precisely, increasing the pelvic muscles xphys.arousal may start via conversations, music, reading,
activity before or at the beginning of the penetrative act fantasies, or viewing erotic materials, or physical stim-
may result in more pressure on the vulvar and vaginal ulation. Once xphys.arousal is triggered, xsubj.arousal may
skin, that in its turn allows less blood flow and lubri- increase and motivate to continue the sexual activity (even
cation (Lunsen, H.W. and Ramakers, 2002; Binik et al., if this is not always the case, since a subjective arousal may
2006). Thus a non-negligible xmuscles (0) (where we explicit not necessarily be translated into sexual action, specially
the time index to remark it) may decrease xlubrication and when the mere experience is already satisfying enough).
xvasocongestion . Unfortunately, though, this relationship de- Notice that while xphys.arousal and xsubj.arousal are high,
pends on the timing: initial stages of arousal seems to nonetheless, some other psychological factors (e.g., in-
lead indeed to an initial relaxation of the pelvic floor, creased negative affect, disgust, fear, attentional bias) may
i.e., xphys.arousal (0) > 0 =⇒ xmuscles (0) = 0. Then, as work as turn-off and diminish up to vanishing xphys.arousal
the time passes and arousal increases, the deeper located and/or xsubj.arousal , stopping thus the sexual fulfillment
pelvic floor muscles actually undergo contractions that are sensations. Notice that it is not stated elsewhere in the
instrumental to achieve the orgasmic phase, Both et al. known literature that xsubj.arousal ↓ 0 implied by turn-
(2012), but these contractions seem to do not affect the off factors will also imply physiological signals to decrease
lubrication and vasocongestion levels anymore, so that the (i.e., (xlubrication ↓ 0, xvasocongestion ↓ 0)) up to a level that
dynamics seem in this case to decouple. Thus there is some is sufficient to cause dyspareunia in case of penetrative
dynamics on both how xphys.arousal influences xmuscles and intercourse.
xmuscles influences xlubrication and xvasocongestion , but (to Summarizing, there are currently no quantitative models
the best of our knowledge) no mathematical model seem relating direct interrelations between physiological and
to exist in the literature. subjective arousal, and moreover the data available in the
The previous implications thus suggest that a mathe- literature is insufficient to directly connect psychological
matical model of factors with the mechanisms described above.
 the quantities above should satisfy the
logical relation xphys.arousal ≈ 0 or xmuscles (0)  0 =⇒
xpain > 0 that says that penetrative activities with no or 3.3 Relations among xphys.arousal , upressure , xpain , xpleasure
little arousal or initial activity of the pelvic floor muscles and xmuscles
along with mechanical friction (due, e.g., to fear) may
cause vulvar pain and dyspareunia. This logical chain in its To the best of our knowledge there are only two published
turn agrees with other existing medical literature on the papers describing these interrelationships. In particular,
subject (Brauer et al., 2006; Farmer and Meston, 2007; ter (Gruenwald et al., 2007): under u
vibration > 0 as-
Kuile et al., 2010). sumptions, x ↑ =⇒ (T ↑, T ↑), where
phys.arousal pain touch
x ↑ denotes that x increases; more precisely, in this
3.2 Relations between xphys.arousal and xsubj.arousal experiments subjects were exposed to visual and audi-
tory stimuli through erotic clips without manual or vi-
The existing literature orbits around the Basson’s non- bratory self-stimulation. After reaching a sufficiently high
linear model of the female sexual response (Basson, 2000), xphys.arousal state (considered here being equal to the lu-
stating that the subjective sexual arousal xsubj.arousal is brication level xlubrication ), subjects started experiencing
affected by several psychological inputs (e.g., satisfaction vibrations uvibration (but also thermal differences) up to
with the relationship, self-image, previous negative sexual the moment that the patient perceived something. The
experiences, negative cognitions, focus of attention), so conclusions drawn in that study was that touch sensitivity

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Proceedings of the 20th IFAC World Congress
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Toulouse, France, July 9-14, 2017 Damiano Varagnolo et al. / IFAC PapersOnLine 50-1 (2017) 2043–2050

of the vagina did not significantly change as a function of erotic stimuli


sexual arousal;
(Paterson et al., 2013): under upressure > 0 as-
sumptions, xphys.arousal ↑ =⇒ (Tpain ↑, Ttouch ↑) and
xphys.arousal ↑ =⇒
 xpleasure ↑; more precisely, the authors subjective
inserted a punctuated probe to exert a pressure upressure fear
arousal
until the moment that the patients started feeling some-
thing or pain. They thus conclude that pain sensitivity of
the vulvar vestibule increased during sexual arousal. physiological muscular
pleasure pain
arousal tension
4. QUANTITIES INVOLVED IN OUR MODELS

Our aim is to have models that can be analyzed from


quantitative perspectives; this means that the models that
we are seeking are simple enough to admit analytical char-
acterizations. Moreover we are also aiming at obtaining vaginal pressure
models with parameters that can be identified through
data-driven approaches; since the available datasets usu- Fig. 1. Schematic representation of the logical dependen-
ally comprise only a limited set of variables (i.e., measuring cies among the various quantities defined in Section 2.
everything is usually infeasible). Thus, we must limit the Erotic stimuli work as enabling factors for the subjec-
complexity of the proposed models. tive arousal, while work as blocking factors for fear
This implies that we can consider models that comprise (i.e., tend to diminish the fear levels). Vaginal pressure
only a subset of the quantities that are listed in Section 2. stimuli, instead, work as enabling factors in both the
For this reason our subsequent models focus only on implications between muscular tension and pain and
the following quantities, currently considered the most between physiological arousal and pleasure. Vaginal
informative ones from therapeutic perspectives: stimuli may thus lead to either pain or pleasure,
upressure ustimulus xpain xfear depending on the psychophysical status of the subject.
(1)
xmuscles xpleasure xsubj.arousal xphys.arousal the patient may be brought in a state of subjective arousal,
that then causes physiological arousal. We exploit instead
5. A LOGICAL MODEL CONNECTING THE Paterson et al. (2013) to say that if the vaginal pressure
VARIABLES IN SECTION 4 stimulus is strong enough, then, the patient may perceive
pleasure (in its turn reinforcing the subjective arousal as
To the best of our knowledge the existing literature does in the Basson model). Note that it is reasonable to assume
not offer models that describe the relations among all the that erotic stimuli also directly influences the physiological
quantities listed in (1), but only partial logical models sug- arousal apart from the influence on the subjective arousal.
gesting co-implications among subsets of these variables. However, in order to keep this model simple, we assume
In this section we start filling this gap by connecting all that erotic stimuli increases subjective arousal, which then
the variables in (1) through the logical scheme of Figure 1. leads to an increase in physiological arousal. Hence, the
Parts of the scheme thus capture some implications that influence of erotic stimuli on physiological arousal is cap-
have been suggested in the existing literature; other parts tured indirectly here. Importantly, and differently with
of the scheme instead complete the picture through some the already existing literature, we ignore two important
intuition-driven guesses. These guesses are then made so effects:
that, overall, the complete scheme has a logically consis-
tent qualitative behavior. (1) disturbing and turn-off factors: as for the validity of
this simplification, we motivate it by recalling that
The right part of the scheme, called Circle Of Fear (COF), the model is intended to be used for treatments that
models the feedback loop between fear, muscular tension happen in clinical settings and when patients are
and pain in a subject, and summarizes the relations listed in favorable psychological conditions (i.e., not dur-
in Sections 3.1 and 3.3. Summarizing, this part of the ing psychological breakdown periods), where distur-
diagram indicates that when erotic stimuli are associated bances should be minimized naturally by the environ-
with fear (or also associated to some too weak pleasure, in ment;
a sense defined more precisely in Section 6) and the vaginal (2) effects of orgasmic phases: as stated in the literature
pressure is strong enough, then the patient may perceive review, pelvic floor muscle tension can co-affect plea-
pain. This in its turn causes fear, that eventually leads to sure and subjective arousal levels; nonetheless these
an increased muscular tension (in its turn reinforcing the co-dependencies are more remarked towards orgasmic
pain perception). phases, that we neglect due to the clinic nature of the
model. This thus leads us to neglect muscular tension
The left part of the diagram, called Circle Of Pleasure
in the COP.
(COP), models instead the feedback loop between sub-
jective arousal, physiological arousal and pleasure in a Summarizing, the proposed model does not want to cap-
subject, and summarizes plus completes the relations listed ture daily-life conditions but rather what happens during
in Sections 3.2 and 3.3. More precisely we simplify Basson’s specific treatments, and (importantly) being sufficiently
model to say that when erotic stimuli are strong enough, simple to be prone to mathematical analysis.

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6. A QUALITATIVE MODEL EXTENDING THE  ẋphys.arousal = −xphys.arousal + xsubj.arousal ustimulus , (3a)
LOGICAL MODEL IN SECTION 5 ẋpleasure = −xpleasure + xphys.arousal upressure , (3b)

ẋsubj.arousal = −xsubj.arousal + xpleasure + ustimulus . (3c)
In this section we transform the logical model in Figure 1
into a qualitative one capturing the dependencies between More precisely, equation (3a) describes what influences the
the quantities listed in (1). The proposed model does state of physiological arousal over time. The equation sim-
not capture actual time scales of the physiological and plifies the Basson model by stating that the physiological
psychological human dynamics, but enables to find and arousal increases if the patient is being simultaneously
analyze the dynamical behavior of the system. sexually stimulated and subjectively aroused. In our ap-
proximated model, the physiological arousal changes more
In our model the external input signals upressure and rapidly if the level of subjective arousal and/or the sexual
ustimulus are considered to be nonnegative (reflecting the stimulus are higher. Once again the model is designed
fact that negative pressure or stimulus cannot be applied) so that if sexual stimulus or subjective arousal are miss-
and strictly less than 1 (interpretable as upressure and ing (i.e., xsubj.arousal ustimulus = 0) then the physiological
ustimulus being normalised signals where upressure = 1 or arousal decreases naturally to zero. This mimics the fact
ustimulus = 1 corresponds to the maximal bearable pressure that under no external stimulation the subject should tend
or stimulus, respectively). to go towards a resting state.

6.1 Modeling the Circle Of Fear Equation (3b) instead describes what influences the level
of subjective pleasure over time. The intuition captured
We model the feedback loop between fear, muscular ten- by the model is that if the patient is physiologically
sion and pain through the dynamics aroused then vaginal stimuli induce pleasurable sensa-
 √ tions. Similarly to as before, our model states that if
 ẋpain = −xpain + xmuscles upressure , (2a) vaginal pressure or physiological arousal are missing (i.e.,
ẋmuscles = −xmuscles + xfear , (2b) xphys.arousal upressure = 0) then the pleasure decreases ex-

ẋfear = −xfear − xfear ustimulus + xpain . (2c) ponentially to zero.
More precisely, equation (2a) describes what influences Equation (3c) eventually describes what influences the
the level of pain over time. Our model captures the level of subjective arousal over time. This equation mod-
fact (analyzed in Section 3.1) that, at least qualitatively, els this level as increasing when the patient is sexually
pelvic muscles activity before or at the beginning of the stimulated and when perceiving a pleasurable physical
penetrative act may lead to pain in the patient if there is sensation. The two effects moreover are modeled as being
some vaginal stimulus acting on the person. The proposed independently adding to the subjective arousal levels. As
dynamics models the facts that: i) a constant level of in all the various equations above, also here if the various
vaginal pressure eventually leads to an equilibrium in the other variables are zero then the subjective arousal is
pain; ii); xmuscles logically acts as an “enabling” factor modeled as exponentially vanishing in time.
that grows sub-linearly since the influence of upressure
on xpain increases relatively more when xmuscles is small Notice that equations (3b) and (3c) jointly capture the
rather than high (Paterson et al., 2013); iii) when the intuitions developed after Section 3.2. More precisely in
pressure disappears then the pain exponentially decreases our model we do not postulate a direct effect of the
towards zero, since in this case the equation reduces to physiological arousal on the subjective one, but rather
ẋpain = −xpain . exploit the “intermediate” state variable xpleasure . Notice
also that the vice-versa is not true, i.e., in our model the
Equation (2b) instead describes what influences the level subjective arousal affects directly the physiological one
of muscular tension over time. The dynamics of the muscle through equation (3a).
tension are effected by the feeling of fear, which leads to
an increase of muscle tension. However, if the patient is 7. MATHEMATICAL ANALYSIS OF MODEL (2)-(3)
not feeling fear (i.e., for xfear = 0) then the muscle tension
will exponentially decay towards zero.
For notational simplicity we will exploit the notation
Equation (2c) finally describes what influences the level 
xpain
 
xphys.arousal

of fear over time. Due to equation (2b), fear makes the xCOF := xmuscles xCOP := xpleasure .
muscle tension increase; the dynamics of fear instead are xfear xsubj.arousal
s.t. pain makes the fear increase. The proposed model
moreover connects erotic stimuli with fear, and tries to 7.1 Positivity
mimic the implications listed in Section 3.2. More precisely
we postulate that inducing an erotic stimulus can reduce
For model (2)-(3) to be meaningful, all states of the system
fear, and capture this with the last term on (2c): if the
must be nonnegative if all the initial states and all the
patient is being stimulated (i.e., ustimulus > 0) while feeling
external inputs are nonnegative; i.e., the COF and COP
fear then xfear ustimulus acts as a fear-reduction mechanism.
should be positive systems.
6.2 Modeling the Circle Of Pleasure Given that the maps (2) and (3) are continuously dif-
ferentiable, to prove their positivity we can exploit the
Our qualitative model of the feedback loop between phys- characterization in de Leenheer and Aeyels (2001) that
iological arousal, subjective arousal and pleasure is given a continuously differentiable dynamics ẋ = f (x)) with
by x ∈ Rn is positive if and only if for all x at the boundary

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of Rn+ it is true that xi = 0 implies fi (x) ≥ 0. In our case 7.4 Discussion of the equilibria
this condition can be easily verified since, once assuming
all the input signals to be nonnegative, Summarizing, the equilibria of our model depend on
√ ustimulus and upressure as follows:
ẋpain |xpain =0 = xmuscles upressure ≥ 0,
ẋmuscles |xmuscles =0 =xfear ≥ 0, ustimulus = 0 ustimulus > 0
ẋfear |xfear =0 =xpain ≥ 0,
ẋphys.arousal |xphys.arousal =0 =xsubj.arousal ustimulus ≥ 0, (resting state) (arousal state)
upressure = 0 x∗COF = 0 x∗COF = 0
ẋpleasure |xpleasure =0 =xphys.arousal upressure ≥ 0, x∗COP = 0 x∗COP > 0
ẋsubj.arousal |xsubj.arousal =0 =xpleasure + ustimulus ≥ 0
(fear state) (full state)
7.2 Equilibria of the COF upressure > 0 x∗COF > 0 x∗COF > 0
x∗COP = 0 x∗COP > 0
The equilibria of (2) are As graphically indicated above, we can discriminate four

u2pressure different situations:


 x ∗
= (4a)



fear
(1 + ustimulus )2 Resting state: if upressure = ustimulus = 0 then the equilib-

 rium in both circles is the origin, and it is in both cases
u2pressure
x∗pain = (4b) stable: intuitively this means that without external stimuli


 1 + ustimulus a person is supposedly resting and supposedly remaining



 x∗ u2pressure resting.
 muscles = (4c)
(1 + ustimulus )2 Arousal state: if upressure = 0 and ustimulus > 0 then the
so that for a given upressure and ustimulus the linearized origin is an unstable equilibrium for the COF, while the
system is COP has a non-trivial stable equilibrium. The instability
  of the origin for xCOF in this specific case is actually a de-
−1 12 pressure 0
u



xmuscles  sired mathematical property, since this behavior captures
∆ẋCOF =  0 −1 1  ∆xCOF . the intuition that the resting state x∗COP = 0 is tenuous
1 0 −(1 + ustimulus ) when upressure > 0: as soon as some pressure is exerted a
Thus upressure = 0 or upressure > 0 discriminates between patient will eventually feel something (i.e., the COF will
the trivial equilibrium x∗COF = 0 and a non-trivial one activate). The non-null equilibrium for the COP instead
x∗COF > 0. As for the stability of these equilibria, for corresponds to the patient being sexually stimulated but
x∗muscles = 0 the term pressure
u
is unbounded, so that not experiencing any vaginal pressure, which is modeled
∗ xmuscles to lead to an absence of fear or pain. This state is called
choosing the working point upressure > 0 leads to an the “arousal state”.
equilibrium x∗COF = 0 that is unstable irrespectively of
Fear state: if upressure > 0 and ustimulus = 0 then the
ustimulus .
COP is modeled to remain in the stable trivial equilibrium
The equilibrium x∗COF > 0 is instead stable as we only x∗COP = 0, while x∗COF > 0. Hence, the patient is modeled
allow ustimulus ≥ 0 (indeed, since 12 pressure
u
= 12 (1 + to experience pain and fear without any sexual arousal or
pleasure.
∗ xmuscles
ustimulus ) < 1, the eigenvalues of the linearized dynamics
matrix have all strictly negative real parts). Full state: if upressure > 0 and ustimulus > 0 then both
circles have nontrivial and stable equilibria; our model thus
admits a patient to experience simultaneously pleasure as
7.3 Equilibria of the COP well as pain, with amounts depending on the quantitative
measures of applied pressure and stimulus. This is an
The equilibria of (3) are important aspect as patients undergoing treatment must

upressure u2stimulus often learn to tolerate pressure as well as learn to associate

 x∗pleasure = (5a) pressure with pleasure (often referred to as “counter con-

 1 − upressure ustimulus


 ditioning”). Hence, being able to create a state where both
u2stimulus circles are active is essential to understand the treatment
x ∗
= (5b)


phys.arousal
1 − upressure ustimulus of dyspareunia.



 ustimulus
 x∗subj.arousal = (5c)
1 − upressure ustimulus 7.5 Examples
so that for a given upressure and ustimulus the linearized
system is For completeness, we now plot and comment one example
  of system trajectories for each situation but the trivial
−1 0 ustimulus resting state described in Section 7.4.
∆ẋCOF = upressure −1 0 ∆xCOF ,
0 1 −1
that implies that the equilibrium is stable for ustimulus < 1
and upressure < 1. The absence of erotic stimuli, i.e.,
ustimulus = 0, moreover implies x∗COF = 0.

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pain
muscles
fear
0

arousal
pleasure
desire
0

pressure
pain
stimulus
muscles
0 fear
0
time

Fig. 2. (fear state) in this case the model/patient starts at arousal


time zero with a bit of muscular tension; after that pleasure
it is subject to a pressure stimulus (but no erotic desire
stimulus), so that the patient ends up with a pain that 0
is proportional to the pressure stimulus. In this case
the COP is never active, given that ustimulus remains pressure
null for all times.
stimulus

0
time

Fig. 4. (full state) in this situation the model/patient


starts at time zero with a null COP but a non-null
COF, in the sense that the model-patient starts at
time zero with a bit of fear and with a “small” erotic
pain
stimulus, and after that it is subject to a pressure
muscles stimulus. Before the pressure starts the fear decays
fear quickly thanks to the erotic stimulus. The non-null
0
fear, nonetheless, activates the muscular tension, so
that when the vaginal pressure starts, because of the
arousal non-null muscular tension, the patient ends up again
pleasure in pain. In this case, nonetheless, the pain is not
desire directly proportional to the pressure stimulus because
0 it is also diminished by the presence of the erotic
stimulus. Eventually, thus, in this case the circle of
pressure pleasure is active because the erotic stimulus activated
it at the beginning.
stimulus

0
time

Fig. 3. (arousal state) the model/patient starts at time


zero with a bit of physiological arousal and is subject
to an erotic stimulus but no vaginal pressure. In this
case, as expected, the COP is partially active and
the patient ends up in an aroused state but without
physical pleasure, while the COF stays null because
of the opportune input signals.

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8. CONCLUSIONS Roy J. Levin. The Physiology of Sexual Arousal in


the Human Female: A Recreational and Procreational
We presented a simplified and deterministic control- Synthesis. Archives of Sexual Behavior, 31(5):405–411,
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involved in the treatment of genital pain / pelvic disorders Van Lunsen, H.W. and M.J. Ramakers. The hyperactive
by means of vaginal dilators. The model is meant to cap- pelvic floor syndrome (HPFS). Acta endoscopica, 32(3):
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psychological factors and other disturbances; on the other Ronald Melzack and Kenneth L. Casey. Sensory, motiva-
hand it simultaneously captures the typical behaviors of tional, and central control determinants of pain: a new
the average patient and is prone to mathematical charac- conceptual model. The skin senses, 1, 1968.
terizations, offering thus insights on how to design better Laurel Q P Paterson, Rhonda Amsel, and Yitzchak M.
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search directions; among others, next research steps are Vincenzo Puppo. Embryology and anatomy of the vulva:
to perform system identification and verify the predictive the female orgasm and women’s sexual health. European
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this, as a next step, a quantitative model with adequate Biology, 154(1):3–8, 2011.
parameters has to be developed. Then, the parameters can Vincenzo Puppo. Anatomy and physiology of the clitoris,
be determined using system identification methods and vestibular bulbs, and labia minora with a review of
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