Novel Therapeutic and Educational Approaches: Using Technology to Improve Sexuality

Abstract

Technological advancements have greatly contributed to the field of sexual health by offering innovative solutions for people with sexual difficulties. Sexual health is a matter of public concern. Traditional psychosexual therapies, including clinical and educational interventions, have proven to be successful in addressing a number of these concerns. However, people often refrain from seeking sexual therapy due to the societal stigma associated with it. In this light, it appears doubtful that the traditional ways of providing mental healthcare will be able to meet the existing needs. By providing a discreet and confidential platform for individuals to receive the support they need, new technologies present a promising solution to help reduce the stigma and shame associated with seeking help for sexual disorders. With the help of technology, people can now access effective treatment options from the comfort and privacy of their own homes, thereby enhancing accessibility to sexual interventions for those who do not feel comfortable with traditional therapy. Overall, technology seems to have the potential to significantly improve the quality of life for people with sexual issues. The goal of this chapter is to evaluate the available technology choices to determine the most suitable option for a comprehensive and successful sexual intervention.

1. Introduction

Sexuality is one of the most neglected aspects of our society in terms of education, investigation, and intervention. Sexual problems trouble both women and men worldwide. Estimated prevalence studies report that around 40–45% of adults will have a sexual problem at some point in their lives [1, 2, 3]. This makes sexual difficulties twice as common as depression [4]. Sexuality, sex problems, and sexual health are clearly a matter of public interest. Psychosexual treatments, including clinical and educational interventions, are considered effective, but people do not seek them out for sexual help, mostly because of stigma. This stigma is related to the beliefs that specific sexual practices are unnatural, immoral, or sinful, and that individuals who enjoy them are not deserving of the same rights and protections as other individuals. Sexual stigma can lead to social exclusion, discrimination, and harassment, so people tend to hide stigmatized aspects of their sexuality. This leads to both men and women feeling uncomfortable when talking openly about sexual problems, so mostly they keep them hidden. Potential patients feel that going to a hospital or clinic to receive psychological treatment for sexual disorders can be embarrassing [5]. Barriers for these potential patients include feelings of shame and guilt, a lack of perceived need for treatment, and poor intrinsic motivation to change. Due to these barriers, sexual dysfunctions are often untreated, resulting in decreasing sexual and general well-being in the population [6, 7].

The utilization of virtual reality (VR), metaverse, apps, and other technologies presents a promising avenue to enhance accessibility to psychological and educational interventions. This is particularly beneficial for individuals who may not feel comfortable seeking traditional options, including sexual treatments and educational interventions aimed at improving sexual knowledge. This chapter explores the psychological and educational interventions for treating and targeting impaired sexuality through the current available technologies: apps, VR, and metaverse. The purpose is to analyze the available options and determine which option best allows a complete and effective intervention. Other telehealth options exist, such as videocalls, but their potential benefits are much less than the benefits of the technologies included in this chapter (e.g., the technologies presented here offer higher stimulative control, greater confidentiality, and the possibility to face stimuli otherwise difficult to experience in real life). After the literature review, a program proposal for female orgasmic disorder (FOD), adapted to be delivered through a metaverse, is described.

2. Apps: convenient, accessible, and personalized

An app, short for “application,” refers to a software program designed to run on a mobile device (such as a smartphone or tablet) or a computer. Apps can serve a variety of purposes, from providing entertainment and games to facilitating productivity and communication. As there are many types, including social media apps, navigation apps, weather apps, shopping apps, and more, apps are one of the first things that come to mind when thinking about a technology-related intervention. Apps are convenient for the user (designed to be easy to use and accessible from anywhere with an internet connection) and relatively cheap (several programmers offer their services at an affordable price). Actually, various apps that provide a space for sexuality interventions already exist and are described below. The effectiveness of apps, however, is relatively unproven because there is limited research on the use of apps for sexual interventions, whether educational actions or sexual treatments. Some promising results have been obtained using apps to try to improve the sexual health of certain population groups. For example, studies have found that apps used as educational interventions can reduce the risk of unsafe sexual behavior in young people [8], and apps used as clinical interventions have improved sexuality among mothers [9]. One study that addresses FOD provides a comprehensive perspective. The authors [10] propose an intervention that includes both an educational and a clinical section reviewing some of the essential variables to treat the disorder (e.g., improving knowledge about female masturbation techniques). Even if there is limited research, all the interventions that could be found, some of them mentioned above, showed positive results and were effective.

In addition to the academic research, sexual apps in the digital marketplace have great educational and therapeutic potential. However, there is no information available about what benefits they offer, where their content comes from, or if anyone reviews or controls either the apps or the content they include. Some of these apps could be useful resources and potential tools for researchers, educators, and clinicians, but they are only known by commercial descriptors and the information provided online. For example, SexPositiveMe (sexpositiveme) is an app that allows the exploration of various aspects of sex and relationships, from fetishes and BDSM (i.e., bondage, discipline, dominance and submission, and sadomasochism) to ethical issues of non-monogamy and LGTBIQ+ identity (i.e., Lesbian, Gay, Bisexual, Trans, Intersex, and Queer). The app provides information and resources on a variety of sexual topics, including sexual health, pleasure, and communication. Kindara (kindara.com) is another kind of sexual app, designed to help women track their menstrual cycles, ovulation, and fertility. This can be useful for both family planning and understanding one’s own reproductive health.

Due in part to the previously mentioned stigma around sexuality, some apps that may be of interest to researchers existed for only a short period of time. All social media platforms have restrictions to sexual content, even if its purpose is education. To the best of our knowledge, apps that feature sex education content, that would help users to better their sexual well-being, often face difficulties in promoting themselves on social media due to strict regulations placed on them and, therefore, cannot survive. Two examples of one of these apps with a great purpose that did not last are Happy Play Time, which used games and interactive activities to teach children about healthy sexuality, including consent and personal boundaries; and Amaze was designed to educate young people about puberty, sex, and relationships through engaging and informative videos. The discontinuation of these apps may serve as motivation to continue deepening our knowledge on the topic and contribute to dismantle the stigma and taboos surrounding sexuality.

Of the existing apps related to female sexuality, only a small number have the specific and direct objective of improving women’s sexuality, including sexual problems and disorders. The materials and interventions of two of these apps worth highlighting, Caliope (caliope.app) and Emjoy (letsemjoy.com), have been supervised by psychologists. Caliope focuses on improving communication and pleasure through erotic stories and didactic content aimed to help women get to know themselves better. In addition to communication and pleasure enhancement, Emjoy includes other aspects related to sexual well-being, such as self-esteem, present-moment awareness, and maintaining a healthy relationship.

One problem with apps is the disparity between the plethora of apps available online and those that have been verified to be effective. Verified, effective apps are often inaccessible for download and solely intended for research purposes. Considering the large number of individuals with untreated sexual difficulties and the potential for apps to offer education and therapy to a broad population, the inaccessibility of effective apps is astonishing. Further, among the accessible apps, only one (Emjoy) addresses factors that contribute to the persistence of sexual disorders. Additionally, even when apps are effective, they should not be the only form of treatment. Sexual disorders can arise from diverse physical and psychological factors, and they may require a multifaceted approach that includes medical care, counseling, and changes in lifestyle. Apps can serve as a complementary aid to conventional treatment options, but it is imperative to exercise prudence when using any app related to sexual health. Health authorities should urge researchers, educators, and practitioners to meticulously scrutinize any apps they utilize for safety and credibility. Additionally, it is advisable for users to seek guidance from a healthcare professional prior to using any app as a treatment modality. Moving away from the technology of apps, the features of VR and metaverses could also be leveraged to aid individuals with sexual difficulties.

3. Virtual reality: the big brother of technology-based interventions

VR is a technology that employs computer-generated, three-dimensional (3D) environments to simulate reality, and in which people can interact in real time [11]. Currently, it is the technology with the largest number of studies across a variety of fields that prove its effectiveness, and the potential benefits VR presents seems greater than other technologies. VR uses multiple devices, such as a head-mounted display, one or more position trackers, and an interactive 3D visualization system. Regarding the psychological experience, it provides subjective experiences to the user that convey a deep sense of presence. An embodied simulation in VR can mimic the normal functioning of our brain, meaning that our brain may generate a simulation of the body in the environment. This virtual simulation can be used to impersonate behaviors, share thoughts, or represent emotions [11]. It is important to note that while VR and the metaverse are related concepts, they are not the same thing. VR is a technology that allows users to experience a computer-generated environment, which is typically limited to specific applications or games. Metaverses often use VR technology to interact with digital objects and environments but have a broader scope. Rather than being led by a single developer or publisher, metaverses offer fully immersive, virtual worlds that are shared by many users and develop as the users engage with each other according to their needs.

VR is becoming an important tool in the social sciences; various studies have shown the efficacy of VR used to treat different physical (e.g., [12]) and psychological (e.g., [13]) disorders, including acrophobia, general anxiety, and body dysmorphia. Technical innovation, improvement, and affordability have led healthcare to move away from conventional, in-person interventions and toward therapies that make use of technology. The therapeutic benefits of using VR in psychological treatment and educational interventions include greater stimulative control, confidentiality [14], and the ability to experience stimuli that would otherwise be difficult to encounter in real life [15, 16].

The high cost of VR (both in terms of the hardware and the development of the environments) presents an obstacle to broad implementation. That said, regarding interventions to improve sexuality (i.e., sexual health interventions, disorder-focused therapy, or interventions to promote sexual well-being), VR offers the following potential benefits [17, 18, 19, 20]:

1. Increased privacy and comfort: traditional interventions for sexual disorders may require patients to engage in difficult and sometimes embarrassing activities in front of therapists or others. VR provides a more private and controlled environment for patients to explore and work through their sexual difficulties. Additionally, the patient’s image is not compromised because the avatar is the one seen, which allows for less shame and facilitates attending therapy. However, therapists may miss the patients’ nonverbal communication.

2. Greater control over stimuli: VR allows therapists to carefully control and manipulate the stimuli that patients are exposed to, which can be especially important in treating sexual disorders. Patients can be gradually exposed to increasingly challenging stimuli in a controlled environment, helping to reduce anxiety and increase comfort [21]. Interacting with live sexual situations generate anxiety functions as a controlled and experiential form of systematic exposure. Furthermore, VR can help with imagination tasks [22] (e.g., explaining methods of stimulation or other educational content).

3. Realistic simulations: VR can provide realistic simulations of sexual situations and scenarios, allowing users to practice and develop skills, acquiring knowledge in a safe and controlled environment. This can be especially useful for conditions like sexual anxiety, where patients may benefit from exposure therapy in a controlled setting. VR allows the possibility to use virtual sex objects or to experience situations that would normally be impractical or challenging to reach in in-person settings [23].

4. Increased engagement: VR can be more engaging than traditional therapy methods, helping to keep patients focused and motivated to continue with treatment. This can lead to greater success and better outcomes.

Overall, the use of VR in psychotherapy for sexual disorders shows promise in providing a safe, effective, and engaging option for people with sexual impairments. VR allows individuals with sexual difficulties to receive educational and clinical interventions without leaving the perceived safety of their homes [23, 24]. Considering this, it is worthwhile to explore the state of VR educational and psychological interventions that target impaired sexuality.

3.1 Virtual reality interventions for sexual-related problems

No studies on VR educational treatments for impaired sexuality appeared in a review of PubMed, PsycINFO, and Web of Science databases (February 2023). However, this search did result in the identification of six studies presenting VR psychological treatments for people with sexual problems. These studies can be divided into two theoretical approaches: those based on cognitive-behavioral therapy (CBT) and those based on psychodynamic therapy. Before describing each study in detail, it is important to note that all the studies aimed to treat various disorders, including sexual trauma, erectile dysfunction, premature ejaculation, and sexual anxiety. Some of the studies also assessed nonsexual-related variables such as depression or distress. The interventions were tailored to the participants’ ages and other demographic characteristics. Significantly, every VR intervention featured in the retrieved articles reported effective results for the specific issue addressed.

The CBT studies consisted of three investigations using VR exposure therapy to treat sexual harassment victims and military veterans who were victims of sexual trauma. Loucks et al. [25] worked with male and female (ages 32–72 years) military veterans who were victims of sexual trauma. The authors used an Afghanistan-themed forward operating base and various civilian and military base contexts in VR as trigger stimuli. The participants were exposed to three 2-minute VR scenes, followed by 6–12 sessions of 90-minute BraveMind VR Exposure Therapy. The authors reported a significant reduction in pre- to posttreatment clinician-assessed and self-reported sexual PTSD (sexual post-traumatic stress disorder) symptoms, with a large Cohen’s d effect size, favoring intervention. The study did not report an education section or what meaning participants assigned to the VR therapeutic experience.

The study by Mozgai et al. [26] also worked with military veterans who were victims of sexual trauma, though participants’ ages and genders were not reported. The authors applied 6−12 ninety-minute sessions of BraveMind VR Exposure Therapy, but no other information was provided about the treatment. While the authors did not explain the intervention program employed, there was a significant reduction in clinician-assessed sexual PTSD symptoms, favoring intervention. Results reported a significant reduction in symptoms from pre- to posttreatment, maintained in a 3-month follow-up assessment. Again, no education section or what meaning participants assigned to the experience could be found.

The third study, by Loranger and Bouchard [27], focused on female victims of sexual harassment aged 18–65 years. Virtual systematic desensitization exposed participants to a nighttime bar and various stages of sexual aggression. The authors targeted sexual anxiety through three immersions of 5 minutes in a CAVE-like system and compared the results with a control group. They found significant differences between conditions, and these differences were maintained at a 3-month follow-up assessment. Once more, the study did not report an education section or what meaning participants assigned to the experience.

In addition to the three CBT studies above, there are three psychodynamic studies on VR psychological treatments for people with sexual problems. The three psychodynamic studies were all led by the same author [28, 29, 30] and focused on using virtual experiences and multimedia recordings to treat male sexual dysfunctions and sexual anxiety. These studies shared the same therapeutic program, known as the “Optale Method”: a VR psychodynamic psychotherapy aimed at evoking childhood mental images by using recordings, multimedia, and virtual experiences that described pathways through a forest. These scenarios treated facts pertinent to the ontogenesis of male sexual dysfunctions and were followed by a discussion about the experience. Some education sections were included as a part of this discussion.

In the first study, Optale et al. [28] worked with two groups of adults. One group (aged 22–75 years) was diagnosed with male impotence, and the other group (aged 21–44 years) was diagnosed with primary premature ejaculation. The intervention lasted 12 one-hour sessions over a 25-week period. Results were descriptive and only focused on the number of participants who improved or had a resolution after the intervention. Assessment criteria and statistical data were unclear, but results suggested an effective intervention. A greater number of participants improved or had a resolution than remained stable after the intervention. After this first study, Optale et al. [29] worked with adults aged 23–66 with psychogenic impotence. These participants received 15 sessions over a 6-month period. Again, results were descriptive, and the authors only presented the number of participants who improved or had a resolution after the intervention. Assessment criteria and statistical data were not provided. That said, it was reported that sexual performance among participants was improved and maintained at a 6-month follow-up. Finally, Optale et al. [30] worked with three groups of adults (average ages 43.7, 53.9, and 39 years) diagnosed with impotence and premature ejaculation. Intervention consisted of 12 sessions over a 25-week period. One more time, results were descriptive, and the authors only presented the number of participants who improved or had a resolution after the intervention. Assessment criteria and statistical data were not provided. This final study and its descriptive results also suggest an effective intervention, with a greater number of subjects improving or having a resolution than remaining stable after intervention.

4. Metaverses for people with sexual problems: present and future challenges

A metaverse is a term used to describe a collective virtual shared space that is typically accessed through the internet. It is a 3D digital world that is designed to simulate a physical world but includes various elements that are not present in real life. It can be categorized as a specific type of VR that entails the same advantages as VR (explained above) with additional benefits, such as a lower price and usability without the need for programming skills. As already stated, cost is the biggest disadvantage of VR; even if reducing market prices can make VR therapy a cost-effective alternative to traditional therapy, it still requires a big investment. In this way, metaverses overcome this weakness of VR, ensuring the increased privacy and comfort, greater control over stimuli, realistic simulations, and increased engagement of VR, along with affordable prices and the possibility of being delivered remotely and without the need for expensive equipment or facilities. In addition, considering the essence of metaverses, these virtual environments can provide a safe and controlled space for individuals to explore and express their sexual identities without fear of judgment or stigma. In a metaverse, users can create their own avatars (i.e., an image or 3D digital representation of a person in virtual environments that is customizable and can be designed to reflect the user’s preferences, personality, or identity). This avatar is then used to interact with other users in real time and engage in various activities and experiences, such as attending virtual events, playing games, socializing, and even conducting business. Metaverses are often designed to be persistent, meaning that the virtual world continues to exist and evolve even when no one is actively using it. Metaverses are becoming increasingly popular, with platforms such as Second Life (secondlife.com), Decentraland (decentraland.org), and Roblox (roblox.com) being some of the most well-known examples. They have the potential to offer new forms of social interaction, entertainment, and commerce and are expected to play a significant role in the future of the internet and technology.

Research on the effectiveness of interventions in metaverses is still relatively limited. However, there is growing evidence to suggest that metaverses can be effective in treating a range of mental health conditions and providing educational programs to help teach about mental health issues. In a review from Boulos et al. [31], the authors analyze the potential of metaverses for mental health education, finding benefits that may be greater than those resulting from traditional interventions. This is the case in a study by Dickey et al. [32], which finds educational intervention on mental health leads to greater knowledge retention and higher levels of engagement among students when delivered through metaverse role-playing exercises rather than through traditional teaching methods. This finding relates to experiential learning, which involves using different senses and procedural memory to learn “how to do” something. This hands-on practice stresses a “learning by doing” style.

There is limited research on the use of virtual environments for sexual interventions, but some studies have explored the potential of metaverses for both educational and clinical interventions. Regarding the latter [16], the authors have designed and tested an avatar-based intervention protocol for FOD, adapted to be administered through the metaverse Second Life. Preliminary results improved not only the diagnosis but also some of the main variables related to the disorder, including sexual satisfaction, function, and communication.

There are also several sex education programs that have been developed for use in metaverses. As with apps, though, they are not validated by the scientific community. For example, the virtual world Second Life has hosted a variety of sexual health and education programs over the years, including virtual clinics, workshops, and peer support groups. In addition, some organizations and individuals have developed custom educational programs using metaverse platforms like OpenSimulator (opensimulator.org), Sansar (sansar.com), and VRChat (hello.vrchat). One notable example is a branch of the “Sex Positive World” project (sexpositiveworld.org). Sex Positive World is an umbrella organization that encourages and supports worldwide sex positive communities. These communities hold an attitude or philosophy that regards all consensual sexual activities as natural and healthy, advocates for the acceptance, exploration, and celebration of sexuality in all its forms, and encompasses open communication, sexual diversity, consent, pleasure, and sexual education. This umbrella organization also includes virtual communities and worlds designed specifically for sexual health and education. The Sex Positive World project includes a variety of resources and activities related to sexual health, such as workshops, support groups, and virtual clinics. The project aims to create a safe and inclusive space for people to learn about and discuss issues related to sexuality and sexual health. Another example is the “Healthy Sexuality in a Digital World” project (share-netinternational.org), which includes a series of virtual environments that allow users to explore various topics related to sexual health, including contraception, sexually transmitted infections, and healthy relationships. These two metaverse sex education programs are mentioned because of the great educational potential they possess, and the useful resources and potential tools for researchers and educators they are, even if they do not meet traditional, peer-review standards of the academic community. In any case, it is important to ensure that virtual interventions for sexuality are evidence-based and culturally sensitive and prioritize informed consent and privacy. In terms of academic work, a study by Ahn et al. [33] did investigate the use of Second Life for providing sexual health education to college students. The authors found that students who participated in the program had greater knowledge gains and more positive attitudes toward sexual health compared to those who did not participate. And another study [34] explored the use of virtual environments to provide sex education and promote healthy sexual behaviors, specifically educating young adults about safe sex practices and contraception methods. Additionally, virtual support groups have been shown to increase social support and reduce feelings of isolation [35], which leads to thinking that online communities and virtual support groups could also be created to connect individuals who share similar experiences or concerns about sexuality. As more people become familiar with metaverse platforms and their capabilities, we may see even more innovative interventions developed in this space.

Sex education programs in metaverses are still relatively new, and more research is needed to fully establish the effectiveness of psychological interventions in these environments. That said, the reality is that metaverses have the potential to provide an engaging and immersive learning experience for students, and they could be a viable avenue for delivering mental healthcare to patients, including those with sexual problems. Below, this chapter broadens the literature by proposing an educational and clinical program designed to be delivered through a metaverse.

5. The virtual road to sexual recovery: a metaverse dual-program intervention for sexual issues

The proposed metaverse program consists of two distinct programs that can be combined to complement each other: one educational and the other clinical. Before describing them, there are a few key considerations to keep in mind when developing such programs:

• The first step in every metaverse program development process is to choose a suitable metaverse platform: as mentioned earlier, there are several metaverse platforms available, each with unique features and capabilities. It is important to consider the features needed for the educational program; for the case detailed below, Second Life (secondlife.com) was the best option.

• Within the design process, the features of the metaverse platform should be considered to create an experience for the users as engaging and interactive as possible (e.g., exploring different sexual health topics, exposure to anxiety-evoking stimuli, participating in role-playing scenarios, and engaging in group discussions).

• The creation of evidence-based, accurate, and suitable content, tasks, and challenges that are tailored to the target audience is a crucial component in the development of any VR or traditional program.

• Privacy and safety must be ensured. In order to address sensitive topics, it is imperative to ensure users’ privacy and safety. While the use of avatars available within metaverse environments can assist in this regard, it is important to establish explicit guidelines for appropriate conduct within the metaverse.

• Finally, it is essential to test and evaluate the program to ensure that it is engaging for the users as well as effective for improving target variables (i.e., as programs address different issues, different target variables should be assessed to evaluate program effectiveness). Evaluation methods to gather feedback can include feasibility studies and user surveys.

The above are considered basic guidelines to consider when developing any metaverse intervention. The proposed programs consider every step described. Both the educational and the clinical programs presented below are based on prior research on FOD [36, 37] and were developed according to effective avatar-based interventions [16]. Similarly, the duration of both interventions was determined based on relevant literature [38].

In order to achieve the goals of each intervention (described below), a virtual environment was created inside the metaverse, in which the participants met virtually with the educator or clinician psychologist in chief. The following images (Figure 1) provide examples of how the metaverse space may be distributed; this space can be adapted to the preferences of each participant.

Figure 1.

A glimpse of two sessions.

As shown in these images, metaverses currently provide a highly realistic representation of the physical world, allowing individuals to engage in similar activities, utilize familiar objects, and exhibit behavior comparable to real life. This enables educational and clinical intervention programs to utilize the same objects and spaces as those found in real-world settings. Programming common stimuli for enhancing stimulus generalization is a strategy used to generalize behaviors. Figure 2 demonstrates how educational content can be presented to participants in a familiar way within the virtual environment, thereby leading to greater generalization.

Figure 2.

Participant accessing educative content through different electronic devices inside the metaverse.

Both images in Figure 2 display actual examples of how participants access educational content within a metaverse. Participants have the comfort of being at home, seated in front of their computer, and utilizing their online avatars to select the remote control of the TV or the stylus pen of the tablet to access the scheduled session. Regarding a clinical intervention, Figures 3 and 4 illustrate how participants may confront various stimuli related to systematic desensitization (a prevalent psychological technique) within the metaverse. Prior to practicing in real life and without the need for attending a physical clinic, participants can use their avatars in a metaverse to confront stimuli.

Figure 3.

Participant exposing herself to the anxiety-evoking stimuli of a couple engaging in sexual stimulation.

Figure 4.

Participant exposing herself to seeing her own naked body, accompanied by her psychologist.

5.1 The educational program for female orgasmic disorder

The majority of sex educational interventions are focused on improving the knowledge of young people on sexual health. Educational interventions typically consist of providing precise information about human sexuality (such as anatomy and human reproduction), teaching communication and assertiveness skills, and assisting young people in cultivating positive attitudes and making responsible decisions [39, 40]. Evidence has demonstrated that this type of intervention is effective in educating younger generations and promoting overall future sexual well-being [39]. However, what about those individuals who already have a sexual disorder? Those that, for example, have not had access to similar programs during their youth due to their age or other factors? Educational interventions can help no matter a person’s age.

As mentioned before, FOD should be a matter of public concern due to its high incidence (i.e., prevalence rates are high) and the distress it causes for the individual and their environment. For these reasons, it is worthwhile to develop an educational intervention program designed explicitly for FOD and adapted to work on a metaverse platform, such as Second Life. The program presented here consists of four, weekly, individual sessions of approximately 60 minutes each. The aim of this educational program is to alleviate subjective sexual anxiety and enhance sexual satisfaction (both of which are significant factors related to the disorder) in women suffering from FOD.

The procedure for each session is uniform. Participants can conveniently access the program from their homes and engage in a secure virtual space. Sessions are scheduled and have fixed durations, but participants are able to access the content and practice at their convenience. At the start of each session, there is a briefing to explain the session to the participant in order to reduce anticipatory anxiety. At the end of each session, there is a debriefing with two objectives: (1) evaluate subjective sexual anxiety and satisfaction levels, and (2) assess if any crucial information is missing from the session, if the participant has any questions, and if the program is achieving its overall objectives. The intervention’s content for each session is presented in Table 1.

Session	Objectives	Content
1	Learn about FOD.	Characteristics.; Prevalence rates of difficulties in getting orgasms.; Causal factors.
	Learn about female sexuality.	Sexual cycle phases.; Desire.; Psychological variables.; The reproductive system.; Genitalia.; Pleasure areas on the body.; Facts and fallacies.
2	Learn information about female orgasm.	What is an orgasm.; Neuronal orgasm.; Factors that may influence consecution.; Sexual response.
3	Learn about masturbation and masturbatory techniques.	Information about the female genitalia (vulva and clitoris’ anatomy).; Key elements to achieve pleasure.; Information about pleasure areas, exploration of the main erogenous zones, and the best way to stimulate them.; Information about the potential benefits masturbation has (e.g., happiness, increased self-confidence, and reduced impact of pain) to help normalize this activity.; Tips on what to do before starting the process, as the environment is as important as the masturbation technique. This includes having the necessary time (having a time limit can generate stress, which blocks orgasm), a comfortable space (the feeling of being secure is a mandatory condition for cerebral endorphins to be released), the importance of position and posture (must be comfortable), and expectations.; Breathing and relaxation techniques.; Kegel exercises (muscle exercises that can enhance sexual sensation and involve repeatedly contracting and relaxing the muscles that form the pelvic floor).
4	Learn techniques to focus attention on one’s body (i.e., an important factor for pleasure).	Information about effective techniques to be able to focus attention on one’s body.; Information about the importance of self-focus and the role it plays in sexuality.; Information about the principles and the key elements of self-focus the participant should consider.; Experiential practices to learn how to employ the techniques of self-focus.
	Psychoeducation about emotions, emotional management, and emotional regulation.	Training in emotional management, to aid in comprehending, embracing, regulating, and conveying emotions more effectively (this helps develop more optimistic and productive ways of responding to positive and negative stimuli in a participant’s surroundings).; Training in emotional regulation to impact which emotions a participant experiences in order to understand how they perceive and express their feelings.; Psychoeducation and management of guilt.; Psychoeducation and management of embarrassment.

Table 1.

Content of the educational intervention in Second Life.

As depicted in Table 1, the different sessions discuss various aspects of sexual health and behavior. Sessions cover physiological and psychological aspects of orgasm and sexual response, including definitions, prevalence rates of difficulties in achieving orgasm, and the factors that may influence it, along with information about female genitalia and how to achieve pleasure. Sessions also delve into factors that affect desire and pleasure and explore misconceptions and myths surrounding sexuality. The topics covered aim to provide a comprehensive guide for individuals looking to explore and enhance their sexual pleasure. This includes the importance of focusing attention on one’s body to experience pleasure during sexual activity, emotional management, and effective techniques for achieving these objectives.

In addition to what is summarized above and included in Table 1, the third session concludes by asking participants to recall the previous session’s content. From there, a discussion is initiated on the topic of pleasure zones (e.g., their personal preferences, what they find enjoyable), providing participants with guidance on the most effective techniques for stimulating these areas. These steps, including the review and conversation about pleasure areas, result in a form of exposure to the anxiety held by participants with FOD. Here, and in the fourth session described below, the metaverse provides a secure environment for participants to practice techniques before attempting them in real life. During the exercises, it is common that different thoughts and emotions arise in the participant, diverting attention away from the body (something that commonly happens during sexual interactions and interferes with the ability to orgasm). Identifying these interrupting emotions becomes an opportunity to learn about the role of emotions in achieving orgasm and to understand the part emotions play in the participant’s life.

The fourth session prepares participants to take their learning outside the educational intervention by working on communication with the participant’s partner (not necessarily a romantic partner, but someone with whom the participant shares a sexual relationship). The goal is for the person to acquire a series of communication skills that culminate in two tasks: (1) informing her partner that she is going to therapy and asking for his/her cooperation, and (2) sharing with her partner a list of pleasure areas identified through the intervention. The session involves planning a conversation with the participant’s partner to accomplish the final two tasks and provides psychoeducation on essential areas for communication, including individual communication and communication within a relationship. If the participant does not have any kind of personal relationship (e.g., a friend or familiar) with whom she can engage in the proposed activities, she can decide whether to discontinue the educational intervention at this point or continue to improve her assertiveness for future relationships.

Among the group of individual communication skills, participants learn about and develop clarity (i.e., being clear and concise in your message), confidence (i.e., speaking with conviction and assertiveness), active listening (i.e., paying attention to what others are saying and demonstrating understanding), empathy (i.e., putting yourself in the other person’s shoes and understanding their perspective), adaptability (i.e., being able to adjust communication style to different situations and audiences), and nonverbal communication (i.e., using body language, facial expressions, and tone of voice to convey meaning). In addition to these individual communication skills, there are unique skills for communication within a relationship. These skills are essential for maintaining a healthy and fulfilling relationship, helping to build intimacy and to overcome challenges together. In terms of communication skills within a relationship, the educational intervention reviews listening actively, expressing emotions in a nonjudgmental and supportive way, using “I” statements instead of “you” statements (i.e., can help to avoid blame and criticism in communication), and being open and honest. A series of role-playing exercises help achieve these objectives and serve both as experiential learning and as a way of exposing the participant to anxiety-evoking situations to reduce anxiety.

Every session tries to be interactive and engaging by including various challenges and games. Examples of the slides, tests, and games are included in Figure 5. The slides, adapted and prepared to be displayed inside the metaverse, are designed (using images from flaticon.com and slidesgo.com) to interact with the user. When participants get an answer right, they receive not only feedback and a brief explanation but also are awarded flags and earn points which can be used to check progress.

Figure 5.

Content examples.

The efficacy of this educational program has been examined through a pilot study of 30 patients diagnosed with FOD. The efficacy was measured through two variables: (1) subjective sexual anxiety (“On a scale of 1 to 10, how much anxiety does this topic make you feel?”), and (2) subjective sexual satisfaction (“Of all sexual behaviors you had this week, how many of them were satisfactory?”). These two subjective variables were monitored every session. Before starting the program, a baseline was established for participants. After the program finished, participants were asked to answer the questions one more time in order to have a post-intervention measure. Figures 6 and 7 show the preliminary results of the intervention achieved by 30 women with FOD. As the graphs show, average subjective sexual anxiety decreased from 9.9 before the intervention to 6.4 after the intervention. Average subjective sexual satisfaction increased from 0 satisfactory sexual behaviors before the intervention to 3.2 after the intervention. Even though future research is still needed, the current study suggests that this metaverse-based educational intervention could be effective for improving sexual well-being in patients with FOD.

Figure 6.

Subjective sexual anxiety.

Figure 7.

Subjective sexual satisfaction.

5.2 The clinical intervention program for female orgasm disorder

As noted earlier, the proposed intervention consists of two distinct programs that can be combined: the educational program described above and a clinical program. While the two programs can be offered separately, merging them provides a complete intervention targeting every important aspect of FOD. The educational program should be completed before beginning the clinical program. This ordering ensures clinical participants have the information needed to confront personal sexual fears, as well as reduced anxiety and increased sexual satisfaction that can work as motivating factors for the clinical program. In this second program, the participant will continue to reduce sexual anxiety and increase sexual satisfaction. At the same time, she will learn how to manage her own dysfunctional thoughts and explores barriers to sexual well-being. Unlike the educational program, the clinical program’s efficacy is yet to be proven, but the sessions described (see Table 2) are based on effective interventions and existent literature on FOD [16, 36, 37, 38].

Session	Main objective	Content
1	Assessment and introduction.	Discuss the goals and expectations of the program.; Begin to explore irrational beliefs related to sexuality.; Begin emotional management training.
2	Identifying and restructuring irrational beliefs.	Review the patient’s irrational beliefs identified in Session 1.; Discuss the impact of these beliefs on sexual well-being.; Work with the patient to restructure irrational beliefs and focus on personal values.; Introduce the concept of systematic desensitization and explain how it will be used in the program.
3	Visual desensitization.	Introduce the concept of visual desensitization.; Patient exposes herself to anxiety-evoking stimuli by visually examining her body excluding genitalia and breasts.; Work with the patient to restructure any irrational beliefs that arise.; Begin to explore the barriers to sexual well-being that are preventing progress.
4	Tactile desensitization.	Introduce the concept of tactile desensitization.; Patient exposes herself to anxiety-evoking stimuli by tactilely examining her body excluding genitalia and breasts.; Work with the patient to restructure any irrational beliefs that arise.; Continue to explore barriers to sexual well-being.
5	Visual desensitization.	Introduce the session, indicating what objectives are to be achieved.; Patient exposes herself to anxiety-evoking stimuli by visually examining her genitalia and breasts.; Work with the patient to restructure any irrational beliefs that arise.; Continue to explore barriers to sexual well-being.
6	Tactile desensitization.	Introduce the session, indicating what objectives are to be achieved.; Patient exposes herself to anxiety-evoking stimuli by tactilely examining her genitalia and breasts.; Work with the patient to restructure any irrational beliefs that arise.; Continue to explore barriers to sexual well-being.
7	Pleasure.	Introduce the concept of pleasure.; Elaborate a list with the pleasure areas identified in previous sessions.; Plan a stimulation program for the week centered on finding pleasure, now that the anxiety has reduced/disappeared.; Create a sketch of items for partner’s desensitization.; Continue emotional management training.
8	Partner involvement.	Systematic desensitization. Exploration with the couple in the following order: (1) visual examination excluding genitalia and breasts, (2) visual examination of the genitalia, (3) tactile examination excluding genitalia and breasts, and (4) tactile examination of the genitalia.; Psychoeducation on sexual positions that guarantee clitoral stimulation.; Work with the patient to identify and restructure any irrational beliefs related to partner involvement.

Table 2.

Content of the clinical intervention in Second Life.

6. Conclusion

In recent years, multiple technologies have been testing their potential to intervene in sexual issues and are showing promising results. Every intervention featured in this book chapter—including app-based, VR, and metaverse interventions—reports effective results across a wide range of sexual issues, from improving the sexuality of young people to fully treating a group of men with premature ejaculation. This chapter offers a metaverse-based, intervention protocol featuring both an educational and a clinical program for one of the most prevalent sexual disorders: FOD. By examining the previous literature about technology-based interventions, analyzing their comparative advantages and weaknesses, and proposing useful tools for educators and clinicians, this chapter extends our knowledge of using technology to effectively intervene in matters of sexual health. We believe that as more people become familiar with these types of interventions, we may see even more innovative interventions developed in the technology field.

Conflict of interest

The authors declare that they have no conflict of interests. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.