Investigating Female Sexual Presence Through Triangulation of

Behavioral and Physiological Measures in Virtual Reality: Towards

Therapeutic Applications for Sexual Disorders

Sara Saint-Pierre Côté

1,2

, Mathieu Brideau-Duquette

2,3

, David Lafortune

, James G. Pfaus

and

Patrice Renaud

2,3

Department of Software and Information Technology Engineering, École de Technologie Supérieure,

1100 Notre-Dame St. W., Montréal, Canada

Laboratoire d’immersion Forensique, Institut National de Psychiatrie Légale Philippe-Pinel, Montréal, Canada

Département de Psychoéducation et Psychologie, Université du Québec en Outaouais, Gatineau, Canada

Département de Sexologie, Université du Québec à Montréal, Montréal, Canada

Department of Psychology and Life Sciences, Charles University, Prague, Czechia

Keywords: Virtual Reality, Sexual Presence, Affordances, Learning, Quantitative Electroencephalography (qEEG),

Vaginal Photoplethysmography, Gaze Behaviour.

Abstract: Exposure to sexual contexts by means of immersive, extended reality technologies, offer an opportunity to

both: better understand sexual responding, and in turn, offers insights as to how the same technology could

help in treating sexual disorders. The present papers reports on the ability of behavioural (i.e., oculometry)

and physiological (i.e., electroencephalography and vaginal plethysmography) to conjointly predict subjective

sexual feelings (i.e., subjective sexual presence), this, using a sample of 12 heterosexual cisgendered women.

Measurements pertained to the participants living a sexual immersion (via a virtual reality headset) with an

opposite sex virtual character engaging in sexually suggestive behaviour. Results suggest that all the tested

behavioural and physiological measurements could play a role in the shaping of sexual presence. Results are

discussed with therapeutic learning processes considerations in mind.

1 INTRODUCTION

Sexual difficulties (e.g., arousal, desire, or orgasmic

disorders) are prevalent, affecting up to a third of

people (Lewis et al., 2010) and impairing their sex

lives and intimate relationships (Brotto et al., 2016;

Caglar et al., 2020; Nappi et al., 2016; Mitchell et al.,

2013). Virtual reality (VR) provides promising new

treatment options for managing these difficulties, and

could assist exposure-based therapy, mindfulness

strategies, and cognitive restructuring (Dubé et al.,

2022; Lafortune, Renaud & Dion, 2020; Lafortune et.

al, 2023a). VR provides a safe, standardized, and

ecologically valid way to elicit emotional, cognitive,

and behavioural responses comparable to those

elicited in real-life situations (Bell et al., 2020). This

could offer patients a new way to safely experience

typically feared or avoided sexual situations, and for

clinicians, a new tool to recreate, closely monitor, and

provide symptom-adjusted exposure to different

levels of sexual explicitness, to decrease the sexual

stimuli’s tendency to trigger the conditioned aversive

response (e.g., performance concerns, pain

catastrophizing), through habituation and extinction

processes. The fictional aspect, controllability, and

versatility of VR, can also facilitate safer exposure in

an environment free from real-world hazards (e.g.,

sexual assault, pressure, or rejection) compared to in

vivo therapy (Lafortune et al., 2023).

VR has shown promise in treating erectile

disorder, premature ejaculation, and female orgasmic

disorder (Optale et al., 1997, 1998, 2003; Vila et al.,

2023), and ongoing studies are currently examining

clinical effects of VR exposure therapy for vaginismus

and sexual aversion disorders (Brown & Brotto, 2023;

Lafortune et al., 2023). Alongside, accumulating data

suggest VR potential to more effectively explore and

assess sexual preference-based response patterns

(Fromberger et al., 2018; Marschall-Lévesque et al.,

2018; Renaud et al., 2013; Trottier et al., 2015).

However, there has been very little research

concerning female sexual response and VR

technologies, as well as the mechanisms that could

694

Côté, S., Brideau-Duquette, M., Lafortune, D., Pfaus, J. and Renaud, P.

Investigating Female Sexual Presence Through Triangulation of Behavioral and Physiological Measures in Virtual Reality: Towards Therapeutic Applications for Sexual Disorders.

DOI: 10.5220/0012754700003693

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 16th International Conference on Computer Supported Education (CSEDU 2024) - Volume 1, pages 694-700

ISBN: 978-989-758-697-2; ISSN: 2184-5026

foster or explain therapeutic changes in VR sex

therapy.

2 RELATED WORKS

2.1 Sexual Presence: Enacting

Affordances in Virtual Intimate

Contexts

The concept of sexual telepresence or sexual presence

(SP) refers to a psychophysiological technologically

induced state of sexual arousal that includes a

subjective erotic perception (Saint-Pierre Côté et al.,

2024; Brideau-Duquette & Renaud, 2023; Milani et

al., 2022). This perception is shaped by the interplay

of individual psychobiological predispositions,

idiosyncratic past experiences, and the sexual

affordances offered by a mediating technology.

Sexual affordance in turn refers to the possibilities

for action that are offered by an environment or

object, which resonate with sexual behaviours and

arousal (Renaud et al., 2013; Renaud et al., 2010).

This concept is grounded in the Gibsonian ecological

approach and the 4E cognition perspective (Gibson,

2014; Newen et al., 2018), suggesting that sexual

behaviours and arousal are influenced by the

affordances perceived in the environment. The

interconnection between sexual presence and sexual

affordance is thus understood in terms of how

environments, objects, or technologies may offer cues

or opportunities that resonate with and potentially

elicit sexual behaviours and responses.

The concept of sexual affordance thus refers to

the qualities or properties of a virtual environment

that suggest possible sexual actions to a person. These

affordances are perceived opportunities for sexual

behaviour that the environment offers, and they are

dependent on the individual's ability to recognize and

enact them.

Enaction is the very process by which an

individual actualizes or carries out these affordances

(Bruineberg & Rietveld, 2014, 2019; Friston, 2022).

When an individual recognizes a sexual affordance in

a virtual environment, she may become sexually

aroused or engaged, leading to a sense of sexual

presence. Sexual presence, again, is the state of being

psychologically and physiologically immersed in a

sexual experience, which is facilitated by the enaction

of sexual affordances.

Integrating this understanding of enaction with

sexual affordance, we can say that the enaction of

simulated affordances contributes to the sense of

sexual presence by allowing individuals to engage

with the virtual environment in a manner that is

meaningful to their sexual behaviours and responses.

This engagement through enaction is what makes the

sexual affordances in virtual environments

compelling and effective for the individual

experiencing them.

The perceptuomotor dynamic coupling between

an individual and the virtual environment's simulated

sexual properties thus leads to the emergence of

specific affordances. The state of sexual arousal

interacts intricately with attentional processes,

allowing for the extraction of critical invariances that

direct sexual behaviour. It is through this enmeshing

of arousal and focused attention that one engages with

the virtual environment, culminating in the

experience of sexual presence. This phenomenon

illustrates not just the recognition of sexual

affordances but their embodiment through enaction,

which in turn reinforces the sense of presence. It is

furthermore a crucial aspect to consider in the

therapeutic learning objectives for treating female

sexual dysfunctions, as it can inform how virtual

environments might be designed to facilitate specific

therapeutic outcomes.

2.2 Neurodynamics of Sexual Presence

At the level of neurodynamics, the understanding of

the enaction of affordances that leads to sexual

presence takes a significant turn by focusing on how

neural circuits synchronize to extract guiding features

from the environment and contexts during attraction,

courtship, and sexual interaction (Saint-Pierre Côté et

al., 2024; Brideau-Duquette et al., 2024; Bruineberg

& Rietveld, 2014, 2019; Pfaus et al., 2023). The

understanding of how neural activation underlies the

recognition and enactment of sexual affordances is

critical. It bridges the gap between the abstract

concept of potential actions within an environment

and the concrete physiological and psychological

experiences of an individual engaging in those

actions. This link is particularly relevant for

addressing sexual dysfunctions, as it provides a

framework for developing therapeutic interventions

that are attuned to the individual's interaction with

their environment, mediated by their neurodynamics.

In this respect, frontal EEG activity, specifically

frontal alpha asymmetry (FAA), is posited as an

indicator of approach or avoidance motivation and

motor inhibition success (e.g., Prause et al., 2014). The

simultaneous considering, in virtual immersion

contexts, of EEG patterns, oculomotor signals, and

measures of physiological sexual arousal highlight

Investigating Female Sexual Presence Through Triangulation of Behavioral and Physiological Measures in Virtual Reality: Towards

Therapeutic Applications for Sexual Disorders

695

complex interrelations (Saint-Pierre Côté et al., 2024;

Brideau-Duquette et al., 2024; Côté et al., 2021;

Renaud et al., 2019). This interplay is particularly

significant as it is encompassed within the broader

subjective phenomenon of sexual presence, suggesting

that the subjective experience of sexual presence is

intricately linked with, and potentially discernible

through, these psychophysiological signals.

Our primary research goal is to elucidate the

intricate dynamics between female sexual arousal and

the sense of sexual presence within virtual reality

environments. By doing so, we aim to operationally

delineate the functional relationships between

therapeutic learning objectives in addressing female

sexual dysfunctions and the impacts elicited by virtual

reality simulations. This foundational step is critical for

precisely mapping the operant conditioning

contingencies inherent to synthetic environments onto

the perceptuomotor and physiological facets of the

organismic response we seek to alter; in turn, said

facets could guide clinical interventions. Our study

begins by examining the synergy between visual-

behavioural indicators, cerebral neurodynamics, and

sexual arousal. It then integrates these elements to

assess their collective influence on the emergence of a

sense of sexual presence.

3 CURRENT EXPERIMENT

The data used for this paper had been collected in a

study in which participants encountered four

immersive conditions wherein a Virtual Character

(VC) engaged in sexually arousing movements. For

the purposes of this paper, our focus is solely on the

initial immersive condition, wherein female

participants found themselves in a bedroom alongside

a VC they had previously customized to embody an

ideal sexual partner.

This study enlisted twelve heterosexual ad

cisgendered women aged between 20 and 30 years,

age

= 23.7 years, SD = 3.92). Each participant was

compensated with 70 CAD for their involvement. The

research obtained ethical clearance from the

Université du Québec en Outaouais, École de

technologie supérieure, and Université de Montréal.

4 MATERIALS AND METHODS

4.1 Modelling and Animation Software

The Unity game engine (Version 2020.3.36, Unity

Software Inc.) was employed to model and render the

virtual environment (VE). The VC utilized in this

environment was obtained from the Genesis 8

collection (Daz3D, Daz Production Inc.). Animation

for the character was achieved through a motion

capture session featuring a male performer, utilizing

eight Prime13 cameras and Motive: Body software

(Version 2.3.1, NaturalPoint Inc.). The animation

production process was made using MotionBuilder

software (Version 2019, Autodesk Inc.).

4.2 Virtual Reality Apparatus

The experiment took place within our laboratory

located at École de Technologie supérieure. The

computer employed was outfitted with an 8GB Nvidia

GeForce RTX 3080 graphics card and an Intel Core i7-

10700K processor, complemented by 32 GB of RAM.

The visualization device utilized was the HTC Vive

Pro Eye HMD.

4.3 Measurements Instruments

4.3.1 Electroencephalography

EEG measurements were obtained using a 32-active

electrode EEG cap adhering to the 10-20 system

(Acticap, Brain Vision). Real-time amplification of

the EEG signal was executed with the ActiChamp

amplifier from Brain Vision and recorded using Brain

Vision's MOVE and Recorder software (Version

1.20.0401, Brain Vision). The online reference point

was established at Cz. EEG sampling rate was set at

500 Hz, and online filtering was implemented,

encompassing a low-pass filter at 1.59 Hz, a high-

pass filter at 70 Hz, and a notch filter at 60 Hz.

Preprocessing of the EEG data was performed using

Analyzer software (Version 2.1, Brain Vision).

Channels deemed noisy upon visual inspection were

excluded from the analysis. Spontaneous and isolated

artifacts unrelated to eye movement were manually

eliminated. Subsequently, all channels were re-

referenced to the mean of the mastoids. Ocular

Independent Component Analysis (ICA) further

contributed to artifact removal, employing the

meaned slope algorithm, the given condition’s

dataset, and the Infomax and sum of squared

correlations methods available in Analyzer.

Components specifically related to horizontal or

vertical ocular artifacts were removed. Frontal alpha

asymmetry (FAA) scores were calculated for F4-F3

and F8-F7 pairs. Prior to computing the asymmetry, a

natural logarithm transformation was applied to

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696

standardize the data distribution, as per Equation 1

(e.g., (Smith et al., 2017)

𝐿𝑁(𝐸𝐸𝐺𝑟𝑖𝑔ℎ𝑡 ) − 𝐿𝑁(𝐸𝐸𝐺𝑙𝑒𝑓𝑡 ) (1)

4.3.2 Vaginal Plethysmography

The vaginal plethysmograph (VPG) is constructed

from transparent acrylic plastic and is designed in the

shape of a menstrual tampon. Integrated into the

device is an infrared light- emitting diode (LED) that

projects light toward the vaginal wall. A portion of

this light is reflected to a phototransistor situated

within the probe, while the remaining light is

expected to disperse through the vaginal tissue;

researchers typically hypothesize that an elevated

amount of returned light to the phototransistor

corresponds to an increase in blood volume in the

vaginal blood vessels (see Prause & Janssen, 2005).

This alteration is quantified as a change in millivolts

(mV) from a baseline value. In this manuscript, we

examine the alternating current, signal, also known as

vaginal pulse amplitude. This signal is believed to

reflect variations in pressure within the blood vessels

of the vascular walls of the vagina. We filtered the

signal with a low- pass filter to remove high

frequency noise. We then computed the mean (M),

standard deviation (SD) and variation coefficient

(VC) of the signal. We also computed the area under

the curve (AUC) of the signal.

4.3.3 Oculometry

Eye movement data were captured using the HTC

Corporation's SRanipal software development kit via

the headset, with a sampling rate of 90 Hz. The eye-

tracking precision of the HTC Vive Pro Eye system

ranges between 0.5 and 1.1 degrees. The Gaze Radial

Angular Deviation (GRAD) is determined by

assessing the angle between two vectors: one

connecting the eye's center to a virtual measurement

point (VMP), and the other representing the

normalized eye direction acquired directly through

SRanipal. In our context, the VMP was located on the

VC. Evaluation of the direction and consistency of

visual search behaviour involves computing the mean

(GRAD Mean) and its standard deviation (GRAD

SD), respectively. The GRAD variation coefficient

(GARD CV) in turn is a standardized measure of

dispersion of a probability distribution or frequency

distribution (SD/AVG). The GRAD’s related

variables were computed offline using a custom

program developed in MATLAB (version R2021B,

The MathWorks Inc., Natick, USA).

4.3.4 Questionnaires

To gain insights into participants' subjective sexual

experiences during virtual exposure, the Sexual

Presence Questionnaire was used (Renaud et al.,

2019), with items adapted for the immersive context

when applicable. It consisted of three questions

gauging realism and seven questions assessing

involvement. The overall subjective presence score

was then determined by summing the scores of these

two subscales.

4.4 Data Analysis

We analysed data focusing on a particular segment of

the animation, specifically when the VC engages in

sexually explicit movements. This sequence unfolds

25 seconds after the VC first appears in the Virtual

Environment (VE) and spans a duration of 30

seconds. We conducted two regression analysis to

predict VPG AUC and Self-Reported Sexual

Presence (SP). This involved leveraging the collected

data from quantitative electroencephalography

(qEEG), vaginal plethysmography (VPG) and

oculometry.

5 RESULTS

To explore potential relationships between the

triangulated variables, bivariate correlations were

computed and are presented in Table 1.

Noteworthy correlations emerged, including a

significant association between Self-reported Sexual

Presence and the AUC of the VPG signal (r = 0.66, p

= 0.021). Additionally, significant correlations were

identified between AUC of the VPG signal and two

other variables of interest: the relative asymmetry in

F8 and F7 in the Alpha band (r = -0.68, p = 0.03) and

the variation coefficient of the Gaze Radial Angular

Deviation (GRAD CV) (r = -0.62, p = 0.03).

In the linear model proposed to predict the AUC

of the VPG signal (Table 2), the relative asymmetry

in F8 and F7 in the Alpha band (β = -0.55, p = 0.019)

and the variation coefficient of the Gaze Radial

Angular Deviation (β = -0.54, p = 0.02) collectively

contribute to explaining 60% of the observed

variance. The residuals of the regression display

linearity are conformed to a normal distribution

(Shapiro-Wilk: p = 0.15) and demonstrate

homoscedasticity.

Investigating Female Sexual Presence Through Triangulation of Behavioral and Physiological Measures in Virtual Reality: Towards

Therapeutic Applications for Sexual Disorders

697

Table 1: Bivariate correlations between AUC of the VPG signal, qEEG relative asymmetry in frontal regions and GRAD

variables.

VPG (AUC)

0.66 *

EEG (F4-F3)

-0.16

0.28

EEG (F8-F7)

-0.44

-0.68 *

-0.17

GRAD (M)

-0.18

0.41

0.09

-0.10

GRAD (SD)

-0.49

-0.12

0.10

0.18

GRAD (CV)

-0.13

-0.62 *

-0.10

0.15

-0.83 **

0.03

VPG (AUC)

EEG (F4-F3)

EEG (F8-F7)

GRAD (M)

GRAD (SD)

GRAD (CV)

Note: *p < 0.05, **p <0. 01, ***p < 0.001.

Table 2: Linear model of predictors of the AUC the VPG

measure (n = 12). 95% confidence intervals reported in

brackets.

SE B

Constant

365.57

3.29

< 0.001

[348.46, 383.01]

qEEG (F8-F7)

-27.96

9.82

-0.55

0.019

[-50.17, -5.71]

GRAD (CV)

-45.38

16.21

-0.54

0.021

[-82.05, -8.70]

Note: R = 0.82, R2 = 0.68, Adjusted R2 = 0.60, F = 9.36, p = 0.006

In the linear model for predicting Self-Reported

Sexual Presence (Table 3), the AUC of the VPG signal

(β = 0.98, p < 0.001), the mean Gaze Radial Angular

Deviation (β = -0.55, p = 0.013), and the relative

asymmetry in F4 and F3 in the Alpha band (β = - 0.38,

p = 0.049) collectively contribute to explaining 73% of

the observed variance in sexual presence. The

residuals of the regression demonstrate linearity,

conformity to a normal distribution (Shapiro-Wilk: p=

0.20), and exhibit homoscedasticity.

Table 3: Linear model of predictors of Sexual presence (n

= 12). 95% confidence intervals reported in brackets.

SE B

Constant

-746.22

147.49

< 0.001

[-1086.34, -406.10]

VPG (AUC)

2.36

0.43

0.98

< 0.001

[1.37, 3.36]

GRAD (M)

-2.82

0.89

- 0.55

0.013

[-4.87, -0.77]

qEEG (F4-F3)

-28.38

12.26

- 0.38

0.049

[-56.65, -0.11]

Note: R = 0.90, R2 = 0.80, Adjusted R2 = 0.73, F = 10.78, p = 0.003

6 DISCUSSION

This study examined the relationships between

genital, ocular, electroencephalographic and sexual

presence scores, all in the context of a VR immersion

with a personalized VC.

The first regression model revealed robust

correlations between gaze behaviour and FAA with the

AUC of the VPG signal. This indicates that a

substantial understanding of female physiological

sexual arousal can be achieved by accessing data on

brain and gaze dynamics during interactions with

sexual virtual content. More specifically, female sexual

preparedness is associated with less gaze dispersion

around the visual object of interest and more

pronounced asymmetrical frontal brain activation.

The second regression model showed even

stronger correlations between psychophysiological

predictors (i.e., VPG, GRAD and FAA) and self-

reported sexual presence, providing insights into how

these variables can predict SP level or the impression

of realism and sexual engagement felt during our VR

simulation.

Examining the coefficients of these factors, we

observe that each of them significantly and

independently contributes to sexual presence scores.

Peripheral genital arousal appears to be strongly

linked with increased sexual presence levels.

Increased radial angular deviation of gaze is

negatively correlated with sexual presence,

impression of realism and sexual engagement,

suggesting that a more focalized attention on critical

cues of the sexual stimulus plays a role in inducing

sexual presence. Finally, frontal alpha asymmetry,

which is posited as an indicator of approach or

avoidance motivation, has a negative coefficient.

That decreased of frontal alpha EEG activity on the

right side relative to the left is associated with

heightened levels of sexual presence seems to go

counter to the “approach/avoid” interpretation of

FAA (i.e., more sexual presence is associated with

“avoidance” FAA). However, the present results fit

with earlier accounts of FAA in sexual contexts

(Prause et al., 2014; Renaud et al., 2019).

Overall, it appears that sexual presence is strongly

associated with a psychophysiological pattern, which

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698

is concordant with the latter partly shaping sexual

presence. What is achieved here with simple statistical

regressions could very well be tapped into with more

predictive and control power by using machine

learning methods (Côté et al., 2021; Galaup et al.,

2024).

Limitations of this study include the small sample

size of participants, which diminishes the statistical

strength of the presented analyses, the correlational

statistical approach which prevents causal inferences

about SP, and the relative lack of diversity (i.e.,

heterosexual and cisgender) within the sample.

7 CONCLUSION

A key insight to retain here in terms of learning

pertains to the importance of focused attention in the

enacting of affordances. The observed negative

correlation between gaze dispersion and sexual

presence underscores the potential of attention

training in sex therapy protocols. Techniques that

enhance the ability to focus on sexual stimuli could

aid in improving sexual response and functioning.

Training modalities could include mindfulness-based

practices or attention control exercises designed to

reduce cognitive distractions and increase mental

presence during sexual activity.

The significance of visual-behavioural indicators

also points towards the utility of cognitive-

behavioural techniques. Such interventions can help

in restructuring cognitive patterns, managing

maladaptive attentional strategies or biases, and

reduce (experiential) avoidance behaviours that may

hinder sexual arousal. By focusing on the cognitive

and behavioural components of sexual response,

therapists can work with patients to develop healthier

sexual attention and engagement patterns.

Neurofeedback emerges as another promising

avenue for treatment, given the relationship between

frontal alpha asymmetry and sexual presence. This

method could enable individuals to gain control over

their brain activity, potentially leading to improved

sexual arousal patterns. By providing real-time

feedback on brain wave patterns, VR-mediated

neurofeedback could help patients learn to modulate

their physiological responses in ways that may

enhance sexual engagement and satisfaction.

The integrative nature of sexual arousal, as

revealed by the study, implies that a combination of

physiological and psychological strategies may yield

the best treatment outcomes. Incorporating VR

technology into therapy could simulate intimate

situations, allowing patients to navigate and manage

their responses to sexual stimuli within a controlled,

therapeutic setting. This could be particularly useful

for exposure therapy and the practice of skills learned

through other treatment modalities.

Lastly, the potential for data-driven treatment

approaches based on machine learning applications,

could be a game changer to the field (Côté et al.,

2021; Galaup et al., 2024). These methods offer the

prospect of developing predictive models that tailor

interventions to the unique psychophysiological

profile of everyone, optimizing treatment outcomes

and leading to more nuanced and effective therapies.

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