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Persistent Sexual Arousal Syndrome

Persistent sexual arousal syndrome (PSAS) was identified by Sandra Leiblum, a sex therapist and professor of psychiatry, in the year 2001 at the Robert Wood Johnson Medical School in New Jersey. Sandra described women from all age groups who were physically, yet not psychologically aroused. For example; a 36-year old mother with 3 children under the age of 6 found herself having to stimulate herself to orgasm in sets of 6. Another person involved an 81-year old, whose arousal had started 6 years before after a hysterectomy.

Some women developed the syndrome after taking antidepressant medication. One woman said it began after she experienced a bad fall. Others said it began after childbirth, or the onset of menopause.

The syndrome is apparently rare and doctors estimate it affects thousands of women. It also appears to violate one of the basic elements of human sexuality, our ability to control our sexual lives. PSAS makes desire irrelevant and strips away all psychological pleasure from sex, leaving only the mechanics of arousal.

No single, particular area of the brain is responsible for sexual response and a lot remains unknown about the process. Yet when the vagina or the clitoris is stimulated sensory impulses travel up the person's spinal cord to their sensory cortex. The brain interprets the sensations and sends out commands that produce increased heart rate, blood flow, and lubricate the vagina.

Distinguishing Features of PSAS

Leah Millheiser, Director of Female Sexual Medicine at Stanford University Medical Center in California has a dozen patients with the disorder. Leah states, "It's most likely some kind of nerve dysfunction, but we don't know why." The distinguishing features of persistent sexual arousal syndrome (PSAS) include:

  • The physiologic signs of persistent arousal are experienced by the person as intrusive, uninvited and unwanted.
  • Psychological responses characteristic of sexual arousal persist for hours to days and do not subside on their own completely.
  • Signs of physiologic arousal do not resolve with regular orgasmic experience and might require multiple orgasms over hours or days to remit.
  • The physiologic signs of arousal may be triggered not only by sexual activity but also by apparently non-sexual stimuli or no stimuli at all.

Psychological Considerations of PSAS

The experience of PSAS for a woman is not related to demographic concerns such as age, childhood experiences, socioeconomic level, education level, marital status, or family history. The distinguishing characteristics are genital and breast vasocongestion and sensitivity with little to no relief from orgasmic experience. The arousal is not related to sexual desire or excitement. PSAS may be triggered by sexual or non-sexual stimuli or no apparent stimuli whatsoever and is generally undesired.

Chart showing emotional consequences of PSAS
Chart showing emotional consequences of PSAS
Life with PSAS is a unique experience for each person. Every woman with PSAS and her partner endures an individual experience. Their initial reaction to PSAS might be confusion and a lack of understanding; they may be unable to access health care, and experience difficulties with people who confuse the syndrome with hypersexuality. They may experience embarrassment or shame, feelings of personal distress and self-blame, invalidation, and feelings of withdrawal and isolation. A person with PSAS may also experience a lack of support from family members and friends, anger, frustration, and a decline in the quality of their life. Long-term emotional consequences of living with PSAS exist. The consequences include:
  • A feeling of a lack of normalcy
  • A continued sense of shame and isolation
  • Being awakened in the morning by hot flashes
  • Feelings of helplessness, vulnerability and sadness
  • Disruptions in occupational, educational and social functioning

To cope with PSAS it is important to recognize that it is a couple's issue. It is important for the person with PSAS to communicate with their partner and to overcome shame and pursue appropriate treatment and support. The person with PSAS must act as an educator.

Biologic Aspects of PSAS

Physiologic sexual function requires mind, relationships, and body - to include hormones, nerves and genital blood flow. The classification of female sexual dysfunction is based on the sexual response; desire leads to arousal which leads to orgasm, satisfaction and resolution. Sexual dysfunctions are defined as disorders of desire, arousal and orgasm.

Sexual dysfunctions in women are complicated, multidimensional, interrelated and have a wide overlap among the dysfunctions of desire, arousal and orgasm. Sexual dysfunctions that are considered treatable are associated with personal distress related to the sexual dysfunction in terms of dissatisfaction, anger, distress, frustration, embarrassment, guilt, inadequacy, inferiority, stress, regret, unhappiness and worry. In management of female sexual dysfunction, a 70% success in management may be anticipated using sex therapy, physical therapy, hormone therapy, medical therapy and vasodilator therapy.

Chart showing common sexual dysfunctions for women
Chart showing common sexual dysfunctions for women
Unfortunately, the success rate does not yet apply to women who experience persistent sexual arousal, although an increased understanding of the syndrome has found a number of women realizing improvement. Epidemiologically the most common sexual dysfunctions for women include:
  • Pain during sex
  • Lack of interest in sex
  • Trouble with lubrication
  • Lack of pleasurable sex
  • Inability to achieve orgasm

PSAS is not reported frequently enough to be included in national surveys on women's sexual health. It remains unknown how often women complain of persistent arousal, although it is thought to be rare.

Pharmacology and PSAS

Sexual arousal involves the release of chemical into a person's genital tissue that induces genital smooth muscle relaxation. Medication has the ability to inhibit contraction or enhance relaxation of the smooth muscles of the genitals. If there is persistent pharmacologic-induced inhibition of contraction or enhanced relaxation of the person's labial, clitoral, or vaginal smooth muscle the result would theoretically be PSAS. Several people with PSAS have the syndrome based on exposure to certain medication. One medication in particular is trazodone.

Persistent and painful clitoral engorgement has been reported as secondary to use of trazodone. PSAS has been observed as secondary to trazodone use. Based on successful resolution it is recommended for people with PSAS to discontinue using trazodone.

Women with PSAS share common features related to the syndrome. The most common feature is the torment and ruling of their lives by persistent sexual arousal. There is a feeling of despair in part because the medical community fails to recognize the existence of the syndrome and because people feel that they will have to live the rest of their lives with PSAS. One woman stated, "Sitting is unbearable, sometimes causing pressure to orgasm. Standing is the only time I feel nothing. Sitting in a car is torture. The opening of the vagina is just as sensitive and a mere touch will bring me to orgasm. My husband is very sympathetic and relieves the terrible pressure anytime I ask. Those close to me that I've told about this at first think it's funny and then realize that indeed it is not."

Another woman with PSAS said, "I was constantly feeling overwhelming sensations of sexual arousal, which were purely physical and not accompanied by romantic or sexual fantasies. Basically I felt the need to have repeated orgasms which was never relieved by normal orgasmic experience. I was so uncomfortable I thought about jumping off the roof just to make it go away."




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