# Check — The Physiology of Arousal and Desire

Checked 2026-10-19. 66 claims checked; 20 corrected; 8 softened or attributed to the course; 0 removed. All four writer `[fixed]` corrections of the deck confirmed and kept; all seven `[+]` additions confirmed. Every pharmacological claim checked against the current FDA label on DailyMed (Vyleesi, Addyi) or the label text for carbidopa-levodopa. Length brought from 3411 to 3250 words (`wc -w`, headings included; 3117 words of read-aloud paragraph text) by cutting connective tissue only; every named drug, model, figure, study and book remains. Spelling converted to American (behaviour, labelled, counselling, centre, signalling, formalises, practising, millilitres). Lecturer never named; first-person clinical opinions attributed to "the lecturer" or "the course". Markup intact: one `##` per slide (16), two `? ` prompts (the closing one verbatim from class.json), one `> ` quotation (33 words, verbatim from deck slide 39), no lists.

## Corrections (script changed)
- Slide 2: "45 percent said manual stimulation of the genitals by a partner counted. 71 percent said oral stimulation did. 80.8 percent counted anal intercourse" → "45 percent said manually stimulating a partner's genitals counted, 48 percent when receiving it. 71 percent said performing oral sex did. 81 percent counted anal intercourse." Sanders et al. 2010, Sexual Health 7(1):31–34: n=486 (204 men, 282 women), aged 18–96, Indiana RDD telephone survey; manual-genital 44.9% given / 48.1% received; oral-genital 71% performing / 73% receiving; penile-anal 81% (abstract: "one in five said no"; the deck's 80.8 is consistent but not confirmable without the full text). The script's "by a partner" pointed at the received figure (48%), not 45%. Sources: https://scholars.uky.edu/en/publications/misclassification-bias-diversity-in-conceptualisations-about-havi/ ; https://sciencedaily.com/releases/2010/03/100304072713.htm ; doi:10.1071/SH09068
- Slide 4: "published by Perelman in 2006" → "published in 2009". The citable paper is Perelman MA, "The Sexual Tipping Point: a mind/body model for sexual medicine," J Sex Med 2009;6:629–632 (doi:10.1111/j.1743-6109.2008.01177.x). The 2006 J Sex Med paper the deck seems to mean ("A new combination treatment for premature ejaculation: a sex therapist's perspective," PMID 17100933) is about PE and its abstract does not mention the tipping point. Sources: https://en.wikipedia.org/wiki/Michael_Perelman_(psychologist) ; https://tau.amegroups.org/article/view/11164/11777 (ref. 5) ; https://vivo.weill.cornell.edu/display/pubid17100933
- Slide 7: "Hyperpigmentation ... in about 1 percent of participants in the initial studies and as many as 38 percent in later ones" → "about 1 percent at that dosing, in 38 percent of those dosed daily for eight days". Label §5.2: 1% with up to 8 doses/month; 38% after daily dosing for 8 days (a further 14% after 8 more days); may not resolve. Source: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f1d0c1b5-2f39-4bad-a6a4-0066e3ad5dcf
- Slide 7: "25 percent improved in sexual function and satisfaction, against 17 percent on placebo" → "about 25 percent had a meaningful rise in desire score against 17 percent on placebo; satisfying sexual events did not increase". The 25%/17% is the FDA's responder figure for a ≥1.2-point rise in the FSFI desire domain (distress: 35% vs 31%); label §14 reports no significant difference in satisfying sexual events. Sources: label §14 ; https://www.healio.com/news/endocrinology/20190621/fda-approves-vyleesi-for-women-with-low-sexual-desire
- Slide 7: dosing made label-exact: "1.75 milligrams in 0.3 milliliters ... at least 45 minutes before ... no more than once in 24 hours and 8 times a month"; nausea given as the label's 40% (vs 1% placebo). Source: label §2.1, §3, §6.1
- Slide 7: "It should not be used in pregnancy, breastfeeding or by anyone hoping to conceive, and because it can worsen cardiac disease it is contraindicated in uncontrolled hypertension and known cardiac disease" → "The label advises against it in pregnancy, the course also while breastfeeding or trying to conceive, and because it raises blood pressure after each dose it is contraindicated in uncontrolled hypertension and known cardiovascular disease". Label §4 lists only uncontrolled hypertension and known cardiovascular disease; pregnancy is "not recommended" (§8.1, contraception advised), not a contraindication; §5.1: transient +6/+3 mmHg peaking 2–4 h. Source: label
- Slide 7: Semax "derived from adrenocorticotropic hormone ... another melanocortin analog" → "a seven-amino-acid fragment analog of adrenocorticotropic hormone used in Russia ... another melanocortin-related agent". Met-Glu-His-Phe-Pro-Gly-Pro = ACTH(4-7)+Pro-Gly-Pro; registered in Russia 1994, not FDA-approved. Sources: https://en.wikipedia.org/wiki/Semax ; https://www.sigmaaldrich.com/US/en/product/sigma/s8826
- Slide 7: setmelanotide "rare familial forms of obesity" → "rare genetic obesity caused by faults in melanocortin signaling" (Imcivree: POMC/PCSK1/LEPR deficiency Nov 2020; Bardet-Biedl June 2022; MC4R agonist). Sources: https://Drugs.com/history/imcivree.html ; https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/213793s009lbl.pdf
- Slide 8: deck's "available over the counter" (writer had already dropped it) → "in the United States it is prescription-only, the nasal sprays compounded". No FDA-approved intranasal oxytocin; compounded 503A product by prescription only. Sources: https://www.compoundingfinder.com/medications/oxytocin ; https://www.empowerpharmacy.com/drugs/oxytocin-nasal-spray
- Slide 8: receptors in "the olfactory nerves" → "the olfactory bulb" (OXTR mRNA documented in rodent and human olfactory bulb). Sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC9851403 ; https://www.frontiersin.org/articles/10.3389/fnbeh.2022.983421
- Slide 9: "Endocannabinoid levels drop during arousal" → "In a small study of women, circulating endocannabinoid levels fell as arousal rose" (Klein et al. 2012, J Sex Med, n=21, erotic film; arousal associated with decreases in anandamide and 2-AG). Source: https://www.cannabisclinicians.org/2012/06/01/circulating-endocannabinoid-concentrations-and-sexual-arousal-in-women/
- Slide 9: "the drug's federally illegal status" → "federal prohibition in the United States" (still accurate: as of October 2026 only a narrow April 2026 rule moved FDA-approved and state-medical products; general Schedule I→III rescheduling is pending after the June 29–July 15, 2026 hearing). Source: https://www.morganlewis.com/pubs/2026/09/high-time-for-a-change-post-dea-hearing-broader-marijuana-rescheduling-questions-remain
- Slide 9: tobacco "microvascular disease" → "vascular disease" (smoking causes endothelial dysfunction and penile arterial atherosclerosis; not solely microvascular). Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC5086781
- Slide 10: "flibanserin was developed to increase desire through them" → "first developed as an antidepressant, was repurposed to increase desire through them" (Boehringer Ingelheim antidepressant program; Sprout). Source: https://drugs.ncats.io/drug/37JK4STR6Z
- Slide 10: "Fatigue and sleepiness occur in 21 percent" → "dizziness and sleepiness each affected about 11 percent, fatigue 9". Label Table 2 (premenopausal): dizziness 11.4%, somnolence 11.2%, nausea 10.4%, fatigue 9.2%; hypotension 0.2%, syncope 0.4%. The deck's 21% appears to be somnolence plus fatigue summed. Source: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3819daf3-e935-2c53-c527-e1d57922f394
- Slide 10: "The course lists pregnancy and liver disease as contraindications, and alcohol must be avoided" → "the label contraindicates it in liver impairment and with moderate or strong C Y P 3 A 4 inhibitors, requires alcohol be kept hours from the dose, and the course also counsels against it in pregnancy". Label §4: hepatic impairment; moderate/strong CYP3A4 inhibitors; hypersensitivity. Boxed warning on alcohol; since the April 2019 label change the rule is wait ≥2 h after 1–2 drinks or skip the dose after ≥3. Pregnancy: no human data, not a contraindication. Sources: label ; https://www.drugtopics.com/view/flibanserin-addyi-issued-label-change
- Slide 10: "0.5 more sexually satisfying events per month and a 0.3 point rise" → "half to one more satisfying sexual event per month and a 0.3 point rise". Jaspers et al. 2016 (JAMA Intern Med, doi:10.1001/jamainternmed.2015.8565): +0.49 SSE/month, +0.27 FSFI desire; label trials individually +0.6 to +1.0 SSE and +0.3 to +0.4 FSFI desire. Source: https://mdedge.com/content/review-shows-small-benefit-significant-safety-concerns-flibanserin ; label §14
- Slide 15: Pussy Prayers author named ("by Black Girl Bliss, a collective of Black women educators"; Hay House). Source: https://www.goodreads.com/book/show/42439662
- Slide 15: Gromko "a transgender-health specialist practising in Seattle" → "a Seattle family physician specializing in transgender health" (board-certified family physician, Queen Anne Medical Associates, Seattle; book 2015). Sources: https://kcmsociety.org/author/gromkolinda/ ; https://audible.fr/pd/Wheres-My-Book-Livre-Audio/B0971MF59T
- Throughout: American spelling; `[+]` and `[fixed]` markers removed.

## Softened or attributed to the course
- Slide 6: "Peripherally it constricts most vessels while increasing blood flow to the erectile tissue of the penis and the clitoral-urethral complex" → vessels/heart/pupils stated as fact; the erectile-blood-flow claim attributed ("the course also credits it with...") and qualified ("though alpha-1 tone is what keeps the penis flaccid"). Standard physiology: norepinephrine via postsynaptic α1 receptors on cavernosal smooth muscle is the antierectile sympathetic signal; Meston's work supports moderate sympathetic activation facilitating women's genital arousal. Sources: https://www.nature.com/articles/3900348 ; https://labs.la.utexas.edu/mestonlab/the-sympathetic-nervous-system-and-womens-sexual-arousal/
- Slide 6: yohimbine "given alone by intracavernosal injection" → "the course notes it can be ... given by intracavernosal injection". No clinical study of intracavernosal yohimbine found (only rabbit data in patent filings); clinical intracavernosal agents are alprostadil, papaverine and phentolamine. Source: https://findanexpert.unimelb.edu.au/scholarlywork/1384435-erectile-dysfunction--a-global-review-of-intracavernosal-injectables
- Slide 7: off-label bremelanotide for PDE5-failure ED attributed to the course; supported by Safarinejad 2008 (intranasal 10 mg, n=342 sildenafil non-responders, 33.5% vs 8.5%). Source (secondary): https://synapse.patsnap.com/drug/bee0542e9cee48829f49341d048dda2c
- Slide 7: breastfeeding/conception advice attributed to the course (label: no lactation data; contraception advised).
- Slide 8: "one spray in each nostril ... moderate efficiency" attributed to the course (the Quintana review discusses dosing and nose-to-brain routes without this summary).
- Slide 8: "Pregnancy and hypertension are contraindications" → "the course lists ..." (off-label compounded product; no label).
- Slide 10: pregnancy as a flibanserin contraindication attributed to the course (see above).
- Slide 9: endocannabinoid finding hedged to one small study (see above).

## Verified (unchanged)
- Writer `[fixed]`: L-Dopa is a dopamine precursor (decarboxylated to dopamine); carbidopa-levodopa label warns of intense urges including increased sexual urges/hypersexuality, hallucinations and orthostatic effects. Source: https://medlibrary.org/lib/rx/meds/carbidopa-and-levodopa-31/page/3/
- Writer `[fixed]`: yohimbine from the bark of Pausinystalia yohimbe (johimbe), native to West and Central Africa (Cameroon, Gabon, Congo, Nigeria), not Southeast Asia; α2-adrenergic antagonist. Sources: https://www.ncbi.nlm.nih.gov/books/NBK548703/ ; https://en.wikipedia.org/wiki/Yohimbine
- Writer `[fixed]`: setmelanotide, not bremelanotide, is the melanocortin agonist approved for rare genetic obesity (above).
- Writer `[fixed]`: Emily Nagoski, Come As You Are (deck: Nagowski).
- Writer `[+]`: medial preoptic area lies in the rostral (anterior) hypothalamus; bremelanotide/melanocortin agonists act on MC4R in the mPOA to increase dopamine release (Pfaus, Giuliano, Gelez 2007 review). Sources: https://www.medchemexpress.com/publications/17958619.html ; https://www.cambridge.org/core/journals/cns-spectrums/article/neurobiology-of-bremelanotide-for-the-treatment-of-hypoactive-sexual-desire-disorder-in-premenopausal-women/CB2718A94BC8F52E562867A0F1689B15
- Writer `[+]`: Risperdal is risperidone; risperidone is prolactin-raising with high sexual-dysfunction rates; thioridazine in the 40–60% range; quetiapine lower (16–27%). Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10479492/
- Writer `[+]`: yohimbine's target is the presynaptic α2 autoreceptor mediating negative feedback on norepinephrine release (above).
- Writer `[+]`: oxytocin synthesized in the paraventricular and supraoptic nuclei of the hypothalamus, released from the posterior pituitary; receptors in brain, myometrium, mammary myoepithelium. Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9851403
- Writer `[+]`: flibanserin is a 5-HT1A agonist and 5-HT2A antagonist (label §12.2; moderate antagonism at 5-HT2B, 5-HT2C, D4); Stahl's "less serotonin, more dopamine and norepinephrine in prefrontal cortex" (rat microdialysis) is presented as "thought to be". The script keeps the writer's choice not to read receptor subtypes aloud. Sources: Addyi label ; https://pubmed.ncbi.nlm.nih.gov/25659981/
- Writer `[+]`: Addyi 100 mg once daily at bedtime; discontinue after 8 weeks without improvement. Source: label §2
- Writer `[+]`: PLISSIT by psychologist Jack S. Annon; four tiers permission / limited information / specific suggestions / intensive therapy. 1974 holds: The Behavioral Treatment of Sexual Problems, vol. 1 Brief Therapy, Honolulu, ©1974 (the JSET article is 1976). Sources: https://content.www.wellcomecollection.org/works/ydx7xwgz ; https://en.wikipedia.org/wiki/PLISSIT_model
- Slide 3: Masters and Johnson four phases (excitement, plateau, orgasm, resolution; Human Sexual Response 1966, laboratory work from 1957); Kaplan added desire; Basson circular model with responsive desire (c. 2000–2001). Sources: https://contemporaryobgyn.net/view/cme-redefining-female-sexual-response ; https://core.ecu.edu/vailsmithk/HLTH2050/Readings/Kaplan.html
- Slide 7: Vyleesi approved June 21, 2019 for acquired, generalized HSDD in premenopausal women; melanocortin receptor agonist. Sources: Healio (above) ; label
- Slide 7: estradiol raises α-MSH in hypothalamic regions tied to female sexual behavior; melanocortin agonists increase solicitation in female rats. Sources: Pfaus 2007 review (above) ; https://pubmed.ncbi.nlm.nih.gov/17113634/
- Slide 8: Quintana DS, Lischke A, Grace S, Scheele D, Ma Y, Becker B. Mol Psychiatry 2021;26(1):80–91 (six authors; "and colleagues" is right). Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815514/
- Slide 8: intranasal oxytocin for anorgasmia — evidence is one case report (IsHak 2008, J Sex Med) and a small couples study (Behnia 2014, Horm Behav, n=58, 24 IU: no change in drive/arousal, small effects on orgasm intensity); "very limited" stands. Sources: https://www.ovid.com/journals/jsmed/pdf/01222926-200804000-00040~male-anorgasmia-treated-with-oxytocin ; https://www.psychologie.uni-freiburg.de/abteilungen/psychobio/team/publikationen/behia_heinrichs
- Slide 9: chronic opioids → hypogonadism, ED, low desire; methamphetamine → raised libido with ED; alcohol dependence → sexual dysfunction in 40–95%; smoking → ED. Sources: https://pubmed.ncbi.nlm.nih.gov/25336765/ ; https://brieflands.com/journals/ijhrba/articles/22002 ; https://pmc.ncbi.nlm.nih.gov/articles/PMC5086781
- Slide 10: SSRIs raise serotonin, reduce desire and inhibit orgasm; serotonin inhibits dopamine release (deck's mechanism, consistent with Stahl).
- Slide 13: quotation is verbatim from deck slide 39 and is 33 words.
- Slide 15: A Lover's Pinch: A Cultural History of Sadomasochism, Peter Tupper, 2018 (Rowman & Littlefield). Where's My Book? A Guide for Transgender and Gender Non-Conforming Youth, Their Parents, & Everyone Else, Linda Gromko MD, 2015. Great Sex, Michael Castleman. Sources: https://www.goodreads.com/book/show/37512981 ; https://audible.fr/pd/Wheres-My-Book-Livre-Audio/B0971MF59T
- Slide 16: closing question matches class.json verbatim.

## Could not verify (softened or removed)
- Slide 4: "Perelman 2006" (deck slide title) — replaced with the 2009 J Sex Med paper; Perelman dates the model's development to the 1990s.
- Slide 5: "a 2018 lecture by Pfaus" on menopause — a lecture slide, not checkable; left as the course's borrowed schematic.
- Slide 6: intracavernosal yohimbine monotherapy — attributed to the course (no clinical literature found).
- Slide 6: norepinephrine increasing erectile blood flow — attributed and qualified (contradicts standard α1 physiology for the penis).
- Slide 2: the deck's 80.8% for anal intercourse — abstract and press give "one in five said no" / 81%; 81 used.
- Slide 8: oxytocin "one spray each nostril, moderate efficiency" and its pregnancy/hypertension contraindications — attributed to the course.
- Nothing removed for verification reasons. Cut for length only: "If this already feels like a lot, the second half offers a starting point" (slide 2), "After a break and questions, the lecture returns to the consulting room" (slide 11), "The intervention has a structure" (slide 11), and "The course suggests three domains" (slide 14, folded into the preceding slide's last sentence).

## Beats changed
- None. All 16 subjects checked against the envelope: every subject ends with an explicit no-text/no-labels clause; no likeness of a real person; no nudity, restraints, blood or minors; the two human-figure beats (11, 13) are clothed, seated and composed with the portrait-face clause; anatomical beats (5, 6, 8, 9) depict structures, not symptoms. Beat 6 (penile shaft in transverse section) is a histological atlas plate in the series' established register; beat 7's autoinjector is unmarked and beat 4's speedometer is blank of numerals.

## For the editor's attention
- Slide 6, norepinephrine: the deck says it increases blood flow to erectile tissue. In standard physiology norepinephrine at α1 receptors on cavernosal smooth muscle is the antierectile signal (sympathetic tone keeps the penis flaccid; intracavernosal α-blockers produce erection). Meston's work does support moderate sympathetic activation facilitating women's genital arousal. The script now attributes the claim to the course and adds the α1 qualifier; the lecturer may prefer to reword the slide.
- Slide 6, yohimbine by intracavernosal injection: no clinical evidence found. The intracavernosal α-blocker in actual use is phentolamine (with papaverine and alprostadil). Consider swapping on the slide.
- Slide 4, Perelman: the slide title "Perelman 2006" is unsupported; the model's paper is 2009. If the lecturer has a 2006 source for the STP figure (possibly the PE paper's figure), the year can be restored.
- Slide 3, Kaplan: her model is triphasic (desire, excitement, orgasm), merging excitement/plateau and dropping resolution; "added desire" is the common simplification and was left.
- Slide 7, Vyleesi efficacy: the 25%/17% figure is the FSFI-desire responder rate; the trials showed no increase in satisfying sexual events. This strengthens rather than weakens the lecturer's "juice not worth the squeeze" point.
- Slide 7, Vyleesi pregnancy: "not recommended" with contraception advised, not a formal contraindication; the course's stronger advice is attributed.
- Slide 7, Semax: unapproved in the US (Russian registration); listing it beside approved drugs could read as endorsement. Now flagged "used in Russia".
- Slide 10, Addyi 21%: not a label figure; looks like somnolence 11.2% + fatigue 9.2%. Corrected to the label's per-reaction rates. The 2019 label change relaxed the alcohol contraindication to a timing rule; the boxed warning remains. The script does not mention the REMS, so its current status was not checked.
- Slide 10, Addyi effect size: pooled 0.49 SSE/month (Jaspers) vs 0.6–1.0 in the individual label trials; script says "half to one". ISSWSH disputed the Jaspers analysis.
- Slide 8, oxytocin: the deck's "over the counter" is wrong for the US (prescription-only, compounded). "Olfactory nerves" changed to "olfactory bulb".
- Slide 9, cannabis: "federal prohibition" is accurate as of 2026-10-19 but the general Schedule III rulemaking is live; revisit if a final rule lands before recording.
- Slide 9, endocannabinoids: Klein 2012 (decrease with arousal) and Fuss 2017 (2-AG rises at orgasm) point in different directions; the script hedges to "a small study of women".
- Slide 5, antipsychotics: quetiapine is the most prolactin-sparing of the three named, with the lowest sexual-dysfunction rates; "each can substantially blunt" is the deck's wording and was left.
- Slide 12, PLISSIT year: book 1974, journal article 1976; many secondary sources cite 1976. 1974 kept as defensible.
- TTS spellings: "C Y P 3 A 4" (slide 10) and "functional M R I" (slide 4) follow the writer's "P D E five" convention; check they read naturally in the rendered audio.
- Slide 15, Gromko: Queen Anne Medical Associates went telehealth-only in 2024; "Seattle family physician" remains accurate.