1 Introduction

1.1 Sexuality and influential psychological variables

Sexuality is one of our society’s great forgotten areas; estimated prevalence studies report that between 40 and 70% of adults worldwide get a sexual problem in their lives (Pukall and Bergeron 2021; Hendrickx et al. 2019; Sutherland et al. 2019; Lewis et al. 2010; Mitchell et al. 2012a; Hayes et al. 2006) rendering sexual dysfunctions twice as common as depression (Gelenberg 2010). However, despite the high prevalence rates, and the effectiveness of psychosexual treatments, people do not seek help, mostly because of stigma. As a result, sexual dysfunctions frequently go untreated, leading the affected individuals to experience a diminished quality of life (Kohn et al. 2004; van Ameringen et al. 2017).

Sexual health is indeed strongly related to physical and psychological well-being. A person with a full and satisfying sex life may be less affected by medical conditions, such as certain cancers and fatal coronary events (Ebrahim et al. 2002; Brody and Preut 2003; Costa and Brody 2012; Rider et al. 2016; Smith et al. 1997; Lee et al. 2016), and report areduced risk to suffer from depression (Steptoe et al. 2015; Mezones-Holguin et al. 2011; Pastuszak et al. 2013; Mitchell et al. 2012). In this sense, promoting a healthy sexuality is as important as treating disorders (WHO 2022). When talking about sexuality, it is indeed crucial to implement not only tertiary prevention (e.g., interventions for treating sexual dysfunctions)- focused on mitigating the adverse effects of a sexual problem by restoring functionality- but also emphasize primary and secondary prevention measures, aimed at preventing the onset of a disease (e.g., interventions to promote sexual well-being) and to detect early symptoms, respectively (Rosberger et al. 2015).

Several variables may play a significant role in the promotion of sexual well-being, as well as in the development and treatment of sexual disorders (Brotto et al. 2016). One is body image (Gomes and Tavares 2019; Pavanello Decaro et al. 2021; Shepardson and Carey 2016; Nobre and Pinto-Gouveia 2008). The individual's perception of their own body may indeed influence both the behavioral (e.g., sexual avoidance) (La Rocque and Cioe 2011; Pascoal et al. 2019) and cognitive dimensions of sexuality (e.g., sexual esteem, sexual desire, and sexual satisfaction) (La Rocque and Cioe 2011). Individuals with high body dissatisfaction may, in fact, worry excessively about how their bodies look to their partners, fearing to be judged, and reporting great self-awareness about certain physical features perceived as undesirable. This can lead to cognitive distraction during sexual intercourse (Silva et al. 2016; Pascoal et al. 2012; Carvalheira et al. 2017; Nobre and Pinto-Gouveia 2008). As a consequence, the focus on positive sexual experiences and sensations is compromised (Peixoto and Ribeiro 2022), increasing the risk of developing sexual anxiety and sexual disorders (Curran 2003). An alternative hypothesis could be associated with the idea that individuals might be caught in a cycle of reinforcement that confirms their negative bodily perceptions, thereby constraining opportunities for experiences that could potentially confront them (La Rocque and Cioe 2011). For instance, an individual who perceives their body as unattractive may entirely avoid engaging in sexual encounters, thus restricting opportunities to participate in experiences where a sexual partner might provide affirmation of their desirability. Lastly, concerns regarding one's physical appearance may block sexual arousal, thereby attenuating the gratification or enjoyment derived from sexual activity, including the attainment of an orgasm (Quinn-Nilas et al. 2016). This may lessen the motivation to engage in subsequent sexual activity, and culminate in a pattern of sexual avoidance, sexual inadequacy, or diminished sexual esteem. As a consequence, the individual fails to derive the expected pleasure and fulfillment linked to sexual intimacy, and may opt for sexual abstinence (La Rocque and Cioe 2011; Pavanello Decaro et al. 2021).

Other relevant variables in the promotion and treatment of sexuality are sexual self-esteem and sexual communication (Vila et al. 2023a). A multilevel meta-analytic review found self-esteem to be strongly associated with sexual functioning (Sakaluk et al. 2019). Self-esteem and self-confidence may indeed lead individuals to feel comfortable and confident in their bodies, rendering it easier to express their desires, boundaries, and concerns in sexual situations. This transparency in communication may strengthen emotional bonds with partners, eliciting more fulfillment and satisfaction with their sexual life. Conversely, barriers to effective communication may lead to misunderstandings, relationship strain, and sexual dissatisfaction (Rehman et al. 2018; Shepardson and Carey 2016). Lastly, cognitive-affective processes, such as awareness of one's sexual functioning, are also involved in the development of sexual dysfunction and in the promotion of sexual well-being (Wiegel et al. 2007). Personality traits, cognitive schemas, or beliefs, may also contribute to sexual health and to the onset of sexual dysfunctions, complicating individuals' recovery (Brotto et al. 2016). For example, people exhibiting traits of neuroticism, harboring negative cognitive schemas, or presenting dysfunctional beliefs about sexuality may be more prone to experiencing adverse emotional responses during sexual activity, or attribute negative sexual experiences to internal factors (Brotto et al. 2016). These beliefs make people more susceptible to activating incompetence self-schemas in response to unsuccessful sexual experiences. The activation of these self-critical ideas triggers, in return, a cascade of negative automatic thoughts that inhibit focus on erotic stimuli and generate negative emotions (e.g., sadness, disillusion, guilt, lack of pleasure and satisfaction), thereby impairing sexual response. This vulnerability can be linked to the tendency of individuals with sexual problems to make internal, stable, and global attributions for sexual failures (Nobre and Pinto-Gouveia 2008). According to schema theory (Beck 1996), when an incompetence schema is activated in a sexual context, individuals tend to seek out confirming evidence, ignore contradictory information, and amplify negative interpretations of events (e.g., “I am incompetent”).

Since sexual well-being holds significant societal importance (Rider et al. 2016; Steptoe et al. 2015; Mitchell et al. 2012), it is essential to understand why sexual problems persist and remain unaddressed. Given the complexity of the barriers that hinder the provision of assistance (Kohn et al. 2004; van Ameringen et al. 2017; Alcoba Valls et al. 2004), technology, and especially Virtual Reality (VR), have the potential to enhance access to treatments (Vila et al. 2023a; 2023b).

1.2 Virtual reality: a new tool for an old problem

The term VR refers to a set of technologies employing virtual environments and real-time human interactions to simulate reality (Riva et al. 2020; Botella et al.2006). In contemporary times, the trajectory of technological progress, associated with the lower costs of devices, has conferred significant importance to VR, facilitating the transition from conventional face-to-face interventions to therapeutic modalities harnessing technological equipment. VR has been proven effective for different physical (e.g., chronic pain [Ahmadpour et al. 2019], cancer [Sansoni, et al.2022a], etc.) and psychological disorders (e.g., anxiety, post-traumatic stress, psychosis, addiction [Kim and Kim 2020], body dysmorphic disorder [Chorzępa et al. 2023], anorexia and bulimia nervosa [e.g., Brizzi et al. 2023a, b; Sansoni et al. 2024], etc.). These studies, among others, reveal how this technology provides therapeutic advantages such as higher stimulative control, confidentiality (Reeves et al. 2022; Botella et al.2006; Massetti et al. 2018), and the possibility to face stimuli otherwise difficult to experience in real life (Sansoni et al. 2022b, 2022c; Vila et al. 2022; Sansoni and Riva 2022).

When immersive, VR induces a profound sense of presence, the feeling of being within a virtual environment that closely approximates reality. As a matter of fact, this technology targets both the body and mind, aiming to replicate sensory experiences like sight, hearing, and even touch (Brizzi et al. 2023a, b). This simulation process, akin to our brain's typical functioning, helps to represent and predict behaviors, thoughts, and emotions (Riva et al. 2020), making users feel present and embodied in the virtual world. In this sense, by allowing individuals to live embodied sexual experiences as if they were real, VR appears as a useful tool for treating sexual impairments. One of the most promising areas of VR treatment for sexuailty is, in fact, the exposure to the anxiety-inducing stimuli experienced by patients (Geraets et al. 2021). Different from in-person therapy, VR-based exposure reveals several benefits. First, if necessary the patient has the possibility of experiencing events and receiving treatments without leaving the perceived safety of their house (i.e., having the equipment at home and thus undergoing the intervention directly there) (Vila et al. 2023a), but with the same quality of an in-person one (Riva 2009; Vila and Riva 2022).

Second, patients who currently do not seek help may profit from interventions: the person receives support without the embarrassment associated with the diagnosis and the stigma of being seen receiving support for sexual dysfunctions (Vila et al. 2022).

Third, VR guarantees the possibility of using virtual sex objects and experiencing situations that would normally be impractical or challenging to reach in in-person therapeutic settings (Riva 2009) (e.g., being exposed to the view of their own naked body to reduce the anxiety that the situation evokes).

Fourth, this technology allows the user to engage in real-time with a realistic scenario where they can interact with live sexual situations, generating distress, thus functioning as a controlled and experiential form of systematic exposure (Lindner et al. 2019).

Fifth, VR can help with specific parts of sexual therapy, boosting the effectiveness of traditional, in-person therapy. For instance, psychoeducation (e.g., when the clinician proposes contents that may help the person understand how their body works) or skills training (e.g., when the psychologist explains specific sexual stimulation to improve sexual pleasure) require the person to imagine what is being proposed. This sometimes becomes a challenge, especially in sexual treatments. VR can help with imagery (Botella et al. 2006), as it provides a visual approach to these techniques.

Lastly, VR allows to target the psychological variables associated with sexuality -such for example body image- through a diverse array of interventions. These may range from guided exercises and mindfulness practices, to virtual therapy sessions that aim to enhance body image and self-esteem (Navarro-Haro et al. 2017). Addressing body image concerns as part of sexual disorder treatment can significantly enhance overall therapeutic outcomes (Gomes and Tavares 2019; Pavanello Decaro et al. 2021). VR is an effective therapeutic tool for addressing this kind of concerns, as it can promote self-acceptance by providing individuals with a controlled and immersive environment to expose themselves to virtual representations of their bodies (Irvine et al. 2020). This technology can indeed simulate body modifications or alterations in real-time, allowing individuals to experiment with different appearances, as well as receive feedback to challenge distorted perceptions and develop a more accurate and realistic idea of their bodies (Kilteni et al. 2015; Perpiñá, et al. 1999).

While various technologies have been explored for addressing sexuality and sexual disorders, the utilization of VR in this context remains relatively unexplored (Vila et al. 2023a). Previous systematic reviews have investigated the use of alternative technologies such as mobile phones (L’Engle et al. 2016), websites, or text messaging (Sewak et al. 2023), as well as emerging trends like sex robots and remote sexual interactions facilitated by internet-connected devices (e.g., teledildonics) (Jecker 2021).

The first attempt to explore the theoretical frameworks and clinical indications associated with VR use for sex therapy is the work by Lafortune et al. (2020). A notable limitation of this study is, however, the lack of a systematic approach in the literature review methodology. This could lead to bias in study selection and interpretation, incomplete literature coverage, and absence of transparent and reproducible methods, hindering the replication and verification of findings by other researchers and compromising the reliability and validity of the gathered evidence due to the lack of quality assessments (Grant and Booth 2009). Similar limitations apply to the scoping review conducted by Lafortune et al. (2023) which examined VR-based research related to sexual dysfunctions and associated issues to identify promising applications in sex therapy. The systematic review by Marques et al. (2024) presents on the contrary the strengths of this type of approach but focuses only on sexual response outcomes (e.g., sexual arousal, sexual function, sexual dysfunction, sexual attractiveness, physiological sexual responses), not including psychological variables linked to sexual disorders such as emotions.

1.3 The current review

Building on these premises, our systematic review aims to expand on previous works by exploring the state of psychological and educational interventions that utilize VR to promote sexual well-being and support the treatment of sexual disorders. The objective is to identify the limitations in the existing literature and propose an innovative approach to address these gaps. Hence, our research questions are:

  • RQ1: What are the current interventions for treating and promoting sexuality through VR?

  • RQ2: What is the effectiveness of such VR interventions and what variables they target (e.g., sexual responses, outcomes, emotions, psychological features, etc.)?

  • RQ3: What are the limitations and challenges of current VR interventions for sexuality?

The main contributions we aim to provide are:

a) offering the strengths of a systematic approach, including a risk of bias assessment, in contrast to previous studies on the topic; b) including studies that utilize both digital environments and realistic 360-degree videos; c) extending the scope beyond interventions for treating impaired sexuality to also include those aimed at promoting sexual well-being, essential to prevent sexual disorders as well (McCarthy 2005); d) considering the emotions associated with sexuality and other related psychological constructs (e.g., distress, body image), thus not limiting the analysis to sexual response outcomes (e.g., sexual anxiety).

2 Methods

To offer a comprehensive overview of the current state of the art, we did not select a beginning year of publication for the articles to be included, and we used specific iteration research strings that provide a broad overview of the literature.

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Moher et al. 2009), and it was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42022339481). The detailed protocol is available upon request.

2.1 Data sources and search strategy

Data sources were collected on the 26th of May 2023 through a selective computer search in the following databases: PubMed, PsycINFO, and Web of Science. The strings employed to identify the papers to include in the systematic review were a) (Virtual reality) AND (sexual OR sexuality OR sex OR reproductive health OR intimacy); b) (360) AND (sexual OR sexuality OR sex OR reproductive health OR intimacy).

In accordance with the World Health Organization (WHO 2022) definition of sexuality, the keyword sexual was selected for including studies addressing sexual dysfunctions, sexual problems and sexual disorders, along with those focused on sexual health, sexual well-being and sexually related variables such as: sexual arousal (i.e., the combination of genital arousal– physiological modifications brought on by sexual stimulus– and subjective arousal– mental engagement during sexual activity) (Basson 2002), sexual satisfaction (i.e., the feeling of pleasure that one has when the sexual desire has been fulfilled) (Sánchez-Fuentes et al. 2014; Shahhosseini et al. 2014), sexual functioning (i.e., the capacity of having a satisfactory sexual life) (Kammerer-Doak and Rogers 2008), sexual dominance (i.e., a power dynamic in which one partner takes on a more controlling or authoritative role in a consensual sexual context) (Haas and Timmerman 2010), sexual behavior (i.e., behaviors related to sexuality), sexual anxiety (i.e., the anxiety a person gets because of a sexual experience), sexual violence (i.e., the kind of violence which is associated with sex). According to the same definition, reproductive health (i.e., physical, emotional, and social well-being in relation to the reproductive system and its functions throughout all stages of life) (Rani and Rao 2015), and intimacy (i.e., close emotional connection, often characterized by trust, vulnerability, and a sense of deep personal closeness between individuals, present when sharing a sexual relationship with someone) (Forstie 2017) were also considered important concepts and thus employed in the string. The keyword 360 was lastly chosen to include 360-degree videos.

2.2 Study selection and inclusion criteria

To be included in the review, studies were required to meet inclusion and exclusion criteria.

Inclusion criteria were: 1. Improving affected sexuality (e.g., sexual disorders) or promoting sexuality (e.g., sexual well-being); 2. Encompassing participants of all ages (e.g., adolescence, adulthood) and genders; 3. Conducting behavioral, emotional, educational, and cognitive interventions (e.g., cognitive restructuring) for sexual-related problems or for promoting sexual well-being; 4. Targeting at least one sexually related variable (e.g., sexual arousal, sexual function, sexual anxiety, sexual dominance); 5. In the case of studies with an adolescent population, providing self-reported measures of the adolescent (i.e., we excluded papers where the assessment was made only by an adult); 6. Incorporating randomized controlled trials and also non-randomized controlled trials (randomization may be difficult to implement within social science intervention research) (Deeks et al. 2003); 7. Employing either a cross-sectional experimental design, repeated measures (i.e., using the same group as control), a comparison of the experimental group (i.e., the one receiving VR intervention) with another group undergoing a different intervention (e.g., cognitive behavioral therapy—CBT), or being a case report; 8. Featuring either a multi-session treatment or a single-session treatment (as both have been proven to be effective and offer therapeutic advantages [Joseph and Rajan 2024]).

Exclusion criteria were as follows: 1. Inclusion of interventions targeted at individuals other than those affected (e.g., studies focusing on caregivers); 2. Evaluating psychological or educational dimensions unrelated to sexuality (e.g., assessment of health literacy); 3. Not being written in English; 4. Being a qualitative study, reviews, dissertations, theses, books or chapters, conference proceedings, letters to the editor, notes, and articles with no full text available.

Figure 1 illustrates the search strategy of the systematic review conducted under the PRISMA guidelines.

Fig. 1
figure 1

Flow chart of the systematic review.

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2.3 Study inclusion

Each database was searched independently: citations were retrieved for each iterative search, and a complete list of citations and abstracts was exported. Two reviewers (A.V. and M.S.) imported the list in Rayyan (Ouzzani et al. 2016), and independently examined all non-duplicate titles and abstracts. Eligible articles were retrieved, and the full text was independently analyzed by the two reviewers for inclusion. The identified articles were then compared between the reviewers, and disagreements were solved by consensus or through the settlement of the third reviewer (G.R.). To make this study repeatable in the future, detailed results are available in Table 1.

Table 1 Detailed search strategy.
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2.4 Data extraction

From each of the included studies, two reviewers (A.V. and M.S.) independently extracted the following information: type of sample and population (i.e., gender, age), duration of the VR intervention, type of intervention (i.e., psychological or educational), main sexual constructs targeted by the intervention (i.e., sexual variables targeted by the intervention), other psychological variables assessed in the study, content of the intervention, deliver modality, immersion, study design, and effectiveness outcomes.

2.5 Risk of bias

The Downs and Black checklist (Downs and Black 1998) was used to assess the risk of bias (Deeks et al. 2003). Two reviewers (A.V. and M.S.) independently assessed the risk of bias in each included study, assigning scores from 0 to 1 to the 27 items of the checklist (only item number 5 could receive a score from 0 to 2). Disagreements were solved either through consensus or through the settlement of the third reviewer (G.R.). The Downs and Black checklist provides quality information in two ways: (1) an overall index, and (2) four subscales: reporting, external quality, internal validity bias, and internal validity confounding. Being the maximum score possible of 28, scores are considered “excellent” (24–28 points), “good” (19–23 points), “fair” (14–18 points), or “poor” (14 points) (Downs and Black 1998).

3 Results

Of the 15,099 studies that were found using PubMed, PsycINFO, and Web of Science, 11,873 were non-duplicate. After all non-duplicate titles and abstracts had been checked, the full text of 406 papers was examined for the specified inclusion criteria. In this process, 9 studies out of 406 were found to be appropriate for the review. During the data extraction, a decision was made to exclude an additional paper, due to the lack of immersion in the VR environment. Therefore, of the 15,099 studies retrieved, eight studies were ultimately included in the review. Table 2 provides comprehensive information on research features, including the target population, length and kind of VR interventions, main sexual construct targeted from the intervention and other psychological variables of interest, content of the interventions, immersion, delivery modality, study design, and outcome measures.

Table 2 Detailed search strategy
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3.1 Study characteristics

The studies finally included in the systematic review were published within the previous 24 years: 1998–2022 and took place in three different countries: three in the United States (Loucks et al. 2019; Mozgai et al. 2020; Rowe et al. 2015), three in Italy (Optale et al. 1998, 1999, 2003), and two in Canada (Loranger and Bouchard 2017; Lafortune et al. 2022). Regarding the study design, most of them were characterized by a within-subjects design (i.e., repeated measures) (Loucks et al. 2019; Mozgai et al. 2020; Optale et al. 1998, 1999, 2003). Loucks et al. 2019 first described the study as a randomized controlled trial (RCT), but finally opted for analyzing pre-post measures of the whole sample (i.e., no RCT results) because of some inconsistent results found during the research. Two studies were described as non-randomized controlled trials (Loranger and Bouchard 2017; Lafortune et al. 2022). One was described as RCT (Rowe et al. 2015). Lastly, sample sizes differed significantly between the studies, going from 7 (Optale et al. 1999) to 110 individuals (Optale et al. 2003).

3.1.1 Sample characteristics

All studies except one were conducted with adults, with mean ages ranging between 14 and 75 years: Rowe et al. (2015) implemented their intervention with teenagers aged 14–18; Loranger and Bouchard (2017) worked with participants aged 18–65; Loucks et al. (2019) focused on individuals aged 32–72; Mozgai et al. (2020) did not specify the age or the gender of the participants; Optale et al. (1998) worked with two groups of adults aged 22–75 and 21–44; Optale et al. (1999)’s intervention targeted people aged 23–66; Optale et al. (2003) conducted treatment with three groups of participants whose mean ages were 43.7, 53.9, and 39 years old; finally, Lafortune et al. (2022) delivered the intervention to two groups of individuals with mean ages of 28.75 and 33.22 years respectively.

Most of the samples reported in the studies were composed of males (Optale et al. 1998, 1999, 2003), as they all treated erectile dysfunction along with premature ejaculation. Two of them were conducted with female participants (Loranger and Bouchard 2017; Rowe et al. 2015), and focused on victims of sexual trauma and potential victims of sexual victimization respectively. The remaining three were conducted with both female and male samples (Loucks et al. 2019; Mozgai et al. 2020; Lafortune et al. 2022) and examined sexual aversion (Lafortune et al. 2022), and sexual trauma of enrolled military veterans’ victims (Loucks et al. 2019; Mozgai et al. 2020).

About the recruitment process, only four papers provided information on how participants were recruited: via e-mail, posters, and advertisements in local newspapers or social media (Loranger and Bouchard 2017; Loucks et al. 2019; Lafortune et al. 2022), via an all-girls urban public high school (Rowe et al. 2015), and from a bank of respondents who had previously participated in another study (Lafortune et al. 2022). The study by Loucks et al. (2019) also used military outreach events as well as the reference of other professionals (e.g., university medical centers).

3.1.2 Characteristics of VR interventions

All studies consisted of psychological intervention. Thus, none of them was educational. Concerning the target sexual constructs, the focus of most interventions was the treatment of different disorders: sex-related post-traumatic stress disorder (PTSD), (Loucks et al. 2019; Loranger and Bouchard 2017; Mozgai et al. 2020), erectile dysfunction or premature ejaculation (Optale et al. 1998, 1999, 2003), or sexual aversion (Lafortune et al. 2022). The study conducted by Rowe and colleagues (2015) stood out as the sole investigation centered on primary prevention. Rather than targeting an affected sexuality, it aimed to prevent a decline in sexual well-being resulting from sexual violence.

Regarding the other psychological features assessed, one study assessed victimization (Rowe et al. 2015). The remaining works included measures of anxiety (Loranger and Bouchard 2017)—including sexual anxiety (Lafortune et al. 2022), depression (Loranger and Bouchard 2017; Loucks et al. 2019; Mozgai et al. 2020), distress (Mozgai et al. 2020; Rowe et al. 2015), psychophysiological reactivity (Lafortune et al. 2022; Loucks et al. 2019) or other emotions such as disgust, fear (Lafortune et al. 2022) and broad positive and negative affects (Loranger and Bouchard 2017). The three studies by Optale and colleagues (1998, 1999, 2003) did not assess related psychological variables.

Interestingly, none of the interventions included relevant variables to sexuality such as body image, sexual self-esteem, self-confidence, sexual communication, personality traits (e.g., neuroticism), negative cognitive schemas, or dysfunctional beliefs about sexuality.

With respect to the foundational framework of the interventions, the included studies could be classified into two categories: papers based on cognitive behavioral therapy (CBT; five studies: Loranger and Bouchard 2017; Rowe et al. 2015; Mozgai et al. l2020; Loucks et al. 2019; Lafortune et al. 2022), and papers based on psychodynamic therapy (three studies; Optale et al. 1998, 1999, 2003).

Among the CBT studies, Loranger and Bouchard (2017) proposed a virtual systematic desensitization to treat sexual harassment victims by exposing them to a night-time bar, and seven stages of sexual aggression (e.g., the participant leaves the bar and walks to the bus stop; the aggressor walks up to her and blocks the exit). Rowe et al. (2015) proposed a training in assertive resistance skills, followed by a VR experience of sexually threatening situations. Both the study by Loucks et al. (2019) and the one by Mozgai et al. (2020) applied BraveMind VR Exposure Therapy to military veterans’ victims of sexual trauma, although the latter did not justify the intervention program followed. Loucks et al. (2019) introduced an Afghanistan-themed forward operating base, and a set of US civilian and military base contexts (i.e., barracks, offices, apartments, motel rooms, bathrooms), designed to include trigger stimuli. And Lafortune et al. (2022) proposed a virtual room where participants were exposed to six scenarios in which a virtual character (female or male) showed erotic behaviors and audio stimuli of increasing intensity.

Among the psychodynamic papers, all three studies were led by the same author. Optale et al. (1998) and Optale et al. (1999) proposed a VR psychodynamic psychotherapy based on recordings, multimedia, and virtual experiences that described pathways through a forest, aimed at evoking childhood mental images. These scenarios treated facts pertinent to the ontogenesis of male sexual dysfunctions, always followed by a discussion about the experience. The third study by Optale et al. (2003) added some further steps to the previously explained VR psychodynamic psychotherapy and included acoustic therapy (i.e., description of pathways through a forest aimed at evoking childhood mental images: the participant needs to make choices regarding the situation based on what they see and listen), VR psychotherapy and VR experiences, in which the patient interacts alone with the virtual environment.

The duration of the VR therapies was variable, going from three immersions of five minutes (Loranger and Bouchard 2017) to fifteen sessions of one hour each, for a total duration of over six months (Optale et al. 1999). Most of the studies included long-time interventions: Loucks et al. (2019) proposed three VR scenes two minutes long, followed by six to twelve sessions of ninety-minute VR exposure therapy sessions. Mozgai et al. (2020) also proposed six to twelve sessions (i.e., the final session number was based on reaching 70% symptom improvement or on the agreement between the clinician and participant that maximum benefit had been achieved) of ninety-minute VR exposure therapy sessions, while Optale et al. (1998) presented an intervention that lasted twelve one-hour sessions over a twenty-five-week period. Optale (1999) described fifteen sessions over six months and Optale et al. (2003) invited their participants to twelve sessions over a twenty-five-week period. Finally, Rowe et al. (2015) proposed a single 90-min group session of 2 to 4 participants (i.e., number of participants varied), while Lafortune et al. (2022) conducted a single fifty-minute individual session. Every intervention was tailored to participants’ age and characteristics.

3.1.3 Effectiveness of VR interventions

Optale and colleagues (1999) reported that sexual performance was improved after treatment and maintained at a six-month follow-up, but no information about the dimension of the intervention effect was given. They described and made inferences about other measures that were not directly related to an improvement of psychogenic impotence, instead. On the contrary, these variables were associated with brain metabolism: after the intervention, the authors found a balance, not statistically significant, attained between the two hemispheres (with an increase in metabolic activity on the left and a decrease on the right), and an absolute reduction in glucose metabolism, though statistically significant only for the thalamus (< 0.05).

Optale et al. (1998) and Optale et al. (2003) only described the number of participants who improved or had a resolution of the sexual disorder after the intervention. They did not provide any information on the assessment criteria or statistical data. The first of these investigations (Optale et al. 1998), studied three different disorders: impotence due to psychological factors (i.e., inability to achieve or maintain an erection during sex due to psychological factors, including stress, anxiety, guilt, or low self-esteem), impotence due to combined factors (i.e., due to both psychological and physical factors), and premature ejaculation. The authors reported three drop-out cases, three cases that got no results (i.e., they did not improve), three cases that improved, and eleven resolution cases for impotence due to psychological factors. For impotence due to combined factors, they reported five drop-out cases, four cases that got no results, six cases that improved, and fifteen resolution cases. Regarding premature ejaculation, they had one drop-out case, four cases that got no results, two cases that improved, and nine resolution cases. The second of these studies (Optale et al. 2003), reported five drop-outs cases (10%), seven cases that got no results (14%), thirteen cases that improved (26%), and twenty-five resolution cases (50%) for impotence due to psychological factors. For impotence due to combined factors, they reported 10 drop-out cases (17%), twenty-three cases that got no results (38%), eight cases that improved (13%), and nineteen resolution cases (32%). Regarding premature ejaculation, they had thirteen drop-out cases (26%), nine cases that got no results (18%), four cases that improved (8%), and twenty-four resolution cases (48%).

Mozgai et al. (2020) reported a significant reduction in pre- to post-treatment symptoms, favoring intervention. Results reported a significant reduction in pre-treatment to post-treatment clinician-assessed sexual post-traumatic stress disorder (PTSD) symptoms, and self-reported depressive symptoms (that were not part of the original goals), maintained in the three-month follow-up assessments. The authors also reported a reduction in the number of participants who met the criteria for sexual PTSD (which reduced a 53% post-treatment and 33% in the follow-up), with no additional data to support it; significant reductions in pre- to post-treatment severity of the symptoms (CAPS severity: t(10) = 3.69, p = 0.004; PCL-5: t (10) = 3.79, p = 0.004); and significant pre- to post-treatment reduction in heart rate response to a trauma cue, with no additional data to support it.

Loucks et al. (2019) reported a significant reduction in pre- to post-treatment clinician-assessed (CAPS severity: t(10) = 3.69, p = 0.004) and self-reported (PCL-5: t(10) = 3.79, p = 0.004) sexual PTSD symptoms, and self-reported depressive symptoms (not part of the original goals), maintained in the three-month follow-up assessments (CAPS severity: t(8) = 0.45, p = 0.666; PCL-5: t(8) = -1.49, p = 0.174). Cohen’s d effect size was large both for measures of PTSD and depressive symptoms.

Rowe and colleagues (2015) reported significant differences between the two conditions– control and experimental randomized groups– which were maintained at a 3-month follow-up assessment, favoring intervention. The participants that received the intervention were less likely to report sexual victimization than were participants in the control group (b = − 0.77, OR = 0.47, t(70) = − 2.29, p < 0.05). Additionally, the authors analyzed the psychological distress that the experimental condition evokes, which was positively associated with sexual victimization (b = 0.09, OR = 1.10, t(70) = 3.87, p < 0.001).

Lafortune and collaborators (2022) found a main significant large effect for sexual anxiety (F(3.82, 56.37) = 17.25, p < 0.001, ηp2 = 0.46), and sexual disgust (F(2.7,54.01) = 27.58, p < 0.001, ηp2 = 0.58), with results that suggest that both tend to increase as the levels of exposure increase (anxiety, F(1, 20) = 41.54; p < 0.001; disgust, F(1, 20) = 54.36; p < 0.001). Additionally, the authors found significative group by time interactions for both anxiety (F(2.94, 102.71) = 2.66, p = 0.05, ηp2 = 0.07), and disgust (F(2.5, 87.51 = 5.1, p = 0.005, ηp2 = 0.13), indicating that the high exposure group experienced more anxiety and disgust than the low exposure group during the different scenarios. Loranger and Bouchar (2017) found significant Conditions × Time interactions for anxiety, depression, and affects, which deems the environment useful for treating sexual anxiety. These two studies introduce the validation of an environment, targeting the objective variables and presenting results for a sexual intervention.

3.2 Methodological quality of the studies

The Downs and Black checklist (Downs and Black 1998) showed an overall medium–low methodological quality of the studies included in the review. Details can be seen in Table 3. Most studies were indeed classified as “poor” (Mozgai et al. 2020; Optale et al. 1998, 1999, 2003), meaning a high risk of bias. Four studies were classified as “fair” (Loranger and Bouchar 2017; Loucks et al. 2019; Rowe et al. 2015), implying a medium risk of bias, and none of them was classified “good” (mild risk of bias) nor “excellent” (poor risk of bias).

Table 3 Risk of bias assessment using the Downs and Black Checklist (1998)
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Among the identified methodological limitations, the included studies are missing important information about the interventions featured. Nearly all of them reported successful improvements in the target variables (e.g., impotence), but in most cases, no information was given about the assessment criteria or how the cases improved. In addition to this, no study described the distribution of the principal confounders in each group of subjects. Therefore, there was not an adequate adjustment for confounding variables in the analyses. None of the studies attempted to blind those measuring the main outcomes nor the randomized intervention assignment (including all non-randomized studies). Moreover, none of the reported works provided details about whether the subjects in different intervention groups were recruited over the same period. Additionally, only two studies (Rowe et al. 2015; Loucks et al. 2019) provided estimates of the random variability in the data for the main outcomes. Finally, only one study (Optale et al. 1998) demonstrated that there was a comprehensive attempt to measure adverse events at the end of the intervention, while no research among those included analyzed mediating variables, complicating factors, or barriers to care, all key elements for achieving a methodologically strong experimental design.

4 Discussion

This systematic review had the purpose of exploring VR interventions whose aim is to target sexuality, in order to identify the limitations of the current interventions and propose a new approach to overcome them. Eight studies were included in the review; however, among them, educational interventions were conspicuously absent. This omission is noteworthy, as psychoeducation has been previously established as a valuable element in addressing sexual issues and promoting sexual well-being (Prost et al. 2013). For the studies that quantified the effect of the intervention, VR has demonstrated its effectiveness and emerged as an optimal delivery modality for promoting sexuality across primary, secondary, and tertiary levels. Despite the positive outcomes, however, the included studies exhibited consistent methodological constraints as well as significant limitations regarding the variables addressed in the interventions. With regard to this latter aspect, in particular, the main limitations can be grouped into three areas: lack of empowerment, omission of the critical role of the partner, and failure to acknowledge other relevant variables to sexuality such as body image.

4.1 Lack of empowerment

Empowerment is a pivotal element that enhances treatment outcomes and promotes well-being. It is considered a key focus in public health and modern healthcare reform discussions, able to facilitate patient engagement (Mora et al. 2022). Nevertheless, despite its importance, the CBT and psychodynamic interventions included in our systematic review are missing this crucial element. CBT interventions, in fact, primarily rely on exposing patients to their fears. However, these interventions often fail to provide meaning to the patients' experiences. Consider for example a female patient confronting her fear of penetration. If therapy was to conclude at the stage of exposure to the triggering situation, the assessment would remain incomplete. An effective intervention should explore the underlying causes of the fears, which have led to the avoidance of potentially pleasurable sexual activities and to a reduction in sexual well-being. Without this deeper understanding, patients may not be fully empowered to manage their conditions. Conversely, psychodynamic interventions focus on the meaning of experiences but often overlook the importance of confronting fears, necessary for patient recovery. Emphasizing only what the experience represents for the individual, without supporting gradual exposure to the distressing stimulus, misses a crucial aspect of the therapeutic process, too. Consequently, both these approaches are incomplete, as they lack a balanced method that combines immediate, actionable strategies with deeper self-understanding. This limitation restricts patients' ability to take control of their healing and development. Focusing solely on the "what" (i.e., CBT approach) or the "why" (i.e., psychodynamic approach) is indeed insufficient for comprehending "how" to cope with the problem.

To bridge this gap, patient empowerment is essential. Empowerment involves not only understanding one's issues but also actively engaging in the process of addressing and overcoming them. Therefore, it is crucial to design and test interventions that integrate both perspectives—offering immediate coping strategies while fostering deeper self-understanding. This dual approach equips patients with new skills and strategies to manage stressors and helps them identify and assign meaning to their experiences, thereby empowering them. Effective empowerment in therapy ensures that patients are not passive recipients of care but active participants in their healing journey.

4.2 Omission of the critical role of the partner

The second limitation pertains to the current studies' exclusive focus on the patient, neglecting the partner who also experiences sexual-related challenges alongside them. As previously underscored by Dean and colleagues (2008), any sexual dysfunction affecting one member of a couple can promptly evolve into a disorder affecting the entire relationship: the sexual dysfunction experienced by one partner can induce considerable distress in the other one, leading to explicit couple sexual dysfunctions. Consequently, effective therapy should encompass both partners to yield enduring effects. Similarly, to foster sexual well-being, it is crucial to encourage both members of a couple to pursue positive, realistic significance in their intimate lives (Metz and McCarthy 2007). In this light, some preliminary studies attempt to fill this gap. Vila (2022), for example, presents a case study focusing on a new effective sexual intervention including couple therapy. The author aimed to improve the general sexual well-being of a patient diagnosed with female orgasmic disorder by addressing all relevant sexual factors involved. This included five sessions, delivered inside a virtual world, in which the participant explored the difficulties present in her relationship to solve them, together with her partner. Additionally, the study conducted by Sansoni et al. (2023) introduces an innovative VR approach with the goal of assisting couples in enhancing their well-being following cancer treatments, which may impact various facets of well-being, including sexuality. By seeing through their partner's eyes the difficultiesthey faceg and feeling in their own body the impact of such struggles, the VR experience proposed by these authors allows the other member of the couple to understand their partner's emotions and experiences, facilitating the couple’s communication and well-being..

4.3 Failure to acknowledge body image

Lastly, the third and last limitation of current VR interventions is that they often do not acknowledge the importance of other relevant variables to sexuality such as body image. As stated in previous sections of this paper, body dissatisfaction may lead people to experience sexual dysfunctions, and poor sexual well-being (e.g., Nobre and Pinto-Gouveia 2008; Carvalheira et al. 2017). One of the possible explanations for the influence of body image on sexuality could be the Allocentric Lock Theory (ALT) (Riva 2012). According to this theory, individuals suffering from body image distortions may be locked into an allocentric perspective of their bodies (i.e., third-person perspective). This could arise from a foundational disruption in the way the body is perceived and recollected, leading the allocentric perspective to remain unaltered, as it fails to be updated by divergent egocentric representations derived from perceptual experiences (Riva et al. 2015).

The persistence of individuals in an allocentric frame of reference can be understood through the lens of social constructionism. Drawing upon objectification theory (Fredrickson and Roberts 1997), the socio-cultural context places women and men within a framework where their identities predominantly hinge on externally visible attributes (such as appearance), often relegating internal and non-observable facets (including needs, emotions, and competencies) to a secondary status (Morry and Staska 2001). This leads individuals to internalize a third-person perspective (i.e., allocentric view), treating themselves as objects detached from their holistic being (Fredrickson and Roberts 1997; Roberts et al. 2018). As a result, people presentimpairedattention, reduced awareness of bodily states, body shame, appearance-related anxiety, but also mental health problems such assexual dysfunctions (Calogero et al. 2011; Fredrickson and Roberts 1997), and impairedsexual well-being(Meana and Nunnink 2006). In this sense, focusing on body image concerns may be a key element to boost the effectiveness of treatments for sexual problems.

VR has already shown its effectiveness in unlocking the allocentric memory of the body (Riva et al. 2021a, b) for example through a body image rescripting protocol (Riva 2011; Riva et al. 2021a, b; Sansoni et al. 2024) able to reorganize body-related memories and shift the frame of reference from an allocentric to an egocentric one. The goal is to reduce the distress attributed to negative memories and subsequently reshape their implications. The body image rescripting protocol offers indeed patients a novel lens through which past events are viewed, thereby evoking novel emotional responses, identifying latent psychological needs, and prompting an engagement with reality conducive to fostering a constructive process of psychological adaptation.

5 Future directions

Summarizing, to deliver a complete and comprehensive therapy to treat impaired sexuality and improve sexual health and well-being, an intervention should empower the patient by featuring not only the experience but also the meaning that the person attributes to it, acknowledge the inter-relational aspects of sexuality, thus including partners in the therapy, and target other psychological variables related to sexuality such as body image concerns, providing in this way the possibility to reconnect with the body and overcome the lock into an allocentric view that self-objectification and our culture tend to promote.

Building upon the findings of the systematic review, the idea of employing the Metaverse to address the major challenges arised (Vila and Riva 2022).

Metaverses are indeed pre-existing virtual environments that researchers or clinicians can access without requiring specific technical expertise (Riva et al. 2021a, b; Vila et al. 2023a). They offer therapeutic advantages over traditional treatments, such as enhanced subjective security and the ability to use virtual objects that may be expensive or difficult to obtain in real life. Additionally, the affordability of software and hardware makes their everyday use feasible. In a metaverse, users can design their avatars, replicate their physical characteristics, and communicate with other users in real-time, engaging in diverse experiences and activities, such as socializing, gaming, attending virtual events, and conducting business. Essentially, users can perform in the metaverse activities they would typically undertake in real life within a highly realistic environment. Among the existing metaverses, Second Life (secondlife.com) allows users to explore virtual sexuality as well.

Considering these advantages, metaverses could provide an additional approach to address the limitations observed in current VR interventions. Prior research has demonstrated encouraging outcomes, illustrating how activities conducted within metaverses can elicit experiences akin to those in real-life settings (Furlanetto et al. 2013). However, what specific attributes must a metaverse-based intervention possess to effectively address the issues that we identified in this systematic review?

Based on the insights from Vila et al. (2024) and Vila and Riva (2022), incorporating an educational component at the outset is essential. This should include a thorough explanation of key aspects of sexual well-being or of the sexual disorder, if present, such as its characteristics, associated psychological variables, and prevalence rates. Additionally, foundational knowledge about sexuality should be provided, covering topics like the phases of the sexual cycle, desire, the reproductive system, genitalia, and pleasure areas, as well as information on orgasms, including what constitutes an orgasm, neuronal orgasms, and factors influencing orgasm achievement. Notably, our systematic review did not identify any VR educational interventions aimed at improving sexuality, nor were such modules included within broader intervention programs. Psychoeducation is a critical factor in patient empowerment (Vázquez et al. 2017), the first feature identified by our systematic review as missing in currently available VR interventions.Providing knowledge can demystify and normalize individuals’ experiences, reduce anxiety and stigma, and enhance self-awareness and self-efficacy. This, in turn, enables individuals to make informed decisions regarding their sexual health, equipping them with the necessary tools and information to actively engage in their well-being and have control over their lives.

Second, the intervention program should include both Individual Sexual Therapy (IST) and Couple Sexual Therapy (CST). IST is to provide an empowering experience in which patients can explore themselves and get in contact with their sexuality in a safe space, accompanied by a psychologist who supports them in the process. Working individually with the patient allows one to apply techniques, such as systematic desensitization or exposure, to face the stimuli that may be blocking sexuality. This virtual desensitization is complemented by learning techniques to focus the attention on one’s body (i.e., an important factor to pleasure), acquiring insights into emotions such as guilt or embarrassment, cognitive restructuring, as well as working with pleasure areas. Additionally, CTS sessions need to be included with the purpose of addressing the inter-relational aspects of sexuality.

Figures 2 and 3 represent an example of the two different types of sessions: Fig. 2 depicts a possible individual therapeutic situation (i.e., IST) in which a woman receives information about her sexual disorder and goes through cognitive restructuring; Fig. 3 depicts another possible therapeutic situation, in this case, related to CST. In the picture, the same individual and her partner are receiving psychoeducational exposure to couple sexual stimulation.

Fig. 2
figure 2

Example of a participant during IST.

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Fig. 3
figure 3

Example of a participant during CST.

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In addition, to empower the person and consider the interpersonal dimension of sexuality, the creation of a new approach to sexuality should consider the challenge of targeting other psychological variables, such as body image concerns. In the Metaverse the clinician could target body image first by modifying the frame of reference, shifting from an egocentric to an allocentric one (Figs. 4 and 5): this important step could, in fact, help rectify body image distortions, leading to a more accurate and positive body image, with new egocentric representations supplanting the distorted allocentric perspective.

Fig. 4
figure 4

Example of a participant seeing herself from an allocentric (i.e., third person) perspective.

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Fig. 5
figure 5

Example of a participant seeing herself from an egocentric (i.e., first-person) perspective.

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Second, the metaverse could support the psychologist in addressing, during the sessions, body image concerns that may block the person from living the desired sexuality: for example, editing the avatar according to certain physical characteristics that may represent a trigger for the patient (e.g., the circumference of their thighs, a large body as shown in Figures 4 and 5, etc.) could be an option for gradually exposing the person to such situations.

In conclusion, this study, which identifies key challenges and introduces a novel therapeutic approach, aims to significantly contribute to advancing research and practical applications in the field of sexual interventions. While our preliminary findings are encouraging, further research is crucial. This metaverse-based approach necessitates indeed thorough testing and analysis of all its components to determine its potential benefits accurately. Comparative studies with alternative interventions, such as app-based solutions, in-person therapy, and conventional VR approaches, are also necessary to assess its effectiveness and evaluate if it is superior to other technological tools or standard in-person therapy. In addition to this, future research in the domain of sexuality and VR should consider the methodological and content-related limitations identified in our study to mitigate biases and enhance intervention efficacy. Our work aspires to provide a robust foundation for future endeavors, fostering innovation and improvements in this vital aspect of human well-being.