Female Sexual

Dysfunction
Kevin Gilligan
Raquel Grimes
Cornelia Grose
Nicholas Hahn

Sexual problems in females

are very prevalent and
commonly associated with
physiological concerns and
the quality of life.

Female sexual disorders include:

Sexual desire disorders:

Hypoactive sexual desire disorder

Sexual aversion disorder

Sexual arousal disorder

Orgasmic disorder
Sexual pain disorders:

Dyspareunia
Vaginismus

Sexual Desire Disorders:

Hypoactive sexual desire disorder

Persistently or recurrently deficient (or absent) sexual

fantasies and desire for sexual activity. The judgment of
deficiency or absence is made by the clinician, taking
into account factors that affect sexual functioning, such
as age and the context of the person's life.
The disturbance causes marked distress or interpersonal
difficulty.
The sexual dysfunction is not better accounted for by
another Axis I disorder (except another Sexual
Dysfunction) and is not due exclusively to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
( www.behavenet.com, 2004)

Sexual Desire Disorders:

Sexual aversion disorder
Persistent or recurrent extreme aversion

to, and avoidance of, all (or almost all)

genital sexual contact with a sexual
partner.
The disturbance causes marked distress
or interpersonal difficulty.
The sexual dysfunction is not better
accounted for by another Axis I disorder
(except another Sexual Dysfunction).
(www.behavenet.com, 2004)

Sexual Arousal Disorder

Persistent or recurrent inability to attain, or to

maintain until completion of the sexual activity,
an adequate lubrication-swelling response of
sexual excitement.
The disturbance causes marked distress or
interpersonal difficulty.
The sexual dysfunction is not better accounted
for by another Axis I disorder (except another
Sexual Dysfunction) and is not due exclusively
to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition.
(www.behavenet.com, 2004)

Orgasmic Disorder

Persistent or recurrent delay in, or absence of, orgasm following a

normal sexual excitement phase. Women exhibit wide variability in
the type or intensity of stimulation that triggers orgasm. The
diagnosis of Female Orgasmic Disorder should be based on the
clinician's judgment that the woman's orgasmic capacity is less than
would be reasonable for her age, sexual experience, and the
adequacy of sexual stimulation she receives.

The disturbance causes marked distress or interpersonal difficulty.

The orgasmic dysfunction is not better accounted for by another

Axis I disorder (except another Sexual Dysfunction) and is not due
exclusively to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition.

(www.behavenet.com, 2004)

Sexual Pain Disorders:

Dyspareunia

Recurrent or persistent genital pain associated with

sexual intercourse in either a male or a female.
The disturbance causes marked distress or interpersonal
difficulty.
The disturbance is not caused exclusively by Vaginismus
or lack of lubrication, is not better accounted for by
another Axis I disorder (except another Sexual
Dysfunction), and is not due exclusively to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
Due to Combined Factors

(www.behavenet.com, 2004)

Sexual Pain Disorders:

Vaginimus

Recurrent or persistent involuntary spasm of the

musculature of the outer third of the vagina that
interferes with sexual intercourse.
The disturbance causes marked distress or
interpersonal difficulty.
The disturbance is not better accounted for by
another Axis I disorder (e.g., Somatization
Disorder) and is not due exclusively to the direct
physiological effects of a general medical
condition.
(www.behavenet.com, 2004)

Female Sexual Response Cycle

Masters and Johnson characterized cycle with four phases:

Excitement

Plateau
Orgasmic

Resolution

Kaplan proposed idea of desire and a three-phase model.

Desire

Arousal
Orgasm

(Berman et. al, 1999)

Evaluation

Female sexual arousal results in a combination

of vasocongestive and nueromuscular events,
including increased clitoral, labial, and vaginal
wall engorgement and increased vaginal luminal
diameter and lubrication.
Muscle tension, respiratory rate, heart rate, and
blood pressure rise steadily during arousal,
finally peaking during orgasm.

(Berman et. al, 1999)

Evaluation (cont.)
Evaluations may differ from person to

person .
The way of diagnosing is through
physiological response which could result
in problems with not considering
psychological evaluations.

Populations who may experience

female sexual dysfunction (FSD):

Abused
Perimenopausal
Pregnancy
Multiple sclerosis
Childhood sex abuse
Chemotherapy
Genital mutation
Post menopausal
Lack of sensitivity

Gynecological cancer
Radiation
Battered
Nuerogenic disease
Sexual trauma
Spinal cord injury
Vascualr disease
Post-hysterectomy
Post-partum

(Brassil et. al, 2002)

Statistics

Based on the National Health & Social Life

survey of 1749 women, 43 % experienced
sexual dysfunction.
30 % of men report sexual problems
US population data revealed that 9.7 million
American women aged 50-74 years self-report
complaints of diminished vaginal lubrication,
pain and discomfort with intercourse, decreased
arousal, and difficulty achieving orgasm.
(Berman et. al, 1999)

Etiology
The etiologies of female sexual

dysfunction affect a variety of populations

and may be caused by psychological,
emotional, or physiological reasons.
Often, the etiology is multifactorial And
interrelated.

(Brassil et. al, 2002)

Psychological Causes

As with most
disorders, female
sexual dysfunction
can be caused and
aggravated by
psychological causes.

There are five main Psychological

Causes to FSD.
Sexual or Emotional Abuse
Depression
Relationship Issues
Stress
Self Esteem

( Brassil & Keller, 2002)

Sexual or Emotional Abuse

This can include child abuse, domestic violence,

rape, and sexual exploitation.
These can lead to long term sexual dysfunction
with women due to problems such as overall
trust issues to desensitization.
Between 75% to 94% of women with a sexual
dysfunction could be accurately identified on the
basis of prior abuse, but many nondysfunctional
women were misclassified.
(Sarwe & Durlak, 1996)

Depression
Depression is a prevalent cause of sexual

dysfunction in both men and women.

Most women, when grieving, experience a
loss of sexual desire.
Depression can be a double edged sword
for some, due to the increase of sexual
dysfunction caused by anti-depressants.

Relationship
A healthy relationship is based on trust,

intimacy, and communication.

A study in the last five years found that
sexual dysfunction is highly associated
with negative experiences in sexual
relationships and overall well-being.

( Laumann et al., 1999)

Relationship (cont.)

Other factors that can

affect the sexual health of
a relationship are
conflicts about cultural,
social or religious beliefs.
These can invoke
feelings of guilt during
sexual activity and affect
the ability of a women to
be aroused, obtain an
orgasm, or have any
desire to have sex.

Stress
Today most people are so busy and are

often too stressed or too exhausted to

have sex.
When some women have decreased
desire to have sex, it will become more
difficult to become aroused and to orgasm
High stress factors include workplace
stress, social or financial crises

Stress (cont)

Couples who are

infertile and who are
participating in invitro
fertilization will often
experience a
decrease in desire
associated with the
stress of having to
perform.

(Brassil & Keller, 2002)

Self Esteem
To have a healthy response to sex, a

woman must have a good body image and

self esteem.
If a woman does not feel comfortable in
her own body, she will not feel comfortable
experiencing sex.

Diagnosis and Treatment

The chance of a female expressing sexual

concerns is influenced by her perception of the
health care professionals level of comfort in
discussing the subject.
When diagnosing sexual dysfunction, a sexual
function questionnaire is to be completed by the
patient, then they will be interviewed by a
psychologist to determine any history of abuse
or relationship issues that may be affecting the
females sexual response.
(Brassil & Keller, 2002)

Treatment

Once it is determined that the sexual disorder is

psychological in nature the patient will then be
referred to a psychologist who specializes in
sexuality.
When possible her partner should be included in
this therapy.
If you are considering therapy with a specialist in
sexual disorders you can call the American
Association of Sex Educators, Counselors, and
Therapists at (312) 644-0828 or go to their
website www.aasect.org for local referrals.

Psychiatric Drugs Role in Female

Sexual Dysfunction
Female Sexual Dysfunction is highly

prevalent in the general population and is

highly co morbid with many psychiatric
syndromes.

Many prescribed psychiatric drugs have

sexual side effects.

( Segraves, 2002)

Brief history

The first case study of antidepressant-induced orgasm

disorder in female patients was reported by Wyatt, R.J.
in 1971.
In 1977 a case study documenting antipsychotic induced
sexual dysfunction in both sexes was reported.
In 1994 the DSM IV included a category for drug induced
sexual dysfunctions.
The success of sildenafil as a treatment for male erectile
disorder leads to the increase interest in FSD, more
specifically: clinical trials, development of new
assessment tools, increase interest in biological
contributions to FSD, and refinement of diagnostic
understanding.

Prevalence

The National Health and Social Life Survey

conducted in 1992 involving interviews with a
probability sample of the US population between
the ages of 18-59 found that:

43% of females have had significant sexual

complaints in the preceding year
33% reported lack of sexual interest
24% reported difficulty reaching orgasm
19% reported lubrication problems

Co Morbidity

Population surveys indicate a high concordance

of FSD and marital discord and symptoms of
anxiety and depression.
Studies of sexual function in psychiatric patients
suggests that sexual disorders are more
common in patients diagnosed with depression,
schizophrenia, anorexia, and anxiety disorders.

On the other hand sexual activity and libido are

reported to increase in manic episodes.

Effects of Psychiatric Drugs

Antidepressants

Double-blind have indicated that monoamine

oxidase inhibitors (MAOs), benzodiazepines,
and tricyclic antidepressants (TCAs) delay
orgasms.
Unfortunately these side effects were not
noticed by psychiatrist until after several years
of clinical use
such side effects were not noted unless directly
asked by physicians and most common side
effects were delayed orgasm and decreased libido.

Effects of Psychiatric Drugs

continued
Antipsychotics

Most traditional antipsychotics can cause

difficulties with orgasm

Mood Stabilizers

The relationship with these drugs and FSD is

unclear because it is difficult to separate
illness cycle from the drug effect also, sexual
activity frequently increases during manic
episodes and decreases during depressive
episodes.

Pharmacological Treatments of
Female Disorders

Vasoactive Drugs

Sildenafil increases the genital vasocongestion and lubrication

but there is no evidence that these agents have therapeutic
benefits for FSD.
This may not be effective because females with FSD often show
objective arousal but do not report subjective arousal.

Other treatments in progress

Androgen and estrogen treatments have been fairly extensively

researched and suggests that a relationship exists between
libido and androgen levels in females.
Testosterone treatments are also being researched though
chronic dosages would result in masculinization and other side
effects.
However it has been shown that testosterone within normal limits
influence libido.

Redefining FSD

Development of research has been hindered by lack of strong

definitions and a multidimensional structure for diagnosis and
classification.
Recapping past definitions:

World Health Organization International Classifications of

Disease-10 (ICD-10) defines FSD as the various ways in which
an individual is unable to participate in sexual relationships as he
or she would wish (Basson et al., 2001).

DSM-IV defines FSD as disturbances in sexual desire and in

the psychophysiological changes that characterize the sexual
response cycle and cause marked distress and interpersonal
difficulty (Basson et al., 2001).

These definitions have been based on the human sexual

response described by Masters and Johnson.

( Basson et al., 2001)

Shortcomings of previous
definitions of FSD

Large overlap has been found among sexual disorders, particularly

in females, indicating a need to refine the diagnostic system
currently being used.

Research has focused primarily on causes and treatment of male

sexual disorders, leaving female sexual disorder research much
less developed.

The first International Consensus Development Conference on

Female Sexual Dysfunction was organized to confront the problems
associated with past classifications of FSD.

( Basson et al., 2001)

International Consensus Development

Conference on FSD

The first International Consensus Development Conference on

Female Sexual Dysfunction met in October 22, 1998 in Boston, and
developed a new system to classify FSD including altered
definitions for the different disorders.

The major categories (desire, arousal, orgasmic, and sexual pain

disorders) drawn from the DSM-IV and ICD-10 were not changed.

While the definitions remained similar in basic aspects of each

disorder, an important addition was the emphasis on personal
distress of the patient.

( Basson et al., 2001)

New definitions from the Consensus

Conference

Sexual Desire Disorders

Sexual Arousal Disorders:

Hypoactive sexual desire disorder: the persistent or recurrent

deficiency (or absence) of sexual fantasies/thoughts, and/or desire for
or receptivity to sexual activity, which causes personal distress (Basson
et al., 2001).
Sexual aversion disorder: the persistent or recurrent phobic aversion to
and avoidance of sexual contact with a sexual partner, which causes
personal distress (Basson et al., 2001).
the persistent or recurrent inability to attain or maintain sufficient sexual
excitement, causing personal distress, which may be expressed as lack
of subjective excitement, or genital (lubrication/swelling) or other
somatic responses (Basson et al., 2001).

Orgasmic disorder

the persistent or recurrent difficulty, delay in or absence of attaining an

orgasm following sufficient sexual stimulation and arousal which causes
personal distress (Basson et al., 2001).

( Basson et al., 2001)

New definitions from the Concensus

Conference (cont.)

Sexual Pain Disorders

Dyspareunia: the recurrent of persistent genital pain associated

with sexual intercourse (Basson et al., 2001).

Vaginismus: the recurrent or persistent involuntary spasm of

the musculature of the outer third of the vagina that interferes
with vaginal penetration, which causes personal distress
(Basson et al., 2001).

Noncoital sexual pain disorder: recurrent or persistent genital

pain induced by noncoital sexual stimulation (Basson et al.,
2001).
This category was added to the others already included in DSM-IV
and ICD-10 classification in order to encompass other sexual pain,
recognizing the experience of pain that does not involve penile
vaginal intercourse.

( Basson et al., 2001)

A Feminist Perspective of FSD

A working group on A New View of Womens Sexual Problems met in the
summer of 2002 to discuss the attention brought to female sexuality through
publicity generated around treatment for erectile dysfunction in men.
The DSM-IV criteria of FSD was revisited and critiqued on its relevance
when applied to females.

According to Tiefer, Hall and Travis (2002), there is a false notion of sexual
equivalency between men and women.
Desire and arousal are typically not differentiated from one another by women,
but the nomenclature marks these terms as separate.
The social environment a woman lives in is also not considered, yet environment
can affect physiological sexual functioning.
Relational dimensions of sexuality are also overlooked, yet relational aspects are
often at the base of both satisfaction and problems related to sexuality.
With psychological aspects of FSD being determined through measurement of
physiological symptoms, the assumption becomes if the sexual parts work, there
is no problem (Tiefer et al., 2002).
( Tiefer et al., 2002)

A Feminist Perspective of FSD (cont.)

With the interplay of research and drug company funding, as well as

publicity of treatments for sexual dysfunction, physiological
problems have been overemphasized and separated them from the
overall problem encompassed by FSD.
Problems, such as those related to relationship or cultural/moral
conflict, are pushed into the vague category of psychological without
being fully addressed or studied.
In an effort to bring more subjectivity and female perspective to
researching and understanding FSD, the working group on a New
View of Womens Sexual Problems developed a new definition.

Female sexual problems were defined as discontent or dissatisfaction

with any emotional, physical or relational aspect of sexual experience
(Tiefer et al., 2002)

( Tiefer et al., 2002)

A Feminist Perspective of FSD (cont.)

The definition developed by the group encompassed the four

aspects considered sources of female sexual disorders.

Sociocultureal, political, or economic factors

Partner and relationship factors
Psychological factors
Medical factors

The New View group convened to discuss the current knowledge of

FSD and has called for a change in the definition of FSD to more
accurately apply to womens sexuality, as well as create a deeper
understanding of the multidimensional nature of FSD.

( Tiefer et al., 2002)

Areas of Further Research in FSD

Epidemiological research

Researchers need to build their knowledge of prevalence,

predictors, and outcomes of FSD
Anatomical research

The anatomy of normal female sexual function has been

overlooked in the light of research concerning male physiology.

The actual biological mechanism of arousal and orgasm in

females and normal female sexual response needs to be
researched and understood more clearly before FSD can be
researched and more effectively treated.

Affect of aging and menopause which are unique to women

should be looked at closer to understand the hormonal
processes involve in FSD.

(Basson et al., 2001)

Areas of Further Research in FSD

(cont.)

There is a lack of understanding concerning the interaction of

simultaneously occurring physiological and subjective aspects of
female sexual arousal. This area is important in understanding why
women experience FSD despite the presence of physiological
indicators of sexual arousal.

Methods of measuring arousal need to be improved to make them

more generalizable to the spectrum of individual differences from
woman to woman.

A final area of importance is the effort to make health care providers

aware of FSD and encourage more knowledge and training in this
area of womens health.

( Basson et al., 2001)

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permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000).