Female Sexual Dysfunction

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 ina 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.

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 Populations who may experience female sexual dysfunction (FSD): (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 professional’s 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 female’s 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 (MAO’s), benzodiazepines, and tricyclic antidepressants (TCA’s) 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 • 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).” • Sexual Arousal Disorders: • “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 Women’s 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 Women’s 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 women’s 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 women’s health. ( Basson et al., 2001)

Bibliography • Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., Fourcroy, J., Goldstein, I., Graziottin, A., Heiman, J., Laan, E., Leiblum, S., Padma-Nathan, H., Rosen, R., Segraves, K., Segraves, R. T., Shabsigh, R., Sipski, M., Wagner, G., & Whipple, B. (2001). Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and classifications. Journal of Sex & Marital Therapy, 27, 83-94. • Berman, J.R., Berman, L., and Goldstein, I. (1999). Female Sexual Dysfunction: incidence, Pathophysiology, evaluation, and treatment options.Urology, 45, 385-391. • Brassil, D.F, Keller, M. (2002). Female Sexual Dysfunction: Definitions, Causes, and Treatment. Urologic Nursing, 22, 237-242. • Laumann, E.O, Paik, A., Rosen, R.C. (1999). Sexual Dysfunction in the United States. Journal of the American Medical Association, 281, 537-544. • Sarwer, D.B, Durlak, J.A. (1996). Childhood Sexual Abuse as a Predictor of Female Sexual Dysfunction: A Study of Couples Seeking Sex Therapy. Child Abuse & Neglect, 20, 963-972. • Segraves, R.T. (2002). Female Sexual Disorders: Psychiatric Aspects. Canadian Journal of Psychiatry, 419-426. Retrieved April 6, 2004 from Ebsco host. • Tiefer, L., Hall, M., & Travis, C. (2002). Beyond dysfunction: A new view of women’s sexual problems. Journal of Sex & Marital Therapy, 28, 225-232. • http://www.behavenet.com/ (2004). Behavenet Clinical Capsule: DSM-IV-TR (Text Revision). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000).

Female Sexual Dysfunction