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A woman’s sexual responsiveness is not the same as a man’s. Ignoring its complexity can make difference look like dysfunction.

The more things change, the more they remain the same. Just when it began to seem as though gender-specific medicine was here to stay, medical research in males is once again being applied to women. The success of sildenafil (Viagra) in treating erectile dysfunction in men has spawned a spate of studies of that drug in women, which have shown little promise. It has also given rise to a movement to establish female sexual dysfunction (FSD) as a new disease category, just as erectile dysfunction had been in the 1990s. 

Coming up with a definition

The implied parallel between FSD and male impotence is deceptive. The word “dysfunction” — medical parlance for anything that doesn’t work the way it should — suggests that there is an acknowledged norm of female sexual function. That norm has never been established. Unlike penile erection, which is a quantifiable physical event, a woman’s sexual response is qualitative. It embodies desire, arousal, and gratification — and it can’t be measured objectively. Without an empirical standard by which to assess female sexual function, it would seem difficult, if not impossible, to come up with criteria for female sexual dysfunction.

That hasn’t stopped experts from trying. The American Foundation for Urologic Disease has held yearly international consensus conferences on FSD. The goal has been to mirror the work of a National Institutes of Health panel that developed diagnostic and treatment guidelines for erectile dysfunction. In doing so, the FSD panel built on definitions of sexual dysfunction from the World Health Organization’s International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The ICD-10 focuses on physical factors that influence sexual response, and the DSM-IV emphasizes the emotional and psychological factors involved. Although neither publication defines female sexual dysfunction as such, both have subsets of the sexual dysfunction category that apply exclusively to women.

The FSD panel’s first report, which was published in the March 2000 issue of the Journal of Urology, proposed a working definition of sexual dysfunction in women that includes both physiological and psychological symptoms. Experiencing any one of them warrants an FSD diagnosis, but some must also be a source of distress for the woman to qualify as a sign of FSD. 

Definitions of female sexual dysfunction (FSD)
Disorder	Description
Hypoactive sexual desire disorder†	Chronic lack of interest in sexual activity
Sexual aversion disorder†	Persistent or recurrent phobic avoidance of sexual contact with a partner
Sexual arousal disorder†	Persistent or recurrent inability to attain or maintain sexual excitement
Orgasmic disorder†	Chronic difficulty in attaining (or inability to attain) orgasm following sufficient arousal
Dyspareunia	Pain during intercourse
Vaginismus	Involuntary vaginal spasms that interfere with penetration
Noncoital sexual pain	Genital pain following stimulation during foreplay
† These must cause the woman distress in order to qualify as FSD. Source: Basson R, et al. “Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications,” Journal of Urology (March 2000), 163:888–895.

Is there an epidemic?

Viagra alone didn’t spark this interest in FSD. It can also be attributed to the publication of a 1999 study indicating that 43% of American women experienced sexual dysfunction (Journal of the American Medical Association, Feb. 10, 1999).

That simple number, which has become the mantra of FSD advocates, belies the complexity of the issue. The 43% figure emerged from an analysis of responses by 1,749 women and 1,410 men to a similar set of questions. Women who reported any of the following — lack of sexual desire, difficulty in becoming aroused, inability to achieve orgasm, anxiety about sexual performance, reaching orgasm too rapidly, pain during intercourse, or failure to derive pleasure from sex — were conside red to have sexual dysfunction. Women were more likely to suffer from sexual dysfunction if they were single, had less education, had physical or mental health problems, had undergone recent social or economic setbacks, or were dissatisfied with their relationship with a sexual partner. 

In the years since the report’s publication, researchers have revisited it and challenged its conclusions. Several critics have pointed out that the women were not asked whether their problems were severe enough to cause personal distress. Some have also noted that the duration of problems in the survey — two months — may have represented only a temporary response to illness or other stress.

In 2000, critics garnered additional support from a preliminary report by the Kinsey Institute, the organization that published a benchmark study on female sexual behavior in 1953. The most recent Kinsey data indicate that emotional health and personal relationship factors were more important for women’s sexual satisfaction than achieving orgasm. In that survey, general well-being ranked at the top as a requirement, followed by emotional reactions during lovemaking, the attractiveness of one’s partner, physical response to lovemaking, frequency of sexual activity with one’s partner, the partner’s sensitivity, one’s own state of health, and the partner’s state of health.

Women and men are different

In an article published in the October 2002 issue of the Archives of Sexual Behavior, Dr. John Bancroft, director of the Kinsey Institute, suggested several reasons why women and men have evolved to experience their sexuality differently. First, although testosterone stimulates the libido in both sexes, it’s a far stronger determinant of sexual interest in men. Second, male orgasm (ejaculation) is essential for reproduction, while female orgasm is — in strictly reproductive terms — irrelevant.

Bancroft also speculated that women’s greater tendency toward sexual inhibition could be a response to cultural influences. Most societies have restricted women’s sexual expression more tightly than men’s. According to Bancroft, sexual inhibition might also be a protective mechanism evolved to discourage women from having more children than they can raise — a danger when, for example, a partner is unsupportive or the woman has physical or emotional problems. The woman is “turned off” because, in an evolutionary sense, the conditions for motherhood aren’t favorable. If this theory is correct, some women whose sexual response has been deemed dysfunctional might actually be functioning as nature intended.

When is sex truly dysfunctional?

Despite the annual consensus conferences on FSD, both the term and the suggested diagnostic criteria continue to be widely debated. But there is one aspect of the suggested guidelines that no one is disputing — the stipulation that problems with sexual arousal must be “a source of distress” to the woman. If you’re satisfied with your sex life, you don’t have FSD.

Female sexuality in the post-Viagra world

There’s little doubt that Viagra’s influence has spilled over into the arena of women’s health. By kindling a search for a comparable elixir to treat women’s sexual problems, Viagra has made women’s sexuality a high-profile research target. And by enabling older men to recover erectile function, it has stimulated research into later-life sex and drawn welcome attention to the sexual vitality of postmenopausal women. 

But the resulting focus on pharmaceutical rather than emotional solutions has serious limitations. This way of framing the problem threatens to make women’s sexual experience, no less than men’s, a performance issue. Also, without downplaying the significance of any woman’s pain or distress, there can be real danger in defining difference as “dysfunction.”

Improving sexual responsiveness

Although the incidence of sexual dysfunction may have been exaggerated, the problem is real for millions of women. It’s rarely a simple issue, because sexual pleasure — and sexual distress — involve a complex web of physical and emotional factors. If you’re dissatisfied with your sex life, you may want to try any or all of the following:

Have an honest discussion with your partner. Sexual pleasure is the result of a mind/body collaboration — usually involving two minds and two bodies. As surveys attest, the most satisfying sexual activity is the product of a caring, secure personal relationship. When one partner is dysfunctional, the other is affected as well. For example, a woman may interpret her partner’s inability to have an erection as a sign that he no longer finds her attractive. A talk with one’s partner can help to determine whether the problem is primarily physical or emotional.

Seek medical treatment. If sexual problems are new — especially if you’re postmenopausal, have undergone surgery, have developed a chronic medical condition, or are taking a new medication — you should discuss the circumstances with your doctor. A variety of physical changes can be responsible for discomfort or reduced pleasure during sex (see chart), and many can be reversed with appropriate therapy.

 

Conditions, procedures, and drugs that can affect sexual response in women
Condition	Effect(s)
Estrogen insufficiency	Reduced vaginal lubrication
Testosterone insufficiency	Reduced libido
Diabetes	Reduced vaginal lubrication, vaginal infections
Thyroid, adrenal, pituitary disorders	Reduced vaginal lubrication
Sickle cell anemia	Decreased arousal and orgasm
Spinal cord damage, stroke, Parkinson’s disease, multiple sclerosis	Decreased vaginal lubrication, arousal, orgasm
Vaginitis, pelvic inflammatory disease, endometriosis	Vaginismus, dyspareunia
Prolapsed uterus or uterine fibroids	Decreased arousal
Kidney failure requiring dialysis	Decreased arousal and desire due to hormone imbalance
Arthritis	Chronic pain that limits motion
Sjögren’s syndrome	Decreased lubrication
Procedure	Effect(s)
Oophorectomy	Decreased estrogen and lubrication
Episiotomy	Tightness of vaginal opening
Mastectomy, colostomy	Loss of self-esteem and sources of stimulation; fear of discomfort
Drugs	Effect(s)
Antihypertensives (diuretics, beta blockers, calcium-channel blockers, anti-adrenergics)	Reduced libido, difficulty reaching orgasm
Anticholinergics (propantheline, methantheline)	Decreased lubrication
Barbiturates	Various problems at high doses
Benzodiazepines (diazepam, alprazolam)	Difficulty reaching orgasm
Antidepressants	Difficulty reaching orgasm
Cancer chemotherapy (cyclophosphamide, anti-estrogens)	Vaginal dryness, reduced libido, difficulty reaching orgasm
Opiates (morphine, codeine, methadone)	Reduced libido
Sources: Carlson K, et al. Harvard Guide to Women’s Health; Lightner D. Mayo Clinic Proceedings, 2002 77: 698–702

Consider psychotherapy. Althoug h current research, which is heavily financed by pharmaceutical companies, emphasizes the physical causes of sexual dissatisfaction, surveys continue to support the old adage, “A woman’s most important sex organ is her brain.” Our sexual responsiveness is strongly related to our emotional well-being, so deep-seated issues of control and trust, as well as identity and body image, can’t help but influence our sexual responsiveness. If you sense that such issues are interfering with your sex life, you might consider psychotherapy.