Female sexual dysfunction

Ozge Tuncalp and Susan Richman discuss the medicalisation of sexual arousal in women

Sexuality became the focus of academic investigation relatively recently, in the second half of the 20th century. It still remains an exciting, yet sensitive and controversial subject. Although the evaluation and treatment of sexual problems in men have focused almost exclusively on erection, female sexual responses have proved much more difficult to quantify. How do you describe what is "normal"? And what do we diagnose as a "dysfunction," when female sexuality has more than just the mechanical aspect to be taken into consideration. Psychological, sociocultural, and relationship factors are just as important.

For the past 40 years, the clinical ideal for normal sexual functioning has been the model of sexual response first described in 1966 by William Masters and Virginia Johnson.^w1 Their now classic human sexual response model includes four phases-excitement, plateau, orgasm, and resolution. The phases are characterised on the basis of changes in respiration, heart rate, muscle tension, and genitalia.^w1 This model has been criticised, however, for its inability to assess and manage women's sexual problems.

Research confirms that the female experience of sexual arousal is more influenced by thoughts and emotions than by feedback from reflexive genital vasocongestion.^w2 The physical model, therefore, remains inadequate.

An alternative sexual response model, the "biopsychosocial model," has been proposed to describe female sexual response.^w3 This consists of four dynamic components-biology, psychology, sociocultural influences, and interpersonal relationships-and specifies that a large component of women's sexual desire is responsive rather than spontaneous. In this model, spontaneous drive is not essential-lack of it is not considered to be a dysfunction.

Mass marketing

Medical centres, websites, continuing education symposiums, the lay press, and professional organisations have increasingly focused on women's sexual problems in the past decade. After the success of Viagra (sildenafil) in 1998 in men, attempting to equate dysfunctions in female sexuality has become the new venture for drug companies.

The first international consensus development conference in 1998 classified female sexual dysfunction into sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders. It required that a condition would be considered a disorder only if it creates distress for the woman experiencing it.^w4 According to these criteria, female sexual dysfunction can be a persistent or recurring reduction in sex drive, an aversion to sexual activity, difficulty becoming aroused, inability to achieve orgasm, or pain with attempted vaginal penetration. The prevalence of female sexual dysfunction so defined is 43%, based on a US national survey,^w5 which has itself been criticised because it classified women with sexual dysfunction.^w6

Many experts argued against the description of female sexual dysfunction in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. They said that limitations included assuming equivalency between men and women's physiology; exclusive acknowledgment of the medical approach; and neglect of the potential differences in personal values, approaches to sexuality, and social and cultural backgrounds in women.^w7

A new model has been proposed in an attempt to resolve these issues.^w7 It recommends considering women's sexuality within a broader multidimensional framework, emphasising that no single "normal" female sexual response or experience exists. The aspects covered by this model include sociocultural, political, and economic factors as they play a large role both in the development of sexuality and sexual problems as well as partner, relationship, psychological, and medical factors.

In the meantime, an international committee organised by the American Foundation of Urological Disease has published revised and expanded definitions of women's sexual dysfunctions, concentrating on subdividing female arousal disorders and redefining sexual pain disorders.^w8

Let's talk about sex

Few adults, let alone medical and nursing students, have received adequate comprehensive sexuality education. The American Association of Medical Colleges reported that the average medical school curriculum devotes 9-10 hours over four years to what is one of the most important topics to patients.^w9 Such training would ideally be appropriate to age, culturally sensitive, and individualised for varied learning styles. In addition, an important challenge that must be overcome is the clinician's own ability to be comfortable and capable in his or her own sexual belief system and personal life experience.^w10 Doctors and other healthcare professionals need to undergo a process of introspection regarding their own sexual development; sex education; cultural, spiritual, and familial messages; and personal expectations and behaviours to remove any potential bias in their therapeutic approach. In other words, they need to know their own sexual script. The ideal approach to the subject of sexuality requires patience, open ended questions, and a non-judgmental attitude, avoiding assumptions about sexual orientation while assuring confidentiality.

When it comes to treatment, a first approach is non-pharmacological therapy. Improving the couple's communication skills and providing education, information, and reassurance resolves most dysfunctions.^w11 Healthy lifestyle changes, such as drinking more water, quitting smoking, and doing more exercise, may also positively influence sexual function. Sensate focus, a series of specific exercises for couples, which encourages each partner to take turns paying increased attention to their own senses, and vaginal weights can be used for the desensitisation treatment of vaginismus. Hormonal support, which can increase genital blood flow, is useful for postmenopausal genital atrophy. New drugs, such as tibolone (currently available in Europe and Australia) whose products have estrogenic, androgenic, and progestational effects are under investigation.^w11

Considering the variety of female sexual function models and criteria, and the paucity of non-biased objective data, clinicians should be encouraged to take a collaborative approach in the management of sexual problems, using a biopsychosocial interdisciplinary approach.

Ozge Tuncalp, postdoctoral fellow, affiliation
Email: ozge.tuncalp@yale.edu

Susan Richman, director, reproductive health, Department of obstetrics and Gynecology, Yale University School of Medicine


studentBMJ 2005;13:265-308 July ISSN 0966-6494

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