Female Sexuality: Are You Satisfied With Your Sex Life?
by Alan Kronhaus, M.D., Health and Welllness Editor
 Female sexuality is a very touchy subject. If you’re satisfied with your sex life, read no further. If your sex life causes you distress, at least some of the time, you may be suffering from female sexual dysfunction, commonly referred to as FSD.
Female sexual dysfunction? Yup. It’s a new “disease category” just as erectile dysfunction (ED) was in the 1990s. Unlike ED, however, the notion of female sexual “dysfunction” is highly controversial.
The word “dysfunction” is medical parlance for anything that doesn’t work the way it should. With ED, there’s a pretty clear, objective standard of normal functioning. A penile erection is a quantifiable physical event. It occurs (or doesn’t) when the man becomes aroused, and continues (or doesn’t) until he has an orgasm.
Female sexual issues are less clearly defined or easily measured. A woman’s sexual arousal is largely qualitative and therefore harder to measure objectively. Without an empirical standard by which to assess female sexual function, it would seem difficult, if not impossible, to come up with a criteria for female sexual dysfunction.
That hasn’t stopped experts from trying. The clinical standard for normal sexual functioning has been the Human Sexual Response Model (HSRM) described in 1966 by Masters and Johnson. They studied sexual behavior by observing and measuring masturbation and sexual intercourse in the laboratory. Their model has been the basis for the diagnosis and treatment of sexual dysfunction for the past forty years.
The HSRM defines the “natural and normal” human sexual response for both men and women as consisting of a sequence of physical events that can be divided into four phases: excitement, plateau, orgasm and resolution. According to that model, a healthy normal sexual response entails a smooth passage through those four phases. A decade after Masters and Johnson’s work, the stage of “desire” was added to their model.
From the time of Masters and Johnson until roughly the turn of the century, treatment of sexual problems – sex therapy – was the province of psychologists and psychiatrists. Sex therapists emphasized psychological and emotional factors, and educated both sexual partners about effective sexual communication and technique.
In 1998 Viagra was approved by the FDA for the treatment of erectile dysfunction, and things started to change. Interest was directed away from psychosexual treatment strategies to pharmacologic solutions to sexual problems, first among males and more recently among females. Management of sexual problems shifted from psychologists and psychiatrists to urologists, even in matters of female sexuality.
But Viagra alone didn’t spark the “medicalization” of female sexual problems. In 1999, a study published in the Journal of the American Medical Association (JAMA) indicated that 43% of American women experienced sexual dysfunction. Although widely criticized, that simple number became the mantra of FSD advocates, and the basis for the belief that there is an “epidemic” of female sexual dysfunction. The race was on to find an elixir similar to Viagra to treat women’s sexual problems.
At about the same time, considerable efforts were underway to arrive at some consensus about the definition of female sexual dysfunction. In 1998 an international consensus conference on FSD classified women’s sexual problems into four general categories which closely followed the classification system of the International Classification of Diseases (ICD) and the American Psychiatric Association’s Diagnostic and Statistical Manual. The categories are:
• sexual desire disorders
• sexual arousal disorders
• orgasmic disorders and
• sexual pain disorders
Importantly, the conference established that a “condition” would be considered a “disorder” only if it creates distress for the woman experiencing the condition. (The exception was sexual pain disorders, since distress is part and parcel of a “pain” diagnosis.) So one of the key conclusions is: if you’re satisfied with your sex life you don’t have FSD! Critics of the 1999 JAMA study and its 43% prevalence figure for FSD point out that the women in that study were not asked whether their problems were severe enough to cause personal distress.
The anti-FSD lobby argues that the entire new “disease category” is useless because the symptoms are so vague and subjective. Two women with the same symptoms, for example, could have different diagnoses based on whether or not they felt bothered by their symptoms – a situation that does not lend itself to medical diagnosis and treatment. Moreover, the diagnostic criteria are so broad that they could apply to nearly half the female population.
Although the diagnostic criteria for FSD are hotly disputed and the prevalence of the disorder may have been exaggerated by the study published in JAMA, the problem of sexual dysfunction is real for millions of women. In a recent attempt to estimate the prevalence of sexual problems, a huge international study found that lack of interest in sex and the inability to reach orgasm were the most common problems cited by women worldwide, with prevalence figures ranging from 26% to 43% and 18% to 41% respectively.
So the questions remain: If a woman is less interested in sex than she used to be, is she sick? What if she is unable to reach orgasm? When do these “dysfunctions” warrant treatment, and what is the best therapeutic approach? Sexual pleasure and sexual distress both involve a complex web of physical and emotional factors, as well as factors grounded in the relationship between sexual partners, which makes the answer anything but simple.
As you might imagine, the debate about treatment is as heated and political as the debate about diagnosis. Certain groups cite the new biomedical and pharmaceutical approaches to FSD as the most compelling example of the “corporate-sponsored creation of a disease.” They complain that such approaches “medicalize” problems of human sexuality to an extent that will prove unhelpful and possibly harmful. Advocates of the so-called “New View” approach to women’s sexual problems, including some medical professionals, mental-health workers and feminist groups, contend that the “biopharmaceutical” approach tends to downplay the importance of psychological, cultural, socioeconomic, and relational factors that are at least as important, if not more so, than the biologic and physiologic factors.
One thing is certain: Viagra has made women’s sexuality a high-profile research target. It sparked the search for a “little blue pill” – a medical “silver bullet” if you will – that would do for women what Viagra did for men. By restoring erectile function in older men, Viagra has also drawn welcome attention to the sexual vitality of older (postmenopausal) women, and stimulated research into later-life sex.
Considering the commercial success of Viagra and the extent to which it has evolved from a medical to a recreational drug, the market for a “women’s Viagra” is certainly mouth-watering for the pharmaceutical companies. The success of Viagra, however, is based in part on the widespread but mistaken belief that it enhances performance and endurance. Many people seem to believe that the drug would solve problems in their relationship.
Viagra itself has been extensively studied as a treatment for female sexual dysfunction. Several large-scale, placebo-controlled studies involving some 3000 women with female sexual arousal disorder showed inconclusive results regarding the efficacy of Viagra, and the manufacturer (Pfizer) decided not to file for regulatory approval to use the drug for women.
Another approach to female desire disorders involves the use of various preparations of testosterone, the hormone that appears to be the key mediator of sexual desire in both men and women. The results are far from settled and, like most everything in this arena, vigorously debated. Although the unfolding research raises serious questions about the safety and efficacy of testosterone therapy for women with sexual problems, the “off-label” prescribing of testosterone for that purpose is widespread.
Just this summer, The Journal of Sexual Medicine published preliminary data suggesting that an investigational drug that acts in the brain may increase sexual desire in women with sexual arousal problems. If confirmed by subsequent research, this centrally-acting agent could be a major step in the quest for a “silver bullet” to treat women’s sexual problems. Currently, there is no government approved therapy for FSD.
While researchers, pharmaceutical companies and medical professionals are pursuing new therapeutic approaches to FSD, there are many therapeutic options that people who are dissatisfied with their sex life may want to try.
Talk to your partner. Sexual pleasure clearly involves collaboration between mind and body – usually two of each. Most satisfying sexual activity is grounded in caring, secure personal relationship, which in turn is grounded in good communication. We all know from our own experience that if one partner is dysfunctional, the other suffers. So if there’s a problem, talk about it.
For example, if a man does not know how to effectively stimulate a woman, she’s not going to become as aroused as she would otherwise, and may not be able to reach orgasm as easily as she would with a more capable partner. The man might be ignorant (meaning uninformed, not stupid) about female sexual anatomy, or what to do with it, and a little “on the job” training might go a long way towards enhancing both partners’ sexual satisfaction.
But a woman may be unwilling to talk about the fact that she’s not being sexually aroused or satisfied. She may feel that to raising the subject would be interpreted as a “put down” by her partner, or might otherwise jeopardize the relationship. Culturally, she may not feel “entitled” to indulge her impulses or achieve full sexual satisfaction. Even worse, a woman may interpret a man’s inability to stimulate her or to maintain an erection as a sign that he no longer finds her attractive.
Again, a talk with one’s partner can help to determine whether the problem is primarily physical or emotional. It may point the way to a solution, or highlight the need for outside help.
Talk to your doctor. If your sexual problems are new, you should discuss them, and the circumstances surrounding them, with your doctor. This is especially true if you’re taking a new medication, are postmenopausal, have undergone surgery, or have developed a chronic medical condition. The list of drugs, diseases and conditions that can cause sexual problems is long, but many can be addressed with appropriate therapy.
Many antidepressants and antihypertensives, for example, can reduce sexual drive and make it more difficult to reach orgasm. This may be a good thing if you suffer from premature ejaculation, but it can be a very undesirable side effect. Estrogen insufficiency can reduce vaginal lubrication and cause significant discomfort during sex, and testosterone insufficiency can reduce libido, as mentioned earlier.
Consider psychotherapy or sex therapy. Despite the recent emphasis on physical causes of, and pharmaceutical solutions to, sexual dissatisfaction, there continues to be strong evidence to support the old adage that “A woman’s most important sex organ is her brain.”
A woman’s sexuality is strongly related to her emotional well-being and the status of her relationship with her sexual partner. It’s also tied to her perception of cultural norms and expectations, and her ability to meet or conform to them. These points are self-evident, but worth mentioning. They are also worth discussing with a therapist if you feel they are causing or contributing to problems with your sex life.
If you’re satisfied with your sex life, congratulations and good luck. If you’re not particularly satisfied, you’re in very good company. Talk to your partner, practitioner, or maybe even a friend. Try to understand what you can reasonably expect from your partner and from yourself, and how you can help each other. Try to find the locus of the problem(s), and the road that can lead you towards greater satisfaction. Every great journey begins with a few small steps, especially if you’re heading off in the right direction on a noble quest!
Alan Kronhaus, M.D. is owner of Doctor’s Making Housecalls, 919.932.5700 or online at www.doctorsmakinghousecalls.com
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