Female Sexual Dysfunction: What's Going Wrong?

Two Key Types of Sexual Arousal

Let’s talk about the two different types of arousal. One is what we call “subjective arousal,” which is the perception of pleasure: thinking, for example, “I’m so turned on right now.” Then there is physical arousal. For women, this involves physiological changes triggered by sexual stimuli and includes vaginal lubrication, increased blood flow to the genitals, elevation in heart rate, and muscular tension.

Interestingly, when researchers studied these two types of arousal in women, they found a significant mismatch between them. This mismatch, also called non-concordance, can occur as often as 90 percent of the time. Physical responses such as vaginal lubrication, therefore, do not necessarily mean a woman is feeling turned on.

Do Hormone Levels Matter for Female Sexual Desire?

Studies have evaluated levels of hormones such as estrogen and testosterone in women and have not consistently shown that these levels are predictive of sexual desire, particularly in premenopausal women. In other words, we can’t just check an estrogen or testosterone level and diagnose a woman with low sexual desire. Decreased levels of estrogen and progesterone can and do affect women’s sexual functioning in perimenopause and menopause, but more predictive, researchers have found, are the effects of personal history, psychosexual history, psychiatric history, and the state of their current relationship.

What Other Factors May Be Involved?

A number of neurotransmitters and hormones are involved in the Dual Control Model of sexual response, the mixture of sexual accelerators and brakes discussed in my prior article. To begin with, norepinephrine, also known as noradrenaline, which is released continuously in the body, acts as an excitatory molecule for sexual response. Oxytocin, the bonding hormone, also seems to stimulate sexual interest. Finally, dopamine, the pleasure hormone, is involved in the excitatory system.

Within the inhibitory system, serotonin plays a role, creating a feeling of satisfaction or satiety that may diminish the wanting of sexual desire. Also, our endocannabinoids can dampen our sexual interest.

Certainly, sexual function can be influenced by our physical health, including factors like elevated blood pressure, heart disease, cancer, either in treatment or post-treatment, the hormone changes that happen over time with menopause, and certain medications, such as beta-blockers and SSRIs like Prozac or Zoloft.

Depression and anxiety can also negatively affect desire and arousal, with data suggesting nearly half of individuals with untreated depression can experience low desire and difficulty with arousal.

It is also important to note that when people are prescribed medications that boost serotonin activity, helpful for many psychiatric symptoms such as anxiety and depression, they may carry the potential side effect of decreased desire and difficulty reaching orgasm. It is important to be aware of these potential side effects and to let your doctor know if they occur.

DSM-5 Diagnoses of Female Sexual Dysfunction

In the DSM-5, there are three main diagnoses related to female sexual dysfunction, a simplification from prior versions. They are:

1. Female Sexual Interest/Arousal Disorder, which combines the prior diagnoses of hypoactive sexual desire disorder (HSDD) and female arousal disorder
2. Pelvic pain or penetration disorder, which combines dyspareunia (painful sex) and vaginismus (vaginal wall spasm)
3. Orgasmic Disorder, which refers to the difficulty reaching orgasm with adequate stimulation

Importantly, for any of these diagnoses, symptoms must have been present for at least 6 months and must cause the woman significant distress. There is no quantifiable “normal” level of sexual desire and arousal. If it only bothers her partner, or if the woman seeking evaluation just believes she “should” feel differently, a further conversation must occur. Perhaps better communication between partners could be a crucial first step, for example.

Treating low sexual desire is a very individual process, and women should understand that whatever line they want to draw, whatever feels right for them, is an important place to begin.

A. Female Sexual Interest/Arousal Disorder

Female sexual interest/arousal disorder describes women who have always struggled with a distressing lack of sexual desire or arousal (primary) or are experiencing a change from prior experiences (secondary). Before making this diagnosis, I want to make sure the woman understands the difference between spontaneous and responsive desire and knows how to stimulate the latter. If she believes only spontaneous desire is “real,” then changing her (and her partner’s) outlook and behaviors can be very helpful.

Sex Essential Reads

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In addition to significant distress and at least 6 months of symptoms, a diagnosis of female sexual interest/arousal disorder requires at least three of the following six criteria:

1. Lack of desire for sex

2. A lack of sexual thoughts or fantasies

3. Lack of initiation or receptivity of sexual activity

4. Lack of sexual pleasure

5. Inability for sexual stimuli to trigger desire

6. An impaired physical sexual arousal response

If you find that even in situations that previously led to desire, you are no longer having the same experience, this may be something to discuss with a general therapist or sex therapist. Perhaps other factors are contributing to this, including conflict in the relationship, work stressors, physical changes, or body image concerns. In other words, you may have some persistent activation of powerful brakes, and this may be an important starting point for the discussion before any further treatment is considered.

B. Genital Pelvic Pain/Penetration Disorder

The next diagnosis is genital pelvic pain or penetration disorder, combining dyspareunia (painful sex) and vaginismus (vaginal wall spasm), as well as intense anxiety about vaginal penetration.

It is important to find out if these symptoms are new or have been longstanding. If they are new, could there be a physical source, such as perimenopause and its effects on vaginal drying and atrophy?

If sex is painful for women, how long has it been going on? Has it always been this way? Has this been a change? Taking a full history is important to identity what physical and psychological factors may be contributing to this difficult experience for women.

C. Female Orgasmic Disorder

Lastly, female orgasmic disorder, or difficulty reaching orgasm, whether they've never been able to do so (primary anorgasmia), or this is a new change or particular to a situation (secondary anorgasmia). The criteria for this diagnosis include the presence of either of the following in more than 75 percent of occasions of sexual activity:

1. Marked delay in, infrequency of, or absence of orgasm
2. Markedly reduced intensity of orgasmic sensations

One very important issue to consider before diagnosing female orgasmic disorder is how often a particularly sexual activity leads to orgasm. For example, studies show only about 25 percent of women are able to regularly orgasm with penetrative intercourse. The majority of women, therefore, are only occasionally, rarely, or never able to orgasm with this type of sex. This is certainly different from the inaccurate portrayal of consistent, intense orgasms during penetrative sex that you find in most pornography.

For many women, orgasm is much more likely when there are experiencing stimulation with a hand, tongue, or a vibrator, as long as these types of sexual activity stimulate the clitoris. This very important female organ, equivalent to the male penis, is the primary site of women’s sexual pleasure.

Filled with nerve endings and extending far beyond the visible portion, this organ is key to explore, especially if orgasm has been elusive. Having this discussion with women struggling to reach orgasm is so important and frequently avoids an unnecessary diagnosis of female orgasmic disorder.

Seeking treatment for these challenges can lead women down a path of expensive and ineffective stimulants, buying some of the many creams and other enhancing “wellness” products on the market today. I would view these options with skepticism until we have clear evidence they can be helpful, or at least we know they aren’t harmful.

Tune in for the next article to find out how can we treat female sexual dysfunction.