Fact Sheet

What Is Female Sexual Dysfunction (FSD)?

Under the general heading of FSD, there are seven classifications; their official definitions are given below:

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.

Sexual Aversion Disorder: the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.

Sexual Arousal Disorder: the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as a lack of subjective excitement or a lack of genital (lubrication/swelling) or other somatic responses.

Orgasmic Disorder: the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.

Dyspareunia: recurrent or persistent genital pain associated with sexual intercourse.

Vaginismus: recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.

NonCoital Sexual Pain Disorder: recurrent or persistent genital pain induced by noncoital sexual stimulation.

It is important to note that each of these definitions requires the condition to be persistent or recurrent.

Who May Have Female Sexual Difficulties?

A woman’s sexuality is complex. It is the product of her genes, her upbringing, her history, her mood, her physical health, her medications, her environment, and her relationships. Women may find sexual dysfunction upsetting and damaging to their relationships. A survey published in 1999 in the Journal of the American Medical Association it was estimated that 43% of American women had experienced sexual difficulties. In this survey, approximately one third of the women reported lack of interest in sex; one fourth did not have orgasms; and one fifth did not find pleasure in sex. Other research found a total of 24.4% of women reported marked distress about their sexual relationship and/or their own sexuality. In Australia, from early to late menopausal transition, the percentage of women with scores indicating sexual disorders increased from 42% to 88%. In another study from Great Britain, 53.8% of women who had at least one heterosexual partner in the previous year reported at least one sexual problem lasting at least one month. Furthermore, persistent sexual problems, which were defined as lasting at least six months, occurred 15.6%.

What Causes Female Sexual Difficulties or FSD?

This is a new field; much is unknown. Many factors contribute to female sexuality. The cause of FSD in any woman may be psychogenic, physical, mixed psychogenic and physical, or unknown.

Psychogenic factors are very important. These may include ignorance of one’s body and the sexual response, environment, religious beliefs, social pressures, history of sexual abuse, bad sexual experiences, coercive partners, stress, unrealistic expectations, and relationship issues, as well as fear of intimacy, vulnerability, and losing control. Anger and resentment towards a partner, or sexual dysfunction in the partner can strain the relationship. An inattentive, insensitive, or unskilled partner can make sex unrewarding and thus, suppress interest. Stress related to raising children or balancing a job and homemaking can interfere with intimacy.

Physical factors that may contribute to FSD include medications (birth control pills, antidepressants, and some hypertension drugs), depression, hypothyroidism, spinal cord injury, nerve damage (diabetes, perineal trauma, hysterectomy, childbirth), atherosclerosis, and hormonal deficiencies among others.

Mixed physical and psychogenic causes would be those cases in which there is a combination of both types. Since there usually is a psychological reaction to FSD, women who have physical factors may appear to have both.

Finally, some cases will be a mystery. No cause can be identified at this time.

What Treatments Are Available?

An important part of any treatment is an interview with a therapist who can evaluate the psychological causes and the psychological impact of a woman’s FSD. This interview may be conducted individually or with the woman’s partner. The outcome may be that therapy or counseling is necessary.

Medical causes for FSD should be investigated; a complete medical history and physical examination including specific examination of the vulva, vagina, and perineum should be performed. Blood testing including a general panel and specific endocrine tests should be considered. Medications without sexual side-effects should be explored. Hormonal replacement should be addressed. Injuries, atherosclerosis, and diabetes can cause blood flow problems which must be addressed. Some products are available for various conditions; additional products are in research now. Pain disorders and vaginismus can be treated with medications, physical therapy, exercises, and transcutaneous nerve stimulation. Surgery may be considered for certain pain disorders if all other treatments have been unsuccessful.

Are Medical Students Receiving Training in Sexuality and What About Current Providers?

Most healthcare providers have received little or no training in the area of sexuality, and even less in the area of female sexual difficulties.

In 2003, the International Journal of Impotence Research published research concerning sexuality training in US and Canadian medical schools. Schools were surveyed to determine how well prepared physicians were to diagnose and treat sexual problems.

• There were 101 survey responses (71.6%) of a potential of 141 medical schools (74% of United States and 50% of Canadian medical schools).
• A total of 84 respondents (83.2%) for sexuality education used a lecture format.
• A single discipline was responsible for this teaching in 32 (31.7%) schools, but a multidisciplinary team was responsible in 64 (63.4%) schools (five schools failed to respond to the question).
• The majority (54.1%) of the schools provided 3-10 hours of education. Causes of sexual dysfunction (94.1%), its treatment (85.2%) altered sexual identification (79.2%) and issues of sexuality in illness or disability (69.3%) were included in the curriculum of 96 respondents.
• Only 43 (42.6%) schools offered clinical programs, which included a focus on treating patients with sexual problems and dysfunctions, and 56 (55.5%) provided the students in their clerkships with supervision in dealing with sexual issues.

This article concluded that more in depth human sexuality education may be needed to meet the expectation of the patient for appropriate care concerning sexual problems.

D S Solursh , J L Ernst, R W Lewis et al. The human sexuality education of physicians in North American medical schools. Int. J. Impot. Res. 2003; 15 Supp 5:S41-45.

Research

Research is still needed in the area of female sexual health and difficulties. Much is still unknown in the areas of:

• Anatomy
  The nerves of the pelvic basin still have not been identified. The actual size of the clitoris was just discovered a few years ago by Helen O’Connell M.D. She found that the clitoris is larger than originally thought. It is up to 9 cm in length and 6 cm in width in younger women.
• Biochemistry
• Pathology
  What are the triggers that cause difficulties? Why do birth control pills and SSRIs cause sexual difficulties?
• Epidemiology
• Neurological Pathways
  What triggers arousal or an orgasm?

By having a better understanding of these areas, then the correct treatment can be provided.

Unfortunately there is very little funding available from government and non-government sources to discover the answers to these questions and in turn the correct treatment for FSD.

Public Education

Every woman needs to be her own advocate. She can increase her chances of being the best advocate possible by becoming a knowledgeable consumer of healthcare. There are legitimate Internet sites and credible books and magazines that can help her accomplish that goal.