Sexual Dysfunction

A woman's sexuality is a complex interplay of physical and emotional responses that affects the way she thinks and feels about herself. When a woman has a sexual problem, it can impact many aspects of her life, including her personal relationships and her self-esteem. Many women are hesitant to talk about their sexuality with their health care professionals, and many health professionals are reluctant to begin a discussion about sexuality with their patients. Instead, women may needlessly suffer in silence when their problems could be treated.

Sexual activity includes a wide variety of intimate activities, such as fondling, self-stimulation, oral sex, vaginal penetration and intercourse. Every woman differs in her sexual interest, response and expression. A woman's feelings about sexuality can change according to the circumstances and stages of her life. Women also can experience a variety of sexual problems, such as lack of desire, difficulty becoming aroused, difficulty having an orgasm or pain during sex. When a physical or emotional problem associated with sex persists, it's time to contact a health care professional.

Characteristics of Sexual Arousal: Scientific Research

Early Research: Masters & Johnson
Research on the sexual response in the mid-1960s by Masters & Johnson established what is known as the traditional linear sexual-response cycle: desire-arousal-orgasm-resolution. The stages are defined as follows:

• Excitement/Arousal: The feeling that you want to have sex, followed by physical changes that occur in your body as you become sexually excited. These include moistening of the vagina; relaxation of the muscles of the vagina; and swelling of the labia, (skin folds that are part of the vulva), and the clitoris (a small, sensitive organ above the vagina, where the inner labia, which surround the vagina, meet). The nipples also become erect.
• Plateau: The above changes in the genitals continue, there is an increase in blood flow to the labia, the vagina grows longer, and glands in the labia produce secretions. There is an overall increase in muscle tension.
• Orgasm: Known as the peak of the sexual response, the muscles of the vagina and uterus contract leading to a strong, pleasurable feeling.
• Resolution: You return to your normal state.

Contemporary Research: Rosemary Basson, MD
More contemporary research suggests that a woman's sexual response is both more complex and varied than this model suggests, particularly when the woman is involved in a long-term relationship. In 2002, the leader in this field, Rosemary Basson, MD, introduced a new cycle for the female sexual response that focuses on women's need for intimacy.

These differences are important to understanding your sexual health as well as for accurately diagnosing and treating sexual dysfunction. The differences, in part, include recognizing that women's sexual responses are connected more to relationship and intimacy than to physical needs, and that the orgasm stage can be highly variable for women without actually being "dysfunctional."

In addition, it's important to distinguish a woman's sexuality and sexual response from a man's. In men, thinking about sex translates to erection, but in women, arousal often comes about after the actual lovemaking begins. In other words, a woman may start out making love with her partner somewhat uninterested, but as things progress and she focuses on the stimulation and sensations she's feeling, she becomes increasingly more aroused.

Sexual Dysfunctions in Women
Sexual dysfunctions are disturbances in one or more of the sexual response cycle's phases or pain associated with arousal or intercourse. A study published in the Journal of the American Medical Association (JAMA) involving a national sample of 1,749 women estimated that sexual dysfunctions occur in 43 percent of women in the United States. According to this 1999 study, you may be at greater risk for sexual problems if you are:

• single, divorced, widowed or separated
• not a high school graduate
• experiencing emotional or stress-related problems
• experiencing a decline in your economic position
• feeling unhappy, or physically and emotionally unsatisfied
• a victim of sexual abuse or forced sexual contact

Causes of Sexual Dysfunctions
There are several types of sexual dysfunctions. They can be lifelong problems that have always been present, acquired problems that develop after a period of normal sexual function or situational problems that develop only under certain circumstances or with certain partners. Causes of sexual dysfunctions can be psychological, physical or related to interpersonal relationships or sociocultural influences.

Psychological causes can include:

• stress from work or family responsibilities
• concern about sexual performance
• depression/anxiety
• unresolved sexual orientation issues
• previous traumatic sexual or physical experience
• body image and self-esteem problems

Physical causes can include:

• diabetes
• heart disease
• liver disease
• kidney disease
• pelvic surgery
• pelvic injury or trauma
• neurological disorders
• medication side effects
• hormonal changes, including those related to pregnancy and menopause
• thyroid disease
• alcohol or drug abuse
• fatigue

Interpersonal relationship causes may include:

• partner performance and technique
• lack of a partner
• relationship quality and conflict
• lack of privacy

Sociocultural influence causes may include:

• inadequate education
• conflict with religious, personal, or family values
• societal taboos

Types of Sexual Dysfunctions
Lack of sexual desire is the most common sexual problem in women. The Association of Reproductive Health Professionals reports in the National Health and Social Life Survey that 33 percent of women lacked interest in sex for at least a few months in the previous year.

The American College of Obstetricians and Gynecologists (ACOG) reports that a woman's sexual response tends to peak in her mid-30s to early 40s. That's not to say, however, that a woman can't have a full physical and emotional response to sex throughout her life. Most women will have a passing sexual problem at some point in their lives, and that is normal. However, sexual dysfunction in its true sense is most common in women aged 45 to 64.

Often, sexual desire is affected by a woman's relationship with her sexual partner. The more a woman enjoys the relationship, the greater her desire for sex. The stresses of daily living can affect desire, however, and occasionally feeling uninterested in sex is no cause for concern.

• Hypoactive Sexual Desire Disorder: When sexual fantasies or thoughts and desire for sexual activity are persistently reduced or absent causing distress or relationship difficulties, the problem is known as hypoactive sexual desire disorder, or inhibited sexual desire disorder. The Merck Manual estimates hypoactive sexual desire disorder occurs in about 20 percent of women.
• Sexual aversion disorder: Diagnosed when you avoid all or almost all genital sexual contact with a sexual partner to the point that it causes personal distress and relationship difficulties. This condition may affect women who have experienced some type of sexual abuse or who grew up in a rigid atmosphere in which sex was taboo. A study in the journal Archives of Sexual Behavior found that among patients with panic disorder, 75 percent had sexual problems, and that sexual aversion disorder was the most common complaint, affecting 50 percent of women with the disorder.
• Sexual arousal disorder: The persistent or recurrent inability to reach or sustain the lubrication and swelling reaction in the arousal phase of the sexual response to the point that it causes personal distress. It is the second most common sexual problem among women, affecting an estimated 20 percent of women, and most frequently occurs in postmenopausal women. Low estrogen levels after menopause can make vaginal tissue dry and thin and reduce blood flow to genitals. As a result, the arousal phase of the sexual response may take longer and sensitivity of the vaginal area may decline. However, this can happen at any age.
• Female orgasmic disorder: The persistent absence or recurrent delay in orgasm after sufficient stimulation and arousal, causing personal distress. According to the Association of Reproductive Health Professionals, 24 to 37 percent of women have problems reaching orgasm. Most women are biologically able to experience orgasm. Never having an orgasm, or not having one in certain situations, are problems that can often be resolved by learning how the female body responds, how to ensure adequate stimulation and/or how to overcome inhibitions or anxieties. Some medications, including but not limited to those used to treat high blood pressure, depression and psychosis, can reduce your sexual desire and sexual arousal and interfere with orgasm. If you are taking such drugs and experiencing sexual side effects, talk with your health care professional about changing your dosage or prescription.

Another type of sexual arousal disorder has the opposite effect. Some women may always feel sexually aroused, an experience that can be quite uncomfortable and upsetting. Although most health care professionals recognize hyperactive sexual desire as a problem, it is not an official condition according to the DMS-IV. Women who have a hyperactive sexual drive tend to be very demanding sexually because their desire for sex is constant.

Sexual Disorders Involving Pain

Dyspareunia: Pain during or after intercourse, called dyspareunia, occurs in nearly two out of three women at some time during their lives, according to ACOG. Like other sexual disorders, it can have physical and/or emotional causes. The most common cause of pain during sex is inadequate vaginal lubrication occurring from a lack of arousal, medications or hormonal changes. Painful sex also can be a sign of illness, infection, cysts or tumors requiring medical treatment or surgery, another reason why you should discuss the problem with your health care professional.

Vaginismus: The involuntary spasm of the muscles at the opening of the vagina, making anything entering the vagina painful. Vaginismus can have medical causes, including:

• scars in the vagina from an injury, childbirth or surgery
• irritations from douches, spermicides or latex in condoms
• pelvic infections

Vaginismus also can have psychological causes. It can be a response to a fear, such as fear of losing control or fear of pregnancy. It can also stem from pain or trauma such as rape or sexual abuse.

Vulvodynia: Defined as any pain in the vulva. It could be outside the vulva on the labia or an itching, burning or sharp pain within.

Treating Sexual Dysfunctions
If your relationship or sexual problem is new, try having an open, honest talk with your partner to relieve concerns and clear up disagreements or conflicts. Women who learn to tell their partners about their sexual needs and concerns have a better chance at a more satisfying sex life. If the sexual problem persists, discuss your concerns with your health care professional. Most sexual problems can be treat.
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