Female sexual arousal disorder

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Female sexual arousal disorder
Other namesCandace syndrome, [1] female sexual interest/arousal disorder
Specialty Psychiatry, gynaecology   OOjs UI icon edit-ltr-progressive.svg

Female sexual arousal disorder (FSAD) is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The diagnosis can also refer to an inadequate lubrication-swelling response normally present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.

Contents

Although female sexual dysfunction is currently a contested diagnostic, it has become more common in recent years to use testosterone-based drugs off-label to treat FSAD. It is a subtype of female sexual dysfunction. It occurs in distress due to the inability to attain or maintain adequate vaginal lubrication.

Types

There are three types of FSAD which have been identified: genital arousal disorder, subjective arousal disorder, and combined arousal disorder.

With genital arousal disorder, there is still a mental feeling of arousal, but it is not matched by any physical response. For example, a woman may be "turned on" by her partner, but her vagina does not produce lubrication and there is little-to-no increase in blood flow to the genitals. Subjective arousal disorder is the reverse issue, where there is a physical response to sexual circumstances, but an inability to feel mentally aroused. Combined arousal disorder combines both genital arousal disorder and subjective arousal disorder, presenting as a lack of sexual feeling altogether, both mentally and physically. [2]

Causes

A number of studies have explored the factors that contribute to female sexual arousal disorder and female orgasmic disorder. These factors include both psychological and physical factors.

Individual factors

There has been little investigation of the impact of individual factors on female sexual dysfunction. Such factors include stress, levels of fatigue, gender identity, health, and other individual attributes and experiences, such as dysfunctional sexual beliefs [3] that may affect sexual desire or response. An individual's sexual activity is disrupted by overwhelming emotional distress resulting in inability to attain sexual pleasure. Sexual dysfunction can also occur secondary to major psychiatric disorders, including depression. [4]

Relationship factors

A substantial body of research has explored the role of interpersonal factors in female sexual dysfunction, particularly in relation to orgasmic response. These studies have largely focused on the impact of the quality of the relationship on the sexual functioning of the partners. Some studies have evaluated the role of specific relationship variables, whereas others have examined overall relationship satisfaction. [5] Some studies have explored events, while others have focused on attitudes as an empirical measure of relationship functioning. Subject populations have varied from distressed couples to sexually dysfunctional clients to those in satisfied relationships.

Physical factors

Estimates of the percentage of female sexual dysfunction attributable to physical factors have ranged from 30% to 80%. The disorders most likely to result in sexual dysfunction are those that lead to problems in circulatory or neurological function. These factors have been more extensively explored in men than in women. Physical etiologies such as neurological and cardiovascular illnesses have been directly implicated in both premature and retarded ejaculation as well as in erectile disorder, [6] but the contribution of physiological factors to female sexual dysfunction is not so clear. However, recent literature does suggest that there may be an impairment in the arousal phase among diabetic women. Given that diabetic women show a significant variability in their response to this medical disorder, it is not surprising that the disease's influence on arousal is also highly variable. In fact, the lack of a clear association between medical disorders and sexual functioning suggests that psychological factors play a significant part in the impact of these disorders on sexual functioning. [7]

Several types of medications, including selective serotonin reuptake inhibitors (SSRIs), can cause sexual dysfunction and in the case of SSRI and SNRI, these dysfunctions may become permanent after the end of the treatment. [4]

One third of post operation transgender women experience FSAD roughly consistent with menopause women. HSDD in transgender women is largely caused by a lack of testosterone especially after the gonads are removed during bottom surgery, as androgens are produced in smaller concentrations lower than ovulating women. Progesterone has shown to alleviate some symptoms of HSDD in transgender women, as well as other hormone treatments. [8] [9]

Interplay of causes

Kaplan[ clarification needed ] proposed that sexual dysfunction was based on intrapsychic, interpersonal, and behavioural levels. [4] [ page needed ] Four factors were identified that could have a role in the development of sexual dysfunction: 1) lack of correct information regarding sexual and social interaction, 2) unconscious guilt or anxiety regarding sex, 3) performance anxiety, and 4) failure to communicate between the partners. [4] [ page needed ]

Diagnosis

DSM-5

The DSM-5 lists the diagnostic criteria as including a minimum of three of the following: [10]

  1. Little interest in sex
  2. Few thoughts related to sex
  3. Decreased start and rejecting of sex
  4. Little pleasure during sex most of the time
  5. Decreased interest in sex even when exposed to erotic stimuli
  6. Little genital sensations during sex most of the time

DSM-IV

The DSM-IV (American Psychiatric Association 1994) diagnostic criteria were:

  1. persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement, [11]
  2. the disturbance causes marked distress or interpersonal difficulty, and
  3. the sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Marita P. McCabe noted:

Difficulties arise with this definition in terms of what constitutes an adequate lubrication-swelling response. There is no "gold standard" regarding the length of time it should take to become aroused or the level of arousal that should be achieved. These responses may vary from one woman to another and are dependent on a range of factors, which include her general mood when sexual stimulation commences and her partner's skill in stimulating her. There may also be differences in physiological and subjective levels of arousal, with some women reporting no feelings of sexual arousal despite evidence of vaginal vasocongestion and others reporting arousal in the absence of such evidence. The expectations and past experiences of clinicians and clients may also lead them to classify the same symptoms as female sexual arousal disorder in one woman but not in another. [12]

Subtypes

There are several subtypes of female sexual arousal disorders. They may indicate onset: lifelong (since birth) or acquired. They may be based on context: they may occur in all situations (generalized) or be situation-specific (situational). For example, the disorder may occur with a spouse but not with a different partner.

The length of time the disorder has existed and the extent to which it is partner- or situation-specific, as opposed to occurring in all situations, may be the result of different causative factors and may influence the treatment for the disorder. It may be due to psychological factors or a combination of factors.

Treatment

The FDA has approved flibanserin [13] and bremelanotide [14] for low sexual libido in women.

Criticism

One problem with the current definition in the DSM-IV [15] is that subjective arousal is not included. There is often no correlation between women's subjective and physiological arousal. [16] With this in mind, recently, FSAD has been divided up into sub-types:

The third sub-type is the most common in clinical settings. [17]

One criticism is that "the meaningful benefits of experimental drugs for women's sexual difficulties are questionable, and the financial conflicts of interest of experts who endorse the notion of a highly prevalent medical condition are extensive." [18]

Professor of bioethics and sociology Jennifer R. Fishman argues that the categorization of female sexual dysfunction as a treatable disease has only been made possible through the input of academic clinical researchers. Through ethnographic research, she believes she has shown how academic clinical researchers have provided the scientific research needed by pharmaceutical companies to bio-medicalize female sexual dysfunction and consequently identify a market of consumers for it. She questions the professional ethics of this exchange network between researchers and pharmaceutical companies, as the clinical research trials are funded by pharmaceutical companies and researchers are given considerable financial rewards for their work. She argues that the conferences where definition of the disease and diagnostic criteria are defined and research is presented to clinicians are also ethically ambiguous, as they are also funded by pharmaceutical companies. [19]

Heather Hartely of Portland State University, Oregon is critical of the shift from female sexual dysfunction being framed as an arousal problem to a desire problem. In her article, "The 'Pinking' of Viagra Culture", she states that the change from hypoactive sexual desire disorder to female sexual arousal disorder is indicative of "disease mongering" tactics by the drug industry through an effort to match up a drug to some subcomponent of the DSM classification. [20]

Additionally, Leonore Tiefer of NYU School of Medicine voiced concerns that the success of Viagra, in combination with feminist rhetoric, were being used as a means of fast-tracking public acceptance of pharmaceutical treatment of female sexual arousal disorder. The justification behind this, she says, is that "the branding of Viagra has succeeded so thoroughly in rationalizing the idea of sexual correction and enhancement through pills that it seems inevitable and only fair that such a product be made available for women," giving a dangerous appeal to "nonapproved drugs though off-label prescribing". [21]

Related Research Articles

In psychology, libido is psychic drive or energy, usually conceived of as sexual in nature, but sometimes conceived of as including other forms of desire. The term libido was originally developed by Sigmund Freud, the pioneering originator of psychoanalysis. With direct reference to Plato's Eros, the term initially referred only to specific sexual desire, later expanded to the concept of a universal psychic energy that drives all instincts and whose great reservoir is the id. The libido - in its abstract core differentiated partly according to its synthesising, partly to its analytical aspect called life- and death-drive - thus becomes the source of all natural forms of expression: the behaviour of sexuality as well as striving for social commitment, skin pleasure, food, knowledge and victory in the areas of species- and self-preservation.

<span class="mw-page-title-main">Sexual desire</span> Psychological feature arousing organisms to physical pleasure and reproduction

Sexual desire is an emotion and motivational state characterized by an interest in sexual objects or activities, or by a drive to seek out sexual objects or to engage in sexual activities. It is an aspect of sexuality, which varies significantly from one person to another and also fluctuates depending on circumstances.

Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm despite adequate sexual stimulation. Anorgasmia is far more common in females (4.6%) than in males and is especially rare in younger men. The problem is greater in women who are post-menopausal. In males, it is most closely associated with delayed ejaculation. Anorgasmia can often cause sexual frustration.

<span class="mw-page-title-main">Sexual stimulation</span> Anything that causes a sexual response

Sexual stimulation is anything that leads to sexual arousal or orgasm. This thing can be physical or of other senses, and is known as a stimulus.

Persistent genital arousal disorder (PGAD), originally called persistent sexual arousal syndrome (PSAS), is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Hypoactive sexual desire disorder (HSDD), hyposexuality, or inhibited sexual desire (ISD) is sometimes considered a sexual dysfunction, and is characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug, or some other medical condition. A person with ISD will not start, or respond to their partner's desire for, sexual activity. HSDD affects approximately 10% of all pre-menopausal women in the United States, or about 6 million women, 1.5% of men and an unstudied amount of gender non-conforming people.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

The human sexual response cycle is a four-stage model of physiological responses to sexual stimulation, which, in order of their occurrence, are the excitement, plateau, orgasmic, and resolution phases. This physiological response model was first formulated by William H. Masters and Virginia E. Johnson, in their 1966 book Human Sexual Response. Since that time, other models regarding human sexual response have been formulated by several scholars who have criticized certain inaccuracies in the human sexual response cycle model.

Sexual arousal disorder is characterized by a lack or absence of sexual fantasies and desire for sexual activity in a situation that would normally produce sexual arousal, or the inability to attain or maintain typical responses to sexual arousal. The disorder is found in the DSM-IV. The condition should not be confused with a sexual desire disorder.

Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

Sex and drugs refers to the influence of substances on sexual function and experience. Sex and drugs date back to ancient humans and have been interlocked throughout human history. Sexual performance is known as the execution of the act of sex and the quality of sexual activity. This includes elements such as libido, sexual function, sensation. Drugs are termed as any chemical substance that produces a physiological and or psychological change in an organism. Drugs categorized as psychoactive drugs, antihypertensive drugs, antihistamines, cancer treatment, and hormone medication have a significant impact on sexual performance. Various drugs result in different effects, both positive and negative. Negative effects may include low libido, erection issues, vaginal dryness and anorgasmia. Positive effects usually address these issues, overall enhancing sexual performance and contributing to a more enjoyable sexual experience. It is crucial to know that the impact of drugs on sexual performance varies among individuals, especially among different genders.

<span class="mw-page-title-main">Transgender sexuality</span> Sexuality of transgender people

Sexuality in transgender individuals encompasses all the issues of sexuality of other groups, including establishing a sexual identity, learning to deal with one's sexual needs, and finding a partner, but may be complicated by issues of gender dysphoria, side effects of surgery, physiological and emotional effects of hormone replacement therapy, psychological aspects of expressing sexuality after medical transition, or social aspects of expressing their gender.

Delayed ejaculation (DE) is a man's inability or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation. Generally, a man can reach orgasm within a few minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not have orgasms at all or cannot have an orgasm until after prolonged intercourse which might last for 30–45 minutes or more. Delayed ejaculation is closely related to anorgasmia.

<span class="mw-page-title-main">Flibanserin</span> Medication

Flibanserin, sold under the brand name Addyi, is a medication approved for the treatment of pre-menopausal women with hypoactive sexual desire disorder (HSDD). The medication improves sexual desire, increases the number of satisfying sexual events, and decreases the distress associated with low sexual desire. The most common side effects are dizziness, sleepiness, nausea, difficulty falling asleep or staying asleep and dry mouth.

Sexual desire discrepancy (SDD) is the difference between one's desired frequency of sexual intercourse and the actual frequency of sexual intercourse within a relationship. Among couples seeking sex therapy, problems of sexual desire are the most commonly reported dysfunctions, yet have historically been the most difficult to treat successfully. Sexual satisfaction in a relationship has a direct relationship with overall relationship satisfaction and relationship well-being. Sexual desire and sexual frequency do not stem from the same domains, sexual desire characterizes an underlying aspect of sexual motivation and is associated with romantic feelings while actual sexual activity and intercourse is associated with the development and advancement of a given relationship. Thus together, sexual desire and sexual frequency can successfully predict the stability of a relationship. While higher individual sexual desire discrepancies among married individuals may undermine overall relationship well-being, higher SDD scores for females may be beneficial for romantic relationships, because those females have high levels of passionate love and attachment to their partner. Studies suggest that women with higher levels of desire relative to that of their partners' may experience fewer relationship adjustment problems than women with lower levels of desire relative to their partners'. Empirical evidence has shown that sexual desire is a factor that heavily influences couple satisfaction and relationship continuity which has been one of the main reasons for the interest in this research domain of human sexuality.

Robert Taylor Segraves is an American psychiatrist who works on sexual dysfunction and its pharmacologic causes and treatments.

<span class="mw-page-title-main">Lori Brotto</span> Canadian psychologist

Lori Anne Brotto is a Canadian psychologist best known for her work on female sexual arousal disorder (FSAD).

<span class="mw-page-title-main">Sexual arousal</span> Physiological and psychological changes in preparation for sexual intercourse

Sexual arousal describes the physiological and psychological responses in preparation for sexual intercourse or when exposed to sexual stimuli. A number of physiological responses occur in the body and mind as preparation for sexual intercourse, and continue during intercourse. Male arousal will lead to an erection, and in female arousal, the body's response is engorged sexual tissues such as nipples, clitoris, vaginal walls, and vaginal lubrication.

<span class="mw-page-title-main">Cindy Meston</span> Canadian-American clinical psychologist

Cindy Meston is a Canadian-American clinical psychologist well-known for her research on the psychophysiology of female sexual arousal. She is a Full Professor of Clinical Psychology at the University of Texas at Austin, Director of the Female Sexual Psychophysiology Laboratory, and author of Why Women Have Sex. In 2016, the BBC, London, England named Meston one of the 100 most influential and inspirational women in the world.

The medicalisation of sexuality is the existence and growth of medical authority over sexual experiences and sensations. The medicalisation of sexuality is contributed to by the pharmaceutical industry, along with psychiatry, psychology, and biomedical sciences more generally.

References

Behavioral Treatments İn Female Sexual Dysfunctions

  1. ↑ "Female Sexual Arousal Disorder". BehaveNet. Retrieved 2013-05-16.
  2. ↑ "Female Sexual Medicine". Obstetrics & Gynecology (in Samoan). Retrieved 2024-01-09.
  3. ↑ Nobre, Pedro J.; Pinto-Gouveia, José (2006). "Dysfunctional sexual beliefs as vulnerability factors for sexual dysfunction". Journal of Sex Research. 43 (1): 68–75. CiteSeerX   10.1.1.551.3993 . doi:10.1080/00224490609552300. PMID   16817069. S2CID   27633721.
  4. 1 2 3 4 Hales E and Yudofsky JA, eds, The American Psychiatric Press Textbook of Psychiatry, Washington, D.C.: American Psychiatric Publishing, Inc., 2003
  5. ↑ Witting, Katarina; Santtila, Pekka; Alanko, Katarina; Harlaar, Nicole; Jern, Patrick; Johansson, Ada; Pahlen, Bettina von der; Varjonen, Markus; Ålgars, Monica (2008). "Female Sexual Function and Its Associations with Number of Children, Pregnancy, and Relationship Satisfaction". Journal of Sex & Marital Therapy. 34 (2): 89–106. doi:10.1080/00926230701636163. PMID   18224545. S2CID   28315914.
  6. ↑ Hawton, K (1993). Sex Therapy. Oxford, UK: Oxford University Press.[ page needed ]
  7. ↑ Melman et al. 1988[ verification needed ]
  8. ↑ Elaut, E.; De Cuypere, G.; De Sutter, P.; Gijs, L.; Van Trotsenburg, M.; Heylens, G.; Kaufman, J. M.; Rubens, R.; t'Sjoen, G. (May 4, 2008). "Hypoactive sexual desire in transsexual women: prevalence and association with testosterone levels". European Journal of Endocrinology. 158 (3): 393–399. doi: 10.1530/EJE-07-0511 . PMID   18299474 – via www.academia.edu.
  9. ↑ Prior, J. (3 January 2019). "Progesterone Is Important for Transgender Women's Therapy—Applying Evidence for the Benefits of Progesterone in Ciswomen". The Journal of Clinical Endocrinology & Metabolism. 104 (4): 1181–1186. doi:10.1210/jc.2018-01777. PMID   30608551 . Retrieved August 4, 2024.
  10. ↑ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Fifth ed.). Arlington, VA: American Psychiatric Publishing. 2013. p. 433. ISBN   978-0-89042-554-1.
  11. ↑ DSM-IV , American Psychiatric Association 1994, p. 502
  12. ↑ McCabe, Marita P. (29 May 2006). "Female Sexual Arousal Disorder and Female Orgasmic Disorder". Armenian Medical Network.
  13. ↑ Mullard, Asher (1 October 2015). "FDA approves female sexual dysfunction drug". Nature Reviews Drug Discovery . 14 (10): 669. doi:10.1038/nrd4757. PMID   26424353. S2CID   36380932.
  14. ↑ Frellick, Marcia. "FDA Approves New Libido-Boosting Drug for Premenopausal Women". Medscape. WebMD LLC. Retrieved 22 June 2019.
  15. ↑ Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington DC: American Psychiatric Association. 2000.
  16. ↑ Chivers M. L. (2005). "Leading comment: A brief review and discussion of sex differences in the specificity of sexual arousal". Sexual and Relationship Therapy. 20 (4): 377–390. doi:10.1080/14681990500238802. S2CID   44451821.
  17. ↑ Brotto, L. A., Basson, R., & Gorzalka, B. B. "Psychophysiological assessment in premenopausal sexual arousal disorder", The Journal of Sexual Medicine, 1(3), 266–277, 2004
  18. ↑ Moynihan, R. (2005). "The marketing of a disease: Female sexual dysfunction". BMJ. 330 (7484): 192–4. doi:10.1136/bmj.330.7484.192. PMC   545000 . PMID   15661785.
  19. ↑ Fishman, Jennifer R. (2004). "Manufacturing Desire: The Commodification of Female Sexual Dysfunction". Social Studies of Science. 34 (2): 187–218. doi: 10.1177/0306312704043028 . PMID   15295831.
  20. ↑ Hartley, Heather (2006). "The 'Pinking' of Viagra Culture". Sexualities. 9 (3): 363–378. doi:10.1177/1363460706065058. S2CID   143113254. Archived from the original on 6 February 2016. Retrieved 14 December 2012.
  21. ↑ Tiefer, Leonore (2006). "The Viagra Phenomenon". Sexualities. 9 (3): 273–294. doi:10.1177/1363460706065049. S2CID   143714777. Archived from the original on 6 February 2016. Retrieved 1 April 2015.
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