Sexual Difficulties

Although the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (1994) is the currently accepted system for classifying women's sexual dysfunction, there have been criticisms of that system. In particular, the criticism stems from the fact that it is based on a model of sexual response that assumes women first experience sexual desire, then move on to the experience of sexual arousal, followed by orgasm. This linear step-by-step progression through sexual response is challenged by the finding that many women engage in sexual activity despite not experiencing sexual desire at the outset. Instead, they may experience sexual desire after the sexual encounter has begun. Some have termed this type of desire as "responsive desire".

Although there have been numerous challenges to the current DSM taxonomy and some have proposed alternative classification schemes from which to understand women's sexual complaints, one system that resulted from meetings of an international classification committee, sponsored by the American Foundation for Urologic Diseases in 2003, retained the general 4-category system of the DSM while making revisions to the individual diagnoses within each category. It is noteworthy that these are not adopted by the DSM, which is currently revising its manual and is expected to be published in 2013.

The current Sexual Dysfunctions workgroup committee for DSM-5 has proposed that "Hypoactive Sexual Desire Disorder" and "Female Sexual Arousal Disorder" be replaced with "Sexual Interest/Arousal Disorder" (www.dsm5.org). This diagnosis would require women to experience any 3 of 6 symptoms for at least a 6 month period, and these symptoms must evoke significant distress. The proposed criteria for Sexual Interest/Arousal Disorder are:

  1. Lack of sexual interest/arousal of at least 6 months duration as manifested by at least 3 of the following indicators:
    1. Absent/reduced frequency or intensity of interest in sexual activity
    2. Absent/reduced frequency or intensity of sexual/erotic thoughts or fantasies
    3. Absence or reduced frequency of initiation of sexual activity and is typically unreceptive to a partner's attempts to initiate
    4. Absent/reduced frequency or intensity of sexual excitement/pleasure during sexual activity on all or almost all (approximately 75%) sexual encounters
    5. Sexual interest/arousal is absent or infrequently elicited by any internal or external sexual/erotic cues (e.g., written, verbal, visual, etc.)
    6. Absent/reduced frequency or intensity of genital and/or nongenital sensations during sexual activity on all or almost all (approximately 75%) sexual encounters
  2. The problem causes clinically significant distress or impairment.
  3. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Subtypes: Early-Onset (Lifelong) vs Late-Onset (Acquired)

Specifiers:

  1. Generalized vs. Situational
  2. Partner factors (partner's sexual problems, partner's health status)
  3. Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
  4. Individual vulnerability factors (e.g., poor body image, history of abuse experience) or psychiatric comorbidity (e.g., depression or anxiety)
  5. Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
  6. With medical factors relevant to prognosis, course, or treatment

The committee has welcomed considerable feedback on this proposal. The DSM-5 will be published in May 2013.

Women's Sexual Interest/Desire Disorder

  • Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies and a lack of responsive desire. Motivations (here defined as reasons/incentives), for attempting to have sexual arousal are scarce or absent. The lack of interest is considered to be beyond the normative lessening with life cycle and relationship duration.

Sexual Aversion Disorder

  • Extreme anxiety and/or disgust at the anticipation of/or attempt to have any sexual activity.

Subjective Sexual Arousal Disorder

  • Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.

Genital Sexual Arousal Disorder

  • Absent or impaired genital sexual arousal. Self report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital stimuli.

Combined Genital and Subjective Arousal Disorder

  • Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication)

Whether or not these three sexual arousal disorders are distinct and how they may/may not overlap with sexual desire disorder is unclear and requires further research. Many women have a difficult time differentiating sexual desire from sexual arousal and this suggests that the separation of these phenomena by researchers and clinicians may be artificial.

In addition, there is a newly proposed condition, not currently in the DSM-IV, that has been described. There is insufficient scientific research on this condition but it has been described as:

Persistent Genital Arousal Disorder

  • Spontaneous intrusive and unwanted genital arousal (e.g. tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective arousal is typically but not invariably unpleasant. The arousal is unrelieved by one or more orgasms and the feelings of arousal persist for hours or days.

Despite the self-report of high sexual arousal/excitement, there is either a lack of orgasm, markedly diminished intensity of orgasmic sensations or marked delay of orgasm from any kind of stimulation.

Pain with sexual activity is unfortunately a common experience for many women. Studies estimate that between 12-20% of women experience ongoing genital pain. A gynecologic examination that involves gentle touching (usually with a cotton swab) of the opening of the vagina can be crucial for making an accurate diagnosis. After skin conditions, infections, irritations, and other plausible explanations are ruled out, some women may be diagnosed with "Provoked Vestibulodynia", defined as pain around the opening of the vagina in response to touch (whether it is sexual or non-sexual touch). For some women, there is a significant element of pelvic floor tension contributing to the pain. The latter is sometimes referred to as "Vaginismus".

The Sexual Dysfunctions committee for DSM-5 has proposed that these two conditions be merged into one condition. The criteria for a diagnosis of Genito-Pelvic Pain/Penetration Disorder would be:

  1. Persistent or recurrent difficulties for at least 6 months with one or more of the following:
    1. Inability to have vaginal intercourse/penetration
    2. Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts
    3. Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration
    4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration
  2. The problem causes clinically significant distress or impairment
  3. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Subtypes: Early-Onset (Lifelong) vs Late-Onset (Acquired)

Specifiers:

  1. Generalized vs. Situational
  2. With concomitant problems in sexual interest/sexual arousal
  3. Partner factors (partner's sexual problems, partner's health status)
  4. Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity)
  5. Individual vulnerability factors or psychiatric comorbidity (e.g., depression or anxiety, poor body image, history of abuse experience)
  6. Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity)
  7. With medical factors relevant to prognosis, course, or treatment

Sexual difficulties in women are extremely common. There have been a number of large-scale studies on women of various age ranges in an attempt to document the precise prevalence of such difficulties. An important factor to keep in mind when looking at the prevalence of sexual difficulties is that having a difficulty does not imply that the person is necessarily bothered by it. In other words, having a sexual difficulty does not necessarily imply sexual dysfunction as the DSM-IV requires persistent or recurrent distress in order to classify as a sexual dysfunction. Transient sexual concerns in women are common, and may be affected by temporary stressors, life changes, fatigue, medications, medical conditions, and relationship changes.

The Boston Area Community Health (BACH) survey studied a random sample of 3,205 women aged 30-79 living in the Boston, USA region. The study found that 38.4% of sexually active women reported sexual problems in their life. However, only third of that group, or in other words 13.7% of the total sample of women, stated that they had sexual problems and that the problems were distressing and interfered in their life.

Sexual problems were more common as women aged, and were associated with depression, sexual and physical abuse, overall mental health, and use of alcohol.

In a different study in which the prevalence of sexual concerns was studied in 13,882 women aged 40-80 from 29 countries, significant cross-cultural differences were found in how common various sexual problems are. Lack of interest in sex (26-43%) and difficulties reaching orgasm (18-41%) were the most common sexual concerns. Difficulties with genital lubrication were found in 16-38% of women. Negative expectations about sex, depression, and negative feelings about the partner, were all significantly associated with all of the female sexual dysfunctions.

Note: Data taken from the following sources:

Lutfey KE, Link CL, Rosen RC, Wiegel M, McKinlay JB. Prevalence and Correlates of Sexual Activity and Function in Women: Results from the Boston Area Community Health (BACH) Survey. Archives of Sexual Behavior 2008.

Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moiera E, Wang T. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. International Journal of Impotence Research 2005;17: 39-57.

Various treatments exist for helping women with sexual difficulties. To date there are no medications approved by the FDA or Health Canada for the treatment of women's sexual dysfunction. Non-medication approaches include, but are not limited to:

  • Sex Therapy
  • Mindfulness
  • Biofeedback
  • Pelvic Muscle Physiotherapy
  • Vasoactive Medications
  • Hormone Replacement therapy
  • Clitoral Therapy Device
  • Natural Herbal Supplements

To find out more about our current treatment outcome study on women with low desire/low arousal, click here.

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