Sexual Difficulties

Concerns with Low/Absent Sexual Desire and Arousal

Concerns with Low/Absent Sexual Desire and Arousal

The publication of the current Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5; 2013) brought with it a new classification system for Female Sexual Dysfunctions. What was previously identified as Hypoactive Sexual Desire Disorder (HSDD) and Female Sexual Arousal Disorder (FSAD) were now reclassified as Female Sexual Interest/Arousal Disorder, or SIAD. The change in classification came as a result of the need for an expanded definition of desire/arousal disorder that captured the different ways that women may experience their symptoms. There was also longstanding criticism against the HSDD diagnosis for portraying a single expression of sexual desire (or lack thereof). Given the growing body of research supporting the Incentive Motivation Model of sexual response, and clinical recognition of conceptualizing sexual desire as responsive and part of a circular sexual response cycle, the time had come for a rethink in how sexual difficulties were diagnosed.

The current diagnostic criteria for SIAD include:

  1. at least three of the following:
    • Absent/reduced interest in sexual activity.
    • Absent/reduced sexual/erotic thoughts or fantasies.
    • No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate.
    • Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
    • Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual).
    • Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
  2. The symptoms must be present for 6 months.
  3. The symptoms must cause significant distress in the individual.
  4. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

The onset of the sexual concerns may be either:

Lifelong: where the individual has had the symptoms since the beginning of their sexual encounters

Acquired: where the individual has had a period in their life with no sexual concerns, and then the sexual problems began later on.

For many people, their sexual symptoms may involve a combination of both: longstanding issues with intermittent periods of time where they have no sexual difficulties.

In addition, sexual symptoms can be either:

Generalized: Not limited to certain types of stimulation, situations, or partners, and instead, occur across all of these different contexts

Situational: Only occurs with certain types of stimulation, situations, or partners. The person has no difficulties in certain contexts.

Moreover, women may experience a range in the levels of bother or distress that their low desire/arousal may evoke. These were captured in the DSM-5 as:

Mild: Evidence of mild distress over the symptoms.

Moderate: Evidence of moderate distress over the symptoms.

Severe: Evidence of severe or extreme distress over the symptoms.

In diagnosing Sexual Interest/Arousal Disorder (SIAD) in women, the DSM-5 stresses the importance of the individual woman’s experience. For example, a woman who reports lower sexual desire than her partner might not necessarily meet criteria for a SIAD diagnosis. This would be a clear case of “discrepant sexual desire”. In other words, her level of desire is only a problem because it does not meet her partner’s level of sexual desire.

Any short-term changes in sexual interest or arousal that a woman is experiencing might be more commonly attributed to events in a woman’s life rather than significant sexual dysfunction1. In this way, researchers have shown that sexual desire and arousal are responsive to a situation and context-dependent. Often, treatment succeeds when the context around the woman (and her sexual symptoms) changes.

Sexual desire and/or arousal must be a lasting concern for six months or more for a diagnosis of SIAD to be made, in addition to at least three of the six criteria listed above being present. These can vary in their expression as well as severity across women2. Transient sexual symptoms, or symptoms that occur very briefly would not warrant a diagnosis for women.

Genito-Pelvic Pain/Penetration Disorder

Genito-Pelvic Pain/Penetration Disorder

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 criteria for a diagnosis of Genito-Pelvic Pain/Penetration Disorder are as follows:

  1. Persistent or recurrent difficulties with one (or more) of the following:
    • Vaginal penetration during intercourse.
    • Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
    • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
    • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
  2. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
  3. The symptoms in Criterion A cause clinically significant distress in the individual.
  4. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

The onset of the sexual concerns may be either:

Lifelong: where the individual has had the symptoms since the beginning of their sexual encounters

Acquired: where the individual has had a period in their life with no sexual concerns, and then the sexual problems began later on.

There is recognition that the symptoms may be either:

Mild: Evidence of mild distress over the symptoms.

Moderate: Evidence of moderate distress over the symptoms.

Severe: Evidence of severe or extreme distress over the symptoms

Female Orgasmic Disorder

Female Orgasmic Disorder

Many women experience concerns with orgasm, however, it is important to note that a woman who does not reach orgasm from purely vaginal penetration/stimulation does not have a sexual dysfunction, per se. research indicates that most women do not reach orgasm from vaginal penetration alone, and that for most women, clitoral stimulation is important.

  1. Presence of either of the following symptoms and experienced on almost all or all (approximately 75%–100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts):
    • Marked delay in, marked infrequency of, or absence of orgasm.
    • Markedly reduced intensity of orgasmic sensations.

2. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months.
3. The symptoms in Criterion A cause clinically significant distress in the individual.
4. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

The onset of the sexual concerns may be either:

Lifelong: where the individual has had the symptoms since the beginning of their sexual encounters

Acquired: where the individual has had a period in their life with no sexual concerns, and then the sexual problems began later on.

There is recognition that the symptoms may be either:

Generalized: Not limited to certain types of stimulation, situations, or partners.

Situational: Only occurs with certain types of stimulation, situations, or partners.

If a woman has never experienced an orgasm under any situation.

There is recognition that the symptoms may be either:

Mild: Evidence of mild distress over the symptoms.

Moderate: Evidence of moderate distress over the symptoms.

Severe: Evidence of severe or extreme distress over the symptoms.

Prevalence of Sexual Difficulties

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 woman is necessarily bothered by it. In other words, having a sexual difficulty does not mean that the woman has a sexual dysfunction. It is important that the woman experience personal distress over her sexual difficulties (i.e., that they bother her in a significant way). Transient sexual concerns in women are common, and may be affected by temporary stressors, life changes, fatigue, medications, medical conditions, and relationship changes.

In 2013, a large-scale study called the National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) was conducted in the UK to asses the sexual functioning of 11,690 individuals aged 16-74.3 The study asked participants questions about mental health, relationship status and satisfaction, and recent sexual activity and concerns. The researchers found that the most reported sexual difficulty among both men and women was a lack of interest in having sex. This was by far the most common concern for women in all age groups, with 34.2% of women reporting this being a concern for 3 months or more in the past year alone. Furthermore, half of the women sampled disclosed experiencing more than one sexual response problem within the last year.

Women who experience depression are much more likely to report problems with their sexuality, as well as women who have negative beliefs about sexuality, and women who have concurrent medical conditions.

The Boston Area Community Health (BACH) survey studied a random sample of 3,205 women aged 30-79 living in the Boston, USA region4. 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.

A more recent meta-analysis on the prevalence of sexual concerns in premenopausal women was conducted by McCool et. al in 20166. A total of 95 studies and 215,740 participant data was reviewed, and these researchers found the estimated prevalence rates for sexual dysfunction in women under 49 to be 40%, with most experiencing a desire disorder (23-28%), with female orgasmic disorder being next (26%), and pain disorders and lubrication difficulties at equal prevalence (21%).

Treatment

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.

For more information please contact us

References

  1. Hayes DR, Dennerstein L, Bennett CM, Sidat M, Gurrin LC, Fairley CK. (2008). Risk Factors for Female Sexual Dysfunction in the General Population: Exploring Factors Associated with Low Sexual Function and Sexual Distress. The Journal of Sexual Medicine, 5(7), 1681-1693.
  2. Sand M & Fisher WA. (2007). Women's Endorsement of Models of Female Sexual Response: The Nurses' Sexuality Study. Journal of Sexual Medicine, 4(3), 708-719.
  3. Mitchell KR, Mercer CH, Ploubidis GB, Jones KG, Datta J, Field N, Copas AJ, Tanton C, Erens B, Sonnenburg P, Clifton S, Macdowall W, Phelps A, Johnson AM, Wellings KS. (2013). Sexual function in Britain: Findings from the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). The Lancet, 382, 1817-1829.
  4. Lutfey KE, Link CL, Rosen RC, Wiegel M, McKinlay JB. (2009). Prevalence and Correlates of Sexual Activity and Function in Women: Results from the Boston Area Community Health (BACH) Survey. Archives of Sexual Behavior, 38(4), 514-527.
  5. Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moiera E, Wang T. (2005). 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, 17, 39-57.
  6. McCool M, Zuelke A, Theurich M, Knuettel H, Ricci C, Apfelbacher C. (2016). Prevalence of Female Sexual Dysfunction Among Premenopausal Women: A Systematic Review and Meta-Analysis of Observational Studies. Sexual Medicine Reviews, 4(3), 197-212.