Female Sexual Arousal Disorder

23 May

Ellen Laan and Walter  Everaerd

University of Amsterdam, Amsterdam,  The Netherlands

Stephanie  Both

Leiden University Medical Centre, Leiden, The Netherlands and University of Amsterdam,  Amsterdam, The Netherlands

The part on the history of women’s sexuality has previously been published in Everaerd W, Laan E, Both S, van der Velde J. Female Sexuality. In: Szuchman LT, Muscarella F, eds. Psychological Perspectives on Human Sexuality. New York: John Wiley & Sons, 2000:101 – 146.


Most pharmacological treatments that are currently being developed for women with sexual arousal disorder are aimed at remedying a vasculogenic deficit. In a study we did in the late 1990s we compared pre- and postmenopausal women with  and  without  sexual  arousal  disorder,  diagnosed  according  to  strict DSM-IV criteria (1). Women with any somatic or mental comorbidity were excluded.  This study investigated whether pre- and postmenopausal women with sexual arousal disorder were less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems. From the findings of this study we concluded that in such women, sexual arousal dis- order is unrelated to organic etiology. In other words, we are convinced, from this and other studies to be reviewed, that in women without any somatic or mental comorbidity, impaired genital responsiveness is not a valid diagnostic criterion. The sexual problems of women with sexual arousal disorder are not related to their potential to become genitally aroused. We propose that in healthy women with  sexual  arousal  disorder,  lack  of  adequate  sexual  stimulation,  with  or without concurrent negative  effect,  underlies sexual arousal problems. This view is at odds with the dominant view on male sexual arousal problems.

In the history of sexological science, the study of women’s sexuality has been neglected, or has been obscured by comparisons with sexuality of men. In textbooks, descriptions of women and men’s sexuality were often aimed at increasing awareness of similarities in physiological and psychological mechan- isms (2). Even today, as will be shown later in this chapter, clear conceptualiz- ations of women’s sexual problems and dysfunctions seem hindered by dominance of the “male model.”

For a long time, the general idea in western culture has been that although

women may have a disposition for sexual feelings, in decent and healthy women these  feelings  will  only  be  aroused  by  a  loving  husband.  “In  women … , especially in those who live a natural and healthy life, sexual excitement also tends to occur spontaneously, but by no means so frequently as in men. (.. .) Ina very large number of women the sexual impulse remains latent until aroused by a lover’s caresses. The youth spontaneously becomes a man; but the maiden—as it has been said—‘must be kissed into a woman’ ” (3, p. 241). Stekel believed that it was a man’s task to awaken sexual feelings in a woman, a responsibility that should not be taken lightly. “As a matter of fact it is the duty of every man whose wife is unfortunately anaesthetic to investigate for himself his marital part- ner’s erogenous zones, adroitly, carefully until he discovers the areas or positions which are capable of rousing his wife’s libido and of bringing on her orgasm during intercourse” (4, p. 133). He disapprovingly remarked: “There are men so brutally blunt and so selfish that they take no trouble to study their wives so as to become acquainted with their erogenous zones and learn to meet their particular desires” (p. 130). About half a century earlier, a book entitled The Functions and Disorder of the Reproductive Organs by W. Acton, a surgeon (5), passed through many editions and was popularly regarded as a standard auth- ority on the subjects with which it dealt. The book was almost solely concerned with men; the author evidently regarded the function of reproduction as exclu- sively appertaining to men. He claimed that women, if “well brought up,” are, and should be, absolutely ignorant of all matters concerning it. “I should say,” this author remarked, “that the majority of women (happily for society) are not very much troubled with sexual feeling  of any kind.” The supposition that women do possess sexual feelings he considered “a vile aspersion.”

It was not until the late 18th century, however, that the above view had become the dominant one. For thousands of years prior to this, scholars had assumed that conception could not take place without the woman becoming sexu- ally aroused and having an orgasm (6, pp. 2 – 3). Thus, sexual pleasure for women was not only accepted, but also essential. Yet, although sexual feelings in women were acknowledged, they  were not always considered to be unproblematic. Shorter summarized the prevalent view of women’s sexuality in the Middle Ages as follows: “Women are furnaces of carnality, who time and again will lead men to perdition, if given a chance. (.. .) Because the flame of female sexuality could snuff out a man’s spirit, women had sexually to be broken and controlled” (7, pp. 12 – 13).

Ellis had distinctive opinions about differences between women and men concerning the physiological mechanisms involved in sexuality (3). In men, the process of tumescence and detumescence was considered to be simple. In women “we have in the clitoris a corresponding apparatus on a small scale, but behind this has developed a much more extensive mechanism, which also demands satisfaction, and requires for that satisfaction the presence of various conditions that are almost antagonistic. … It is the difference, roughly speaking, between a lock and a key. … We have to imagine a lock that not only requires a key to fit it, but should only be entered at the right moment, and, under the best conditions, may only become adjusted to the key by considerable use” (p. 235). It seems that phrases such as “an extensive mechanism behind the clitoris” served to conceal ignorance about physiological facts. Even today, scholars acknowl- edge that “it is glaringly obvious that we know so little about sexual arousal that we cannot answer some of the most elementary questions about the … human genital function” (8, p. 3).

In his excellent book on the role of the body in female sexuality, Laqueur (6) demonstrated that conceptions about human sexuality were not the result of scientific progress. Instead, he argued, they were part of social and political changes, “explicable only within the context of battles over gender and power” (p. 11). Feminists have long criticized the notion that the behavior and abilities of women are uniquely determined by their biology. This criticism led to an almost total rejection of the role of biology in the construction of gender (9). It also contributed to an image of female sexuality devoid of the body. Masters and Johnson (10) were the first to carefully study and describe the genital and extragenital changes that occurred in sexually aroused women. Tiefer critiqued the suggestion of the human sexual response cycle as a universal model for sexual response, not in the least because the concept of sexual desire was not included in the model, therewith eliminating “an element which is notoriously variable  within populations”  (11,  p.  4).  She  argued that  the  human sexual response cycle, with its genital focus, neglects women’s sexual priorities and experiences. Indeed, Masters and Johnson did not assess the subjective sexual experience of the 694 men and women who were studied. Their emphasis on peripheral physiology, particularly the genital vasocongestive processes associ- ated with sexual response, may reflect the influence of primarily male-dominated theorizing and research in sexology, with its inevitable emphasis on penile – vaginal sexual contact. Tiefer wondered why problems such as “too little tenderness” or “partner has no sense of romance” were excluded (11). These pro- blems have been frequently reported by women (12). The sexual response cycle model assumes men and women have and like the same kind of sexuality. Yet, various studies show that women care more about affection and intimacy, and men care more about sexual gratification in sexual relationships (13). There seems to be support for the cliche´  “Men give love to get sex, and women give sex to  get  love.”  Men and  women are  raised with different sets of  sexual values. Tiefer concludes that focusing on the physical aspects of sexuality and ignoring other aspects of the sexual response cycle favors men’s value training over women’s.

Recently, there has been a growing awareness of the limitations of the “male model” for understanding women’s sexuality (14 – 16). In this chapter, we  will  review  the  current  definitions  of  female  sexual  arousal  disorder (FSAD) and the prevailing difficulties in pinpointing the etiology of the problems clients present. We will then present our view on the activation and regulation of women’s sexual responses, which is derived from modern emotion and motiv- ation theories, underlining differences with men’s sexual responses. We will briefly discuss treatment options, and we will end with a few recommendations for clinical practice that follow from our analysis.


Little research has been conducted on the prevalence of FSAD. A recent review by Simons and Carey (17) estimated the prevalence of sexual dysfunction in the population based on all prevalence studies that have appeared in the 1990s. Although 52 studies have been conducted in that decade, most studies lack sufficient methodological rigor. Only a handful of studies have used unambigu- ous criteria for assessing female sexual dysfunction. The frequently cited study by Laumann et al. (18) for instance, yielded an overall female sexual dysfunction prevalence figure of 43%. The study was done in a large, representative sample, but the prevalence figure was based on an affirmative response to one of seven sexual complaints. On the basis of simple yes/no answers to a problem area it cannot be established whether one is suffering from a sexual dysfunction or whether one is experiencing common sexual difficulties (19). Besides, recent studies show that even when psychometrically sound assessment techniques are used, prevalence figures of the occurrence of sexual dysfunctions are much higher than prevalence figures of the occurrence of sexual dysfunctions that cause personal or interpersonal distress (20 – 22). Simons and Carey therefore conclude that for most female sexual dysfunctions, stable community estimates of the current prevalence are unavailable. Only for female orgasmic disorder reliable  community prevalence  estimates  were  obtained,  ranging from  7  to 10%. Given the difficulties in differentiating between FSAD and female orgasmic disorder (FOD), as will be discussed subsequently, this may be a reasonable estimate for FSAD as well.

Anatomy and Physiology

Clitoris and Surrounding Erectile Tissue

There is a considerable density of tactile receptors in the clitoris. The anterior vaginal wall is also rich in tactile receptors. Freud (23) entertained a developmen- tal idea about excitability to explain how “a little girl turns into a woman.” He argued that from the onset of puberty, libido increases in boys; at the same time, in girls, “a fresh wave of repression” occurs that affects “clitoridal sexu- ality.”  This  finite period  of  “anasthesia,”  Freud  thought,  was  necessary  to enable successful transferrence of a girl’s erotogenic susceptibility to stimulation from the clitoris to the vaginal orifice. Even though his suggestion that there are also tactile receptors in the anterior vaginal wall is correct, there is no evidence that the anterior wall becomes excitable at the expense of clitoral sensitivity. Contrary to Freud’s belief, there is ample evidence that women who learned to know their own sexuality through masturbation are able to transfer this knowledge (or skill) to coital stimulation with a partner (12). For a long time, ideas similar to those of Freud have been used to suppress masturbation in girls and women. Even today there are many women with a partner, who feel guilty when masturbating.

The clitoris contains two stripes of erectile tissue (corpora cavernosum) that diverge into the crura inside the labia majora. On the basis of recent anatom- ical studies, O’Connell et al. (24) proposed to rename these structures as bulbs of the clitoris. They found that there is erectile tissue connected to the clitoris and extending backwards, surrounding the perineal part of the urethra. However, most anatomical facts have been known for a long time (25). The clitoris’ para- sympathethic innervation comes from lumbosacral segments L2 – S2, while its sympathetic supply is from the hypogastric superior plexus. The pudendal and hypogastric nerves serve its sensory innervation. It responds with increased blood flow and tumescence on being stimulated through sexual arousal. Nitric oxide synthase (NOS), among many other neuropeptides, has been identified in the complex network of nerves in the clitoral tissue (26).

The Anterior Vaginal Wall

When Masters and Johnson (10) published their account of the physiology of the sexual response, they opposed Freud’s theory of the transition of erogeneous zones in women. According to these famous sexologists, nerve endings in the vagina are extremely sparse. Therefore, during coital stimulation the clitoris is stimulated indirectly, possibly through the movement or friction of the labia. Hite’s  data  supported  this  point  of  view.  Almost  all  women  who  reached orgasm through stimulation from coitus alone had experienced orgasm through masturbation. Many women needed additional manual stimulation to orgasm during  coitus,  and  an  even  larger  number  was  unable  to  orgasm  during coitus at all (12).

Apparently, coitus alone is not a very effective stimulus for orgasm in

women. In 1950, Grafenberg (25) provided an alternative to Masters and Johnson’s  explanation  for  the  relative  ineffectiveness  of  coitus  to  induce orgasm. He described an area of erectile tissue on the anterior wall of the vagina along the course of the urethra, about a third of the way in from the intro- itus and below the base of the bladder. Strong digital stimulation of this zone would activate a rapid and high level of sexual arousal which, if maintained, induced orgasm. This paper was ignored until 1982, at which time this area was renamed as the G-spot (27). According to Levin (28), however, there is no convincing scientific evidence for the presence of either a unique G-spot with its own plexus of nerve fibers or for the fluid that is often  expelled  when orgasm is  reached  from  stimulation  of  this  area  being anything other  than urine. Because it is difficult to see how strong stimulation of this “G-spot” would not also stimulate other erogeneous structures such as the urethra and cli- toral tissue, Levin argues that the whole area should be regarded as the “anterior wall erogeneous complex.” Grafenberg pointed out that coitus in the so-called missionary  position  (ventral – ventral)  prevents  stimulation  of  the  anterior vaginal  wall  and  would  therefore  not  be  optimally  sexually  arousing  for women. Instead, contact with the anterior wall is “very close, when the inter- course  is  performed  more  bestiarum  or  a  la  vache  that  is,  a  posteriori” (25, p. 148). Thus, Grafenberg’s suggestion was not that coitus itself is an ineffective sexual stimulus for women, but only coitus in the missionary position.

Sensitivity of the entire vaginal wall has been explored in several studies. Weijmar Schultz et al. (29) used an electrical stimulus for exploration under non- erotic conditions. This study confirms sensitivity of the anterior vaginal wall, even though sensitivity of this area was much lower than that of the clitoris.

Central Nervous System and Spinal Chord Pathways

Neural and spinal components of female sexual arousal anatomy have been examined  in  animals  and  spinal  cord-injured  (SCI)  women  only.  There  is strong evidence for the occurrence of sexual arousal and orgasm in women with SCI who have an intact S5 – S5 reflex arc. Not only were genital and extra- genital responses to vibrotactile stimulation similar between able-bodied and SCI subjects in a recent study of Sipski et al. (30), subjective descriptions of sensations were indistinguishable between groups. SCI subjects did take longer than able- bodied subjects to achieve orgasm. Whipple and Komisaruk (31) suggested that, on the basis of their studies in SCI women in whom cervical stimulation was applied, the vagus nerve conveys a sensory pathway from the cervix to the brain, bypassing the spinal cord, which is responsible for the preservation of sexual arousal and orgasm in these women.

There remain large gaps in our understanding of the central nervous control of female sexual function. Most of the animal work relates to receptive behavior in female rats and very little to the control of genital responses. According to McKenna (32), the autonomic and somatic innervation of the genitals is based upon spinal mechanisms, modulated by supraspinal sites. Sensory information from the genitals project to interneurons in the lower spinal cord, which possibly generate the coordinated activity of sexual responses. The spinal reflex mechan- isms are under inhibitory (through serotonergic activity) and excitatory (through adrenergic activity) control from supraspinal nuclei. These nuclei are highly interconnected. Many of them also receive genital sensory information. It is likely that during sexual activity, sensory activation of supraspinal sites causes a decrease in the inhibition, and an increase in the excitation of the spinal reflex- ive mechanisms by the supraspinal sites. Higher order sensory and cognitive processes may modulate the activity of supraspinal nuclei controlling sexual function.

Diagnosing  FSAD

FSAD  refers  to  inhibition  of  the  “vasocongestion – lubrication  response”  to sexual stimulation (1). In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), FSAD (302.72) is defined as the per- vasive or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication – swelling response of sexual excitement, coupled  with  marked  distress  or  interpersonal  difficulty  (1).  The  DSM classification of sexual disorders has been derived from phases of the sexual response cycle, on the basis of the work of Masters and Johnson (10) and Kaplan (33). This model depicts a sexual desire phase and a subsequent sexual arousal phase, characterized by genital vasocongestion, followed by a plateau phase of higher arousal, resulting in orgasm and subsequent resolution. It is assumed in this model that women’s sexual response is similar to men’s, such that  women’s  sexual  dysfunction  in  DSM-IV  mirrors  categories  of  men’s sexual dysfunction. In contrast to the third edition of the DSM manual, subjective sexual experience is no longer part of the definition, possibly in a further attempt to match norms and criteria for men’s and women’s sexual dysfunctions (34).

There are a number of serious problems with the current DSM-IV classifi- cation criteria. Firstly, although the DSM-IV explicitly requires the clinician to assess the adequacy of sexual stimulation only when considering the diagnosis of FOD, adequacy of sexual stimulation is a critical variable  in evaluating each of the female sexual dysfunctions, and FSAD in particular. Exactly what is adequate sexual stimulation? Some sort of physical (genital) stimulation is a necessary, but not necessarily sufficient, prerequisite for arousal. For many women, adequate sexual arousal involves physical as well as “psychological” and “situational” stimulation, such as intimacy with a partner, the exchange of confidences, the sharing of hopes and dreams and fears, and not only directly prior to the sexual event (35). What if certain types of sexual stimulation have been adequate in the past, but not anymore? Is it evidence of FSAD, or could it be explained in terms of habituation or an adaptation to changing life circum- stances? (16) And what is meant by “completion of the sexual activity?” Is it masturbation to orgasm, sexual contact with a partner, sexual contact including coitus? These are very different activities that are known to differ in their sexually arousing qualities (12).

Secondly, the description of the first problem demonstrates that clinical judgements  are  required  about  sexual  stimulation  and  the  severity  of  the problem, the validity of which is questionable. The clinician has to evaluate what is normal, based on age, life circumstances, and sexual experience. Research on the basis of which clear criteria can be formulated, is lacking. There is a great variety in the ease with which women can become sexually aroused and which types of stimulation are required (36).

Thirdly, due to the lack of clear diagnostic criteria, it is often unclear in which cases an FSAD diagnosis or one of the other three main DSM-IV diag- noses is appropriate. The four primary DSM-IV diagnoses pertaining to lack of desire, arousal, orgasm problems or sexual pain, are not independent. Only very  infrequently  do  women  present  with  sexual  arousal  problems  when seeking help for their sexual difficulties, but that does not mean that insufficient sexual arousal is an unimportant factor in the etiology of these difficulties. In actual clinical practice, classification is often done on the basis of the way in which complaints are presented (36). If the woman is complaining of lack of sexual  desire,  the  diagnosis  of  hypoactive  sexual  desire  disorder  is  easily given. If she reports trouble reaching orgasm or cannot climax at all, FOD is the most likely diagnosis. If she reports pain during intercourse, or if penetration is difficult or impossible, the clinician may conclude that dyspareunia or vaginis- mus is the most accurate diagnostic label. In general, women have difficulty perceiving  genital  changes  associated  with  sexual  arousal  (37).  However, women who report little or no desire for sexual activity, lack of orgasm, or sexual pain, may in fact be insufficiently sexually aroused during sexual activity. It is particularly difficult to differentiate between FSAD and FOD. FOD is defined as the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase (1). In cases where the clinician does not have access to a psychophysiological test in which a woman is presented with (visual and/or tactile) sexual stimuli, while genital responses are being measured, it cannot be established that her deficient orgasmic response occurs despite a normal sexual excitement phase, unless she reports feelings of sexual arousal. Ironically, this subjective criterion has been removed in the DSM-IV.

Studies investigating the efficacy of psychological treatments for sexual dysfunction have demonstrated that directed masturbation training combined with sensate focus techniques (38) is very effective for women with primary anor- gasmia to become orgasmic. In fact, this is the only psychological treatment of sexual dysfunctions that deserves the label “well established,” and is probably efficacious in secondary orgasmic disorder (39). The success of this treatment suggests that lack of adequate sexual stimulation is an important etiological factor underlying primary, and probably also secundary, anorgasmia. Conse- quently, if the clinician would strictly adhere to the DSM-IV criteria, the diagno- sis of neither FSAD nor FOD would be appropriate, because the problem can be reversed by adequate sexual stimulation. In any case, primary orgasmic problems may not justify a separate diagnostic category. Perhaps the diagnosis of FOD should be restricted to those women who are strongly sexually aroused but have difficulty surrendering to orgasm (40). There are no clinical or epidemio- logical studies that differentiate between women with primary or secondary anorgasmia and other orgasm problems, so we do not know how prevalent this is. Segraves (41) argued that FSAD hardly exists as a distinct entity, whereas we, in contrast, argue that in a classification system based on the etiology of sexual complaints,  FSAD  should  be  considered  to  be  the  most  important  female sexual dysfunction, with complaints of lack of desire and orgasm, and pain, frequently being consequences of FSAD.

Finally,  there  is a good deal  of evidence  that,  especially for women, physiological response does not coincide with subjective experience. Women’s subjective  experience of  sexual arousal appears to  be  based more  on  their appraisal of the situation than on their bodily responses (37). We will address this issue extensively later in this chapter. Thus, in the DSM-IV definition of FSAD, probably the most important aspect of women’s experience of sexual arousal is neglected, given that absent or impaired genital responsiveness to sexual stimuli is the sole diagnostic criterion for an FSAD diagnosis.

Is Absent or Impaired  Genital  Responsiveness  a Valid

Diagnostic Criterion?

In a recent study we investigated whether pre- and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems (42). Twenty-nine women with sexual arousal disorder (15 premenopausal and 14 postmenopausal), without any somatic or mental comorbidity, diagnosed using strict DSM-IV cri- teria, and 30 age-matched women without sexual problems (16 premenopausal and 14 postmenopausal) were shown sexual stimuli depicting cunnilingus and intercourse. Genital arousal was assessed as vaginal pulse amplitude (VPA) using vaginal photoplethysmography. We found no significant differences in mean and maximum genital response between the women with and without sexual arousal disorder, nor in latency of genital response. The women with sexual  arousal  disorder  were  no  less  genitally  responsive  to  visual  sexual stimuli than age- and menopausal status-matched women without such problems, even though they had been carefully diagnosed, using strict and unambiguous cri- teria of impaired genital responsiveness. These findings are in line with previous studies (43 – 45). The sexual problems these women report were clearly not related to their potential to become genitally aroused. In medically  healthy women absent or  impaired  genital  responsiveness is  not  a  valid  diagnostic criterion.

It is clear that the sexual stimuli used in this laboratory study (even though these stimuli were merely visual) were effective in evoking genital response. In an ecologically more valid environment (e.g., at home), sexual stimuli may not always be present or effective. Sexual stimulation must have been effective at one point in the participants’ lives, because primary anorgasmia was an exclusion criterion. Even though a serious attempt was made to rule out lack of adequate sexual stimulation as a factor explaining the sexual arousal problems, data on sexual responsiveness collected in the anamnestic interview suggested that the women diagnosed with sexual arousal disorder are unable, in their present situ- ation, to provide themselves with adequate sexual stimulation. The exclusion, halfway through the study, of a participant who no longer met the criteria for sexual arousal disorder after having met a new sexual partner, also illustrates that inadequate sexual stimulation may be one of the most important reasons for sexual arousal problems.

In this study, genital responses did not differ between the groups with and without sexual arousal disorder, but sexual feelings and affect did. The women with FSAD reported weaker feelings of sexual arousal, weaker genital sensations, weaker sensuous feelings and positive affect, and stronger negative affect in response to sexual stimulation than the women without sexual problems. Two explanations may account for this. Firstly, women with sexual arousal disorder may  differ  from  women  without  sexual  problems  in  their  appreciation  of sexual stimuli. These stimuli, even though they were effective in generating genital response, evoked feelings of anxiety, disgust, and worry. These negative feelings may have downplayed reports of sexual feelings, and were probably evoked by the sexual stimuli and not by the participants becoming aware of their genital response, because reports of genital response were unrelated to actual genital response. Negative appreciation of sexual stimuli may extend to, and perhaps even be amplified in, real-life sexual situations, because in such situ- ations, any negative affect (i.e., towards the partner or the sexual interaction) may be more salient. Negative affect may, therefore, be partly responsible for the sexual arousal problems in the women diagnosed with sexual arousal disorder.

Secondly, women with sexual arousal disorder may be less aware of their own genital changes, with which they lack adequate proprioceptive feedback that may further increase their arousal. The general absence of meaningful corre- lations between VPA and sexual feelings in this and other studies (see next section)  supports  this  notion.  Perhaps  women  with  sexual  arousal  disorder have less intense feedback from the genitals to the brain; there are no data, at present, to substantiate this idea. It is impossible to decide which of these expla- nations is more likely, because in real-life situations it can never be established with certainty that sexual stimulation is adequate, and awareness of genital response is dependent upon the intensity of the sexual stimulation. In addition, these explanations are not mutually exclusive. We can conclude, however, that the sexual problems of the women with sexual arousal disorder are not related to  their  potential  to  become  genitally aroused. We  propose that  in  healthy women with sexual arousal disorder, lack of adequate sexual stimulation, with or without concurrent negative affect, underlies the sexual arousal problems.

Organic etiology may underlie sexual disorders in women with a medical condition. There are only a handful of studies that have employed VPA measure- ments in women with a medical condition. The only psychophysiological study to date that found a significant effect of sildenafil on VPA in women with sexual arousal disorder was done in women with SCI (46), suggesting that in this group there was an impaired genital response that can be improved with sildena- fil. Another study compared genital response during visual sexual stimulation of women with diabetes mellitus and healthy women, showing that VPA was signifi- cantly lower in the first group (47). A very recent study measured VPA in medi- cally healthy women, in women who had undergone a simple hysterectomy, and in women with a history of radical hysterectomy for cervical cancer (48). Only in the last group was VPA during visual sexual stimuli impaired, whereas the women with simple hysterectomies reported to experience more sexual problems than the other two groups. Not presence of sexual arousal problems but presence of a medical condition that influences sexual response may therefore be the most important determinant of impaired genital responsiveness (49).

Medical conditions that have been associated with sexual arousal disorder, other than SCI and diabetes, are pelvic and breast cancer, multiple sclerosis, brain injury, and cardiac disease (50). Mental disorders such as depression may also interfere with sexual function. It is important to consider the direct biological influence of disease on sexual pathways and function, but equally important is the impact of the experience of illness. Disease may change body presentation and body esteem; ideal sexual scenarios may be disturbed by constraints that accom- pany illness. In many patients, sexual arousal and desire may decrease in connec- tion with grief about the loss of normal health and uncertainty about illness outcome (51). Damage to the autonomic pelvic nerves, which are not always easily identified in surgery to the rectum, uterus, or vagina, is associated with sexual dysfunction in women (52,53). Medications such as antihypertensives, selective serotonine reuptake inhibitors, and benzodiazepines, as well as chemo- therapy,  most  likely  due  to  chemotherapy-induced  ovarian  failure,  impair sexual response (50). In addition, the incidence of women complaining of lack of sexual arousal increases in the years around the natural menopausal transition. According to Park et al. (54), postmenopausal women with sexual complaints, who are not on estrogen replacement therapy, are particularly vulnerable to what they call a vasculogenic sexual dysfunction. However, psychophysiological and preliminary functional magnetic resonance imaging studies of increases in genital congestion in response to erotic stimulation, fail to identify differences between pre- and postmenopausal women (55 – 57). This would suggest that although urogenital aging results in changes in anatomy and physiology of the genitals, postmenopausal women preserve their genital responsiveness when suffi- ciently sexually stimulated. The vaginal dryness and dyspareunia experienced by some  postmenopausal women may  result from  longstanding  lack  of  sexual arousal/protection from pain previously afforded by estrogen related relatively high blood flow in the unaroused state (58).

Diagnostic Procedures

An ideal protocol for the assessment of FSAD should be constructed following theoretical and factual knowledge of the physiological, psychophysiological, and psychological mechanisms involved. The protocol then describes the most parsimonious route from presentation of complaints to effective therapy. Unfor- tunately, we are at present far from a consensus on the most probable causes of FSAD. Despite this disagreement, at least two diagnostic procedures should be considered. Firstly, assessment of sexual dysfunction in a biopsychosocial context should start with a verification of the chief complaints in a clinical inter- view. The aim of the clinical interview is to gather information concerning current sexual functioning, onset of the sexual complaint, the context in which the difficulties occur, and psychological issues that may serve as etiological or maintaining factors for the sexal problems, such as depression, anxiety, person- ality factors, negative self- and body image, and feelings of shame or guilt that may result from religious taboos. Sexual problems are common complications of anxiety disorders and impaired sexual desire, arousal and satisfaction. Labora- tory studies suggest potential enhancement of genital arousal by some types of anxiety,  but  the  precise  cognitive,  affective,  or  physiological  processes  by which anxiety and women’s sexual function are related have as yet to be ident- ified (50). The ongoing work of Bancroft and Janssen (59) exploring a dual control model of sexual excitation and inhibition in men as well as in women, may clarify any role of anxiety in women’s predisposition to sexual inhibition and to sexual excitement. One of the most important but difficult tasks is to assess whether inadequate sexual stimulation is underlying the sexual problems, which requires detailed probing of (variety in) sexual activities, conditions under which sexual activity takes place,  prior sexual functioning, and sexual and emotional feelings for the partner. Several studies have shown that negative sexual and emotional feelings for the partner are among the best predictors for sexual problems (16,60). The clinician should always ask if the woman has ever experienced sexual abuse, as this may seriously affect sexual functioning (61). Some women do not feel sufficiently safe during the initial interview to reveal such experiences; nevertheless, it is necessary to inquire about sexual abuse to make clear that traumatic sexual experiences can be discussed. The initial clinical interview should help the clinician in formulating the problem and in deciding what treatment is indicated. An important issue is the agreement between therapist and patient about the formulation of the problem and the nature of the treatment. To reach a decision to accept treatment, the patient needs to be properly informed about what the diagnosis and the treatment involve.

Ideally, in the case of suspected FSAD, the initial interviews is followed by a  psychophysiological assessment. In assessment of the  physical aspects of sexual arousal, the main question to be answered is whether, with adequate stimu- lation by means of audiovisual, cognitive (fantasy), and/or vibrotactile stimuli, a lubrication – swelling response is possible. Although psychophysiological testing to date is not a routine assessment, we feel that such a test is crucial in estab- lishing the etiology of FSAD for two reasons. The study that was discussed extensively in the previous paragraph (42) demonstrated how difficult it is to rule out that sexual arousal problems are not caused by a lack of adequate sexual stimulation. Secondly, it showed that impaired genital response cannot be assessed on the basis of an anamnestic interview. Women with sexual arousal dis- order may be less aware of their own genital changes, with which they lack ade- quate proprioceptive feedback that may further increase their arousal. If a genital response is possible, even when other investigations indicate the existence of a variable that might compromise physical responses, an organic contribution to the arousal problem of the individual women is clinically irrelevant. As was shown before, sexual arousal problems in medically healthy women are most likely more often related to inadequate sexual stimulation due to contextual and relational variables than to somatic causes. For estrogen deplete women, care must be taken not to simply facilitate painless intercourse in the nonaroused state with a lubricant but to consider the possibility that  estrogen lack has unmasked long-term lack of sexual arousal that is of contextual etiology. Of note, nonresponse in the psychophysiological assessment does not automatically imply organicity. The woman may have been too nervous or distracted for the stimuli to be effective, or the stimuli offered may not have matched her sexual preferences. This problem of suboptimal sensitivity is not unique to this test, many other well established diagnostic tests of this nature have a similar dis- advantage (62).

Two other procedures could be used to corroborate findings from the clini- cal interview and the psychophysiological assessment. The first is the use of self- report measures supplementary to the clinical interview. The Female Sexual Function Index (FSFI) is a brief, multidimensional scale for assessing sexual function in women, and is currently the most often used measure. Recently, diagnostic cutoff scores were developed by means of sophisticated statistical procedures (63). Self-report measures are not very useful for clinical purposes because they lack sensitivity and specificity with regard to causes of the individ- ual patient’s dysfunction.

Secondly, a careful focused pelvic exam in medically healthy women may be in order when lack of arousal is accompanied by complaints of pain or vagi- nistic response during sexual activity, or when a psychophysiological assessment has yielded nonresponse. In the latter case, rare diseases such as connective tissue disorder, can be identified. In the former cases the purpose of the exam may be more educational than medical, for instance to observe the consequences of pelvic floor muscle activity (50). An examination that found no abnormalities may also be of therapeutic value. Sometimes a general physical examination, including central nervous system or hormone levels is necessary (64), but in most of the cases only genital examination is required. In women with neurologi- cal disease affecting pelvic nerves or with a history of pelvic trauma, a detailed neurological genital exam may be necessary, clarifying light touch, pressure, pain,  temperature  sensation,  anal  and  vaginal  tone,  voluntary  tightening  of anus, and vaginal and bulbocavernosal reflexes (50). The clinician should be aware of the emotional impact of a physical examination and the importance of timing. When a woman is very anxious about being examined it may be appro- priate to wait until she feels more secure. In the case of women who are not familiar  with  self-examination  of  their  genitalia,  it  is  preferable  to  advice self-examination at  home before a  doctor carries  out  an  examination.  It  is recommended that the procedure is explained in detail, what will and what will not take place, and the woman’s understanding and consent obtained. It is import- ant to realize that any medical exam is not able to examine function, because the genitalia are examined in a nonaroused state. As such, a medical exam can never replace a psychophysiological assessment.

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