What is a Sexual Dysfunction?
The experimental evidence and theoretical notions presented earlier strongly suggest that for women, sexual dysfunction is not about genital response. The women in our study who were diagnosed with FSAD according to strict DSM-IV criteria (42) turned out not to be sexually dysfunctional according to these same criteria because their genital response was not impaired. This study demonstrated that it is difficult to be sure that sexual arousal problems are not caused by a lack of adequate sexual stimulation, and that impaired genital response cannot be assessed on the basis of an anamnestic interview. This implies that the current DSM-IV criteria for sexual arousal disorder, which states that genital (lubrication/swelling) response is strongly impaired or absent, is unworkable. For most women, even those without sexual problems, it is difficult to accurately assess genital cues of sexual arousal, but this is exactly what the DSM-IV definition of sexual arousal disorder requires. The group of women the DSM-IV refers to may even be virtually nonexistent. Medi- cally healthy women who have complaints of absent or low arousal but are geni- tally responsive, given adequate sexual stimulation, do not qualify for a sexual arousal diagnosis according to DSM-IV. Women with a somatic condition explaining the sexual arousal difficulties do not qualify for one of the four primary diagnoses, including FSAD, either, even though, as we have argued, the presence of a somatic condition that affects sexual response may be the most important predictor for impaired genital responsiveness. In medically healthy women impaired genital responsiveness is not a valid diagnostic criterion. Consequently, we believe that the DSM-IV criteria for sexual arousal disorder are in need of revision.
A first consensus meeting on the definitions and classifications of female sexual problems in 1998 did not generate a significantly different classification system but did propose to replace the “marked distress and interpersonal diffi- culty” criterion of DSM-IV with a “personal sexual distress” criterion (95). Bancroft, Loftus and Long subsequently investigated which sexual problems predicted sexual distress in a randomly selected sample of 815 North American heterosexual women aged 20 – 65, who were sexually active (16). The best pre- dictors were markers of general emotional and physical well being and the emotional relationship with their partner during sexual activity. Sexual distress was not related to physical aspects of sexual response, including arousal, vaginal
lubrication, and orgasm. The study provided data supporting the possibility that relationship disharmony may cause impaired sexual response rather than the opposite. The authors concluded that the predictors of sexual distress do not fit well with the DSM-IV criteria for the diagnosis of sexual dysfunction in women. These findings are in line with the problems with DSM-IV that were dis- cussed in this chapter. When one believes, as we do, that the problems that generate most sexual distress deserve most of our research and clinical attention, the current focus of DSM-IV on genital response is unjustified. The choice of DSM-IV to exclude women with a somatic condition from the four primary diag- noses of sexual disfunction seems unwarranted as well, because women with such a condition reported highest levels of sexual distress. On the other hand, a high sexual distress score does not automatically implicate sexual dysfunction.
When should we consider a sexual problem to be a sexual dysfunction? The objective and medical connotation of the word “dysfunction” has probably pro- moted the choice for impaired genital responsiveness as the criterion for an arousal disorder in DSM-IV. In this chapter, we have argued that many women with a medical condition have sexual problems that may or may not be caused by the disease directly, but that the sexual problems of healthy women are better explained by lack of adequate sexual stimulation and sexual and emotional closeness to their partner. Similarly, Tiefer (96) has presented a “New View of Women’s Sexual Problems” that strives to de-emphasize the more medicalized aspects of sexual problems that currently prevail, and that looks at “problems” rather than at dysfunctions [see also Refs. (19,97)]. Bancroft (98) argues that a substantial part of the sexual problems of women are a logical, adaptive response to life circumstances, and should not be considered as a sign of a dys- functional sexual response system, which would explain why prevalence figures based on frequencies yield much higher dysfunction rates (19) than actual distress figures.
The latest classification proposal also embraces the personal distress cri- terion and has reintroduced a subjective criterion, but avoids an answer to the question of when a sexual problem is a dysfunction. In this proposal the word “dysfunction” is used to mean simply lack of healthy/expected/“normal” response/interest, and is not meant to imply any pathology within the woman (15). This does again suggest, however, that we have clear criteria for healthy and normal response.
The answer to the question of what is not a sexual dysfunction is more easy than generating clear cut criteria for sexual dysfunction. As long as lack of ade- quate sexual stimulation—whether this is the result of absence of sexual stimu- lation or of lack of knowledge about, bad technique of, a lack of attention for, or negative emotions to sexual stimuli—explains the absence of sexual feelings and genital response, the label “dysfunction” is inappropriate. Problems that are situational do not deserve the label dysfunctional, as is now possible in DSM-IV.
The study of Bancroft and colleagues might be taken to imply that only medical and somatic problems that generate sexual unresponsiveness, which cannot be understood as adaptations to life circumstances and which cause sexual distress, should be considered a dysfunction. This is a view that we can endorse. Without completely resolving this issue, we might at best suggest that a differen- tiation between genital and subjective unresponsiveness in all circumstances (“dysfunction”) and not being able to create the right conditions for sexual arousal (“problem”) is the most theoretically and clinically meaningful.
TREATMENT Psychological Treatments
Currently, we are in a climate that overlooks and dismisses psychological treat- ments (99). One of the reasons for this may be that due to sociocultural pressure in the medical and larger culture, physiological treatments are seen as superior (100). The emphasis on impaired genital unresponsiveness in the DSM-IV and the success of pharmacological treatments for men’s erectile dysfunction have undoubtedly contributed as well.
Prior to publication of Masters and Johnson’s seminal book on sex therapy (101), sexual problems were seen as consequences of (nonsexual) psychological conflicts, immaturity, and relational conflicts. Masters and Johnson proposed to directly attempt to reverse the sexual dysfunction by a kind of graded practice and focus on sexual feelings (sensate focus). If sexual arousal depends directly on sexual stimulation, that very stimulation should be the topic of discussion (masturbation training). A sexual dysfunction was no longer something pertain- ing to the individual, rather, it was regarded as a dysfunction of the couple. It was assumed that the couple did not communicate in a way that allowed sexual arousal to occur when they intended to “produce” it. Treatment goals were asso- ciated with the couple concept: the treatment goal was for orgasm through coital stimulation. This connection between treatment format and goals was lost once Masters and Johnson’s concept was used in common therapeutic practice. People came in for treatment as individuals. Intercourse frequency became the gold- standard indicator of sexual function. Male orgasm through coitus adequately fulfills reproductive goals, but it is not very satisfactory for many women because they do not easily reach orgasm through coitus. What has remained over the years since 1970 is a direct focus on dysfunctional sex and a focus on sexual sensations and feelings as a vehicle for reversal of the dysfunction.
Psychological treatment of sexual arousal problems generally consists of sensate focus excercises and masturbation training, with the emphasis on becom- ing more self-focussed and assertive (38). A lack of meaningful treatment goals for women, the difficulty in obtaining adequate control groups, and a lack of clear treatment protocols, may explain the paucity of well-controlled randomized trials of psychological therapy (50).
In the mid-1990s, a number of reviews of treatments for sexual dys- functions following the criteria for validated or evidence based practice were published (39,102,103). Almost all of the data on psychological treatments were collected in the mid-1980s or earlier. The high success rates published by Masters and Johnson (101) have never been replicated. In their 1997 review, Heiman and Meston concluded that only the directed-masturbation treatments for primary anorgasmia fulfil the criteria of “well-established,” and directed-masturbation treatment studies for secondary anorgasmia fall within the “probably efficacious” group. This conclusion is still valid up to date. There are no psychological treat- ments for FSAD that can be considered “evidence-based” treatments, but as we have argued earlier, directed-masturbation or comparable treatments may be as effective for FSAD as they are for FOD.
Recently, a new nonpharmacological approach to treatment was developed. The EROS Clitoral Therapy Device consists of a small cup that can be placed over the clitoris, and a pump that creates a vacuum over the clitoris. A study in 20 women with sexual arousal complaints and 12 women without sexual problems found improvements in genital sensation, vaginal lubrication, ability to reach orgasm, and sexual satisfaction relative to pretreatment (104). The authors specu- late that “the increased vaginal lubrication resulting from clitoral engorgement with the EROS-CTD is due to activation of an autonomic reflex that triggers arter- ial vasodilatation with subsequent increases in transudate and lubrication.” The EROS-CTD is marketed as an effective medical device for female sexual dysfunc- tion (105), even though there was no control treatment such as clitoral vibration (cf. 106). For us, this “medical” device again demonstrates that, if proven effective in larger groups of women with sexual arousal difficulties, many if not most sexual arousal problems are due to a lack of adequate sexual stimulation.
Despite our support for evidence-based practice, care for people with sexual problems, according to the rules of “good clinical practice,” must con- tinue, even without solid proof of efficacy. There clearly is a great need for con- trolled efficacy studies in this area. From our analysis that the majority of sexual arousal problems in healthy women are not related to impaired genital respon- siveness, it follows that we expect more benefit for FSAD from psychological treatments than from pharmacological treatments.
In the relatively short time span, compared to psychologic treatments, that pharmacological treatments have become available for men, since 1998, the effect of pharmacological treatments in women with sexual arousal problems has been investigated in several controlled and uncontrolled studies. To date, none of the treatments listed here have been approved.
Phosphodiesterase Inhibitors Sildenafil is the first pharmacological treatment that has been investigated on a reasonable scale in controlled studies with female subjects. In the very first laboratory study, 12 healthy premenopausal women without sexual dysfunction were randomized to receive a single oral 50 mg dose of sildenafil or matching placebo in the first session and alternate medication in a second session (107). Although sildenafil was found effective in enhancing vaginal engorgement (VPA) during erotic stimulus conditions, these changes were not associated with an effect on subjective sexual arousal. The first large controlled at home study in 557 estrogenized and 204 estrogen-deficient pre- and postmenopausal women with sexual problems that included, but were not limited to, sexual arousal disorders, found no improvement with 10 – 100 mg of sildenafil on sub- jective sexual arousal and subjective perception of genital arousal, as assessed by several different measures (108). Women identified as having DSM-IV arousal disorder without concomitant hypoactive sexual desire disorder did show benefit of sildenafil beyond placebo (109). Also, an Italian study found improvement on subjective sexual arousal, pleasure, orgasm, and even on fre- quency of orgasm, in premenopausal women with sexual arousal complaints, although these results were obtained with unvalidated questionnaires (110). A second study from the same group in sexually functional women showed benefit of sildenafil over placebo on arousal, orgasm, and enjoyment, now with a validated questionnaire (111). A small, recent placebo-controlled laboratory study of women diagnosed with genital arousal disorder suggested only a small minority of them might benefit from sildenafil (112). The controlled labora- tory study of Sipski et al. (113) in women with SCI found an enhancing effect of sildenafil on genital (VPA) and subjective sexual arousal. The beneficial effects of sildenafil over placebo were most evident in the strongest stimulus condition of both visual and manual stimulation. Several, yet unpublished, controlled studies in women with FSAD found no improvement of sildenafil.
These conflicting findings have probably led to Pfizer’s recent decision to end their program of testing efficacy of sildenafil in women (114). It would be theoretically and clinically meaningful to investigate which factors may have been responsible for these inconsistent findings. Possible candidates are: inadequate sexual stimulation (sildenafil will not be effective without sexual stimulation); inadequate outcome measures; wrong patient group (e.g., women with sexual problems unrelated to genital responsiveness); estrogen depletion. In most studies, women with a medical condition were excluded from the trials. This may have been an unfortunate choice. We have argued that women with various medical conditions may have an impaired genital response and may therefore have more to gain from a genital arousal enhancing agent such as sildenafil than medically healthy women.
One placebo-controlled, single-blind, dose response study has been published investigating the effect of a local application of alprostadil in women with arousal difficulties (115). No significant differences with placebo were found. A comparison of the lowest with the highest dose did show some effects in the expected direction, but these effects were estimated by visual inspection by an MD. It is unknown whether that MD was also blinded to treatment. Apparently a larger, as yet unpublished study, in postmenopausal women did find significant improvement over placebo on genital sensation, subjective sexual arousal, and sexual satisfaction (116).
Two controlled studies have investigated the effect of the alpha-1 and alpha-2 adrenergic receptor antagonist phentolamine on the basis of the hypothesis that, as in men, the smooth muscle surrounding the vaginal arterial vascular bed is mainly alpha adrenergically innervated. In the first study, an oral application was used that showed a positive effect on subjective and genital sexual arousal (VPA) in postmenopausal women with sexual arousal difficulties (117). A second placebo-controlled study studied both oral and vaginal applications in estrogen- ized and nonestrogenized postmenopausal women (118). Genital response was higher with the highest dose of vaginally applied phentolamine than with placebo, in estrogenized postmenopausal women only. Subjective sexual arousal was higher with the highest doses of both applications of phentolamine than with placebo, again in the estrogenized women only.
Dopaminergic drugs might be interesting because unlike the previously discussed drugs, they have a direct effect on the brain and may therefore have a positive influence on sexual arousal and desire. The only controlled study published to date found an enhancing effect of levodopa on an index of somatic motor prep- aration, the Achilles tendon reflex, in men, but not in women (119). Sumanirole is a dopamine agonist that specifically targets D2-receptors. We investigated the effect of this drug in women with complaints of sexual arousal and desire in a placebo-controlled laboratory study, but found no effects on genital or subjective sexual arousal (data not published). Buproprion was used in one uncontrolled study to counteract the sexual side-effects of selective serotonine reuptake inhibi- tors. Keeping in mind that no adequate control was used, the authors conclude that the results point to relief of the sexual complaints (120).
Several companies have begun to study the effects of various androgen products and androgen – estrogen combinations. The relationship between declining andro- gens and sexual response has not been clarified. Sexual problems related to androgen deficiency are to be expected only when there is a real deficiency of biologically available testosterone. Recently, a consensus conference has tried to establish clear criteria for such an androgen insufficiency syndrome (64). Fourcroy (116) recently published a detailed overview of androgen treatments that are being developed, and concluded that it remains to be seen whether these products will show promise in female sexual dysfunction. Besides efficacy, there are increasing concerns about safety. For an overview of a small number of other treatments and a listing of pharmaceutical companies that are involved in these treatments, see Ref. (116).
RECOMMENDATIONS FOR CLINICAL PRACTICE
We would like to end with five questions that may help establish the heart of the problem in women with complaints about reduced or absent arousal and desire.
The first question is whether the client wants to be sexual at all. This ques- tion may refer to people that were excluded from Masters and Johnson’s studies. These may be people so deeply involved in relational conflict, that they, as Masters and Johnson put it, need legal advice instead of sex and relationship therapy (101). The prognosis for a rewarding sexual relationship, even if all the relational discord was to be resolved, seems to be poor (121). Learning to stop arguing or learning to do that more effectively does not necessarily improve the sexual relationship. For that, as we have argued, situations with posi- tive sexual meanings are a first prerequisite.
The second question refers to the sensitivity of the sexual system. As we have seen, in healthy women problems related to genital unresponsiveness are unlikely. For clinicians who need to rule out that organic etiology is underlying sexual arousal difficulties, or who question genital responsiveness for other reasons, a psychophysiological assessment will provide indispensable additional information.
Next, are there, on the basis of sexual history, positive expectations regard- ing sex? Are there any sexual rewards? And are these expectations activated in the given sexual situation, and which new sexual stimuli are likely to be sexually rewarding? When there are no or only a few positive experiences, one can try to help women find these experiences. A confrontation with sexual stimuli will probably only be rewarding by the sexually rewarding experience. Our disposition to respond positively to tactile stimulation must become associated with sexual stimuli.
If all these conditions are satisfied and the sexual system is activated, there will be a cascade of events that occur partly automatic and partly on the basis of conscious decisions. Whether we will be sexually active will depend, ultimately, on decisions about the partner, the circumstances, and on ideas about how we want to shape our sexual lives.