His and Her Health

 

"A full appreciation of women’s sexual function requires an understanding of the underlying psychosocial, as well as physiological, components."  This excerpt outlines common beliefs about women's sexuality and discusses the various disorders women face.

 

Reproduced with permission of The Johns Hopkins University Press, 2006.

To  read the first excerpt , click here. 

To read the second except, which focuses on  issues surrounding male orgasm, click here.

Challenging Beliefs about Female Sexuality Participants at the International Consultation on Sexual Medicine, held in Paris in June 2003, challenged some of the common beliefs about women’s sexual response (Basson, Leiblum, et al., 2003). Here we briefly summarize these beliefs and the challenges to them. Belief 1: Organic sexual problems can be separated from psychogenic problems.

 

Sexual disorders in women may involve multiple psychological, interpersonal, and biological/organic causes, and these influences are not always separate entities. Belief 2: The primary reason women engage in sexual behavior is conscious or subliminal awareness of sexual desire (e.g., sexual thoughts or sexual fantasies). Women seem to be motivated to have sex for highly complex and varied reasons.

 

Women in new relationships are more likely to experience spontaneous desire—in the form of sexual thoughts and Fantasies —than are women in established relationships, who may think of sex infrequently. Belief 3: Sexual desire always precedes sexual arousal. Arousal often occurs before desire for women, or women may experience desire and arousal simultaneously. Again, desire is not the only reason that women engage in sexual activity; they have a wide variety of other motives, including a wish to be intimate with their partner. According to Basson, Althof, et al. (2004), “Desire is consequently experienced after arousal such that continued arousal and a responsive type of desire coexist and reinforce each other in keeping with the conceptualization of women’s sexual response.”

 

Belief 4: Women’s sexual arousal can be characterized by genital vasocongestion, vaginal lubrication, and an awareness of genital throbbing and tingling. Many women who have genital signs of arousal do not feel subjectively aroused, and many women may not even be aware of the physiological changes in their bodies when they are aroused. Even if they are aware of genital and breast vasocongestion, the changes may not correlate with increased vaginal engorgement. (Engorgement can be measured with a vaginal photoplethysmograph, a vaginal probe with a light source and light detector that measures changes in the amount of light reflected through the vaginal wall as an indication of changes in vaginal blood flow.) Still, vaginal lubrication commonly occurs during sexual stimulation even when a woman does not desire or enjoy the stimulation.

 

Belief 5: The sexual response of women remains stable over time and circumstance. The sexual response of women varies naturally over the lifespan and is influenced by a host of factors, including the context of sexual interactions, pregnancy and menopause, medical conditions, and psychological factors (most notably the interpersonal relationship).

 

Research suggests that a normative, gradual decline in sexual interest and response occurs with aging and natural menopause. Belief 6: Women feel distress when they experience changes in their sexual response. Many women do not feel distress when they lose interest in sex or experience a lack of response. And unless women do feel distress, these are not really problems and are of little clinical relevance (Basson, Leiblum, et al., 2003).

 

Problems for Women Research on women’s sexual problems and concerns is lagging behind research on men’s sexual problems by a 2:1 or 3:1 ratio. Researchers and health care providers are now beginning to recognize that sexual response in men and women differs in significant ways. The diagnostic categories of women’s sexual “dysfunction” as presented in the DSM-IV are based on a conceptualization of sexual response depicted by Masters and Johnson (1966, 1970) and Kaplan (1974).

 

For their time, their work was a great advance in the knowledge of human sexuality. However, the concept of one linear sequence of predominantly genitally focused events has not proven helpful in assessing and managing women’s sexual problems and disorders (Basson, 001).Several models have been proposed, each of which views women’s sexual response as more of a circular than a linear pattern (Whipple & Brash-McGreer, 1997; Basson, 2001; Plaut, Grazziottin & Heaton, 2004).

 

A full appreciation of women’s sexual function requires an understanding of the underlying psychosocial, as well as physiological, components. When assessing women’s concerns, the health care provider’s focus must extend beyond physical short issues to encompass the emotional and relationship milieu in which the concerns exist (K. P. Jones, Kingsberg & Whipple, 2005). As with men, problems with women’s sexual function can be lifelong or acquired, global or situational. The etiology may be organic, psychogenic, mixed, or unknown.

 

We use here the new categories of sexual disorders in women proposed by the International Consultation in June 2003; these categories have not yet been incorporated into the DSM or the International Statistical Classification of Disease and Related Health Problems (ICD-10; World Health Organization, 1992). Guide for characterizing a sexual disorder. (Adapted with permission from R. Basson, W. C. M. Weijmar Schultz, et al., 2004) Sexual Desire/Interest Disorder Sexual desire or sexual interest disorder is newly defined as “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 become sexually aroused are scarce or absent. The lack of interest is considered to be beyond the normative lessening with life-cycle and relationship duration” (Basson, Althof, et al., 2004). The DSM-IV term for desire disorders, as noted above for men, is hypoactive sexual desire disorder (HSDD). Population data indicate a prevalence of HSDD of 33 percent in women between 18 and 59 years of age (Laumann, Paik & Rosen, 1999); this may reach 45 percent in clinical samples, especially after menopause (Plaut, Grazziottin & Heaton, 2004). The term libido refers to a sexual appetite, desire, drive, sexual impulse, and sexual interest that motivates individuals to focus their attention on having a sexual experience.

 

Plaut, Grazziottin, and Heaton (2004) suggest three basic components to desire: biological, motivational, and cognitive. Biologically, desire is hormonally influenced. Hormones may affect the intensity of desire and sexual response. The primary hormonal etiologies of sexual desire disorder are hypoestrogenism, androgen insufficiency syndrome, hyperprolactinemia, and hypothyroidism. Alcohol addiction and smoking may contribute to sexual disorders, as may certain disease processes and medications (Plaut, Grazziottin & Heaton, 2004). Medications that may cause a loss of desire are SSRIs, antihypertensives, estrogen therapies, and corticosteroids.

 

Also, a sudden drop in testosterone levels, as occurs with surgical menopause, can cause a lack of sexual desire (Whipple & Brash-McGreer, 1997; Kingsberg, 2002). Motivationally, the need for intimacy, which seems to be particularly important to women, may contribute to and modulate sexjual desire. The affective disorders of depression and anxiety seem to decrease sexual desire (Plaut, Grazziottin & Heaton, 2004).

 

Cognitive factors may overlap with biological and motivational factors to diminish sexual desire. There are other reasons, beyond awareness of sexual desire, that motivate women to agree to or initiate sexual interactions with a partner. These are currently being investigated in a study of women of different ethnic backgrounds in North America. Some reasons already identified are: to express love, for pleasure, because the partner wants it, and to release tensions. Also identified are some reasons for not being sexually active, including no partner, no interest, too tired, partner has no interest, partner is too tired, own physical problem, and partner’s physical problem (Cain et al., 2003).

 

Basson, Althof, et al. (2004) report multiple reasons or incentives for a woman to be aroused and that once she experiences arousal, if it continues sufficiently long and is enjoyable, she may experience sexual desire. Studies also indicate that sexually healthy women, particularly those in long-term relationships, are frequently unresponsive to spontaneous sexual thoughts (Bancroft, Loftus & Long, 2003).

 

The Massachusetts Women’s Health Study II suggested that most women experiencing decreased sexual drive are married, have symptoms of psychological pathology, smoke cigarettes, and are in perimenopause (Avis et al., 2000). Cognitive factors affecting desire may be many. Indeed, the treatment of disorders of desire is usually cognitive-behavioral therapy, sex therapy, or psychodynamic treatment. Although cognitive-behavioral therapy is widely used, very few controlled trials of its alleged benefits have been conducted.

 

There is some empirical support for the usefulness of sex therapy with sensate focus, but to our knowledge there are no studies on psychodynamic treatment (Basson, Althof, et al., 2004). However, because loss of desire is often related to interpersonal problems rather than biological factors, counseling for relationship and psychological issues should be considered before pharmacotherapy. Currently, there are no drugs specifi cally prescribed for the treatment of any female sexual disorder, including disorders of desire.

 

Several potential therapies are now in clinical trials. Estrogen therapies can help with physical problems related to menopause, but they have little effect in treating decreased desire (Suckling, Lethaby & Kennedy, 2003). Testosterone therapy has been used “off-label” for women with low sexual desire. Some women take oral estrogen and testosterone for low desire, but this treatment was approved only for menopausal symptoms. Other women take testosterone prepared by a compounding pharmacist, and others use a piece of the male testosterone patch or testosterone gel developed for men.

 

None of these treatments is approved for women by the FDA. A recent study by S. R. Davis, Davison, et al. (2005) found no correlation between circulating androgen levels and sexual function in women: “no single androgen level is predictive of low female sexual function, and the majority of women with low dehydroepiandrosterone sulfate levels did not have low sexual function.

 

” These authors stated that their results are not in conflict with testosterone being used pharmacologically to treat HSDD, nor do their data provide support for efficacy of the therapy. In December 2004, the Procter and Gamble company presented to the FDA its positive data on the effects of a testosterone patch (Intrinsa) developed for HSDD in surgically postmenopausal women (Shifren et al., 2000; Goldstat et al., 2003).

 

However, the FDA Advisory Committee voted to send Intrinsa back for more studies, citing insufficient long-term safety data to support approval of the drug. It is interesting that Viagra was approved for use in men in 1998 based on only six months of clinical trials, despite concerns about an increased risk of a fatal reaction if taken together with a nitroglycerin medication or with well-known recreational drugs (Kingsberg & Whipple, 2005).

 

By contrast, after more than three years of study, Intrinsa was not approved for use in women, and long-term safety data are now requested. This difference suggests the existence of a male-female double standard in the treatment of sexual disorder. Subjective Sexual Arousal Disorder Subjective sexual arousal disorder is defi ned as the “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” (Basson, Althof, et al., 2004). The International Consultation panel developed this new category based on data suggesting that most women who complain of arousal problems have genital vasocongestion comparable to that of women who do not complain of a loss of subjective arousal (K. P. Jones, Kingsberg & Whipple, 2005).

 

Genital Sexual Arousal Disorder The International Consultation panel defined genital sexual arousal disorder as “complaints of impaired genital sexual arousal. Self-report may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from non-genital sexual stimuli” (Basson, Althof, et al., 2004).

 

 A woman diagnosed with this disorder can still be subjectively aroused by sexual stimulation, but she has a marked loss of intensity of any genital response, including orgasm. Awareness of throbbing/swelling/lubrication is absent or markedly diminished. It is the woman’s self-report of absent or impaired genital congestion and lubrication that is the basis of the definition of this disorder (Basson, Althof, et al., 2004).

 

This diagnosis pertains mostly to women with autonomic nerve damage and estrogen deficiency who do not experience vasocongestion (K. P. Jones, Kingsberg & Whipple, 2005). Combined Genital and Subjective Arousal Disorder Combined genital and subjective arousal disorder is defined as “absent 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)” (Basson, Althof, et al., 2004).

 

The International Consultation panel noted that this is the most common clinical presentation for female arousal disorders. The woman also complains of a lack of sexual desire (K. P. Jones, Kingsberg & Whipple, 2005). The lack of subjective excitement from any type of sexual stimulation distinguishes these women from those with genital arousal disorder. Persistent Genital Arousal Disorder A provisional defi nition of persistent genital arousal disorder is “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 feeling of arousal persists for hours or days” (Basson, Althof, et al., 2004).

 

This provisional defi nition will allow further investigation of the prevalence and etiology of this poorly understood disorder. It may not be as rare as previously believed. Sexual Aversion Disorder Sexual aversion disorder is defined as “extreme anxiety and/or disgust at the anticipation of, or attempt to have, any sexual activity . . . Many clinicians feel the syndrome of extreme anxiety/panic associated with activation of the autonomic nervous system is a context and sexual repercussions warrant its inclusion as a sexual disorder” (Basson, Althof, et al., 2004).

 

 Orgasmic Disorder Given that most women are unable to experience orgasm from intercourse alone and require extended clitoral or vaginal (G spot) stimulation (Whipple & Brash-McGreer, 1997; N. A. Phillips, 2000), we can assume there is a sizeable subset of women who have difficulty experiencing orgasm. Women’s orgasmic disorder is defined as follows: “Despite the self-report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations or marked delay of orgasm from any kind of stimulation” (Basson, Althof, et al., 2004). Anorgasmia is a common problem that affects an estimated 24 to 37 percent of women (Rosen, 2000). In primary orgasmic disorder, a woman has never experienced orgasm through any means of stimulation; in secondary orgasmic disorder, a woman is anorgasmic after having once been orgasmic, or is orgasmic under some conditions but not others.

 

Thus, secondary anorgasmia can be classified as generalized or situational, such as when a woman can experience orgasm by masturbation but not with a partner (K. P. Jones, Kingsberg & Whipple, 2005). Some evidence was recently presented of a genetic factor playing a minor role in orgasmic response. Based on a questionnaire study of “sexual problems” in a sample of female twins in England, comparing identical and fraternal twins, the researchers concluded that there is a significant heritable component for “difficulty reaching orgasm during intercourse” (K. M. Dunn, Cherkas & Spector, 2005). The underlying mechanism is unknown.

 

The International Consultation panel developed the new definition of orgasmic disorder because the old definitions often ignored the criterion of “high” or “adequate” sexual arousal. The current definition incorporates the criterion that the woman has no problem becoming aroused. Anorgasmia is considered to be a disorder only if the woman finds it distressing. Orgasm is more than simply a reflex. While it incorporates reflexive components, it also includes perception, which is not a necessary component of true reflexes. Orgasm may be triggered by a number of physical and mental stimuli. It does not even require direct genital stimulation.

 

 Mental (imagery-induced) orgasm in women has been demonstrated under laboratory conditions (Whipple, Ogden & Komisaruk, 1992; Komisaruk & Whipple, 2005). Psychosexual issues are more frequently in play for women with lifelong orgasmic difficulties. Biologically, the coexistence of two or more disease processes and pharmacological side effects becomes increasingly likely with advancing age (Plaut, Graziottin & Heaton, 2004).

 

 In the 1970s, the small-group format for the treatment of orgasmic disorders became popular, and books and videos were developed to “give women permission to experience orgasm” (a 1970s expression) and to share ways, in small “preorgasmic groups,” to experience sensual and sexual pleasure (Barbach, 1975). Women were taught about directed masturbation for treating lifelong generalized orgasmic disorder.

 

According to Meston, Hull, et al. (2004), “there are no consistent, empirical fi ndings that psychosocial factors alone differentiate orgasmic from anorgasmic women.” The most common methods used to treat anorgasmia are cognitive-behavioral, pharmacological, and systems theory approaches. Meston, Hull, et al. (2004) note that “cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually-relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction.” Behavioral exercises to deal with female orgasmic disorder include, as noted above, directed masturbation, with and without vibrators, which has been shown to be effective in groups and individually.

 

If a woman is able to experience orgasm through masturbation but not with a partner (and experiencing orgasm with a partner is her desire), couple therapy may be helpful, after issues of anxiety, communication, trust, and past history have been addressed. Another behavioral approach often recommended is the Kegel pelvic floor muscle-strengthening exercises. Physical therapy and biofeedback methods are helpful in the correct use of these exercises (Ladas, Whipple & Perry, 2005). Graber and Kline-Graber (1979) found a positive correlation between the strength of a woman’s pelvic muscles and the intensity of her orgasmic response. In their retrospective study (a study that asks participants to recall past events), these authors found that women with very weak pelvic muscles were anorgasmic. Sensate focus exercises were developed by Masters and Johnson (1970) to reduce anxiety through the use of a series of body-touching exercises, moving from sensual-nonsexual (e.g., scalp and face massage) to increasingly sensual-sexual (e.g., genital massage). These exercises are still widely used today.

 

However, according to Meston, Hull, et al. (2004), there are no reports that these exercises produce any substantial improvement in orgasmic response. A health care provider’s “granting permission” and providing usable information to the woman with anorgasmia may be the most helpful treatment. And given that orgasm is not always essential to sexual satisfaction, and that the inability to experience orgasm during intercourse is not abnormal, one needs to consider whether or not an orgasm difficulty needs a closer look. If not experiencing an orgasm causes a woman distress, then it can be considered a sexual problem. It is important for women to know that they are in charge of their own orgasm; they can have an orgasm, but no one else can give them an orgasm. Women are responsible for their own pleasure and satisfaction. In a laboratory study, a woman who had a complete spinal cord injury chose to participate so as to learn more about her own sexual response (Whipple, Gerdes & Komisaruk, 1996).

 

She had not experienced an orgasm during the two years since her injury. She had been told by a health care practitioner that since she had no movement or feeling below her breast, she could not be orgasmic again, so she had not tried any form of stimulation. During the three twelve-minute periods in the laboratory that included sexual self-stimulation (genital and nongenital), the woman experienced six orgasms. Pain Disorders: Dyspareunia and Vaginismus Dyspareunia is defined as “persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse” (Basson, Althof, et al., 2004).

 

The International Consultation panel updated the definition to include pain during penetration, not just during attempts at penetration. Dyspareunia is estimated to affect 14 percent of women annually, according to the National Health and Social Life Survey (Laumann, Paik & Rosen, 1999). The most common cause of sexual pain disorders among middle aged and older women is atrophic vaginitis (vaginal inflammation related to wasting [atrophy] of the tissue). In a postmenopausal population in the Netherlands, 27 percent of the women surveyed reported vaginal dryness, soreness, and dyspareunia (Van Geelen, van de Weijer & Arnolds, 1996).

 

While psychological and relationship factors play an important role in dyspareunia, it is the only female sexual disorder in which organic factors contribute significantly (Anastasiadis et al., 2002). For treatment to be effective, it is important to determine at the outset whether the dyspareunia is lifelong or acquired. Introital dyspareunia (pain on insertion of the penis into the introitus, the entrance into the vagina) is usually caused by poor arousal, vestibulitis (inflammation of the vaginal vestibule), vulvar dystrophy (vulvar abnormality), perineal surgery, pudendal nerve entrapment, or pudendal neuralgia. Midvaginal pain is usually due to levator ani myalgia (pain in the pelvic floor muscle that elevates the anus).

 

Deep vaginal pain may be caused by endometriosis, pelvic infl ammatory disease, pelvic varicocele (varicose blood vessels), adhesions, referred abdominal pain, outcomes of radiotherapy, or abdominal cutaneous nerve entrapment syndrome (Plaut, Graziottin & Heaton, 2004). The other type of pain disorder, vaginismus, is defined as “the persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any other object, despite the woman’s expressed wish to do so. There is often (phobic) avoidance, involuntary pelvic muscle contraction and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed” (Basson, Althof, et al., 2004).

 

The International Consultation panel revised the defi nition because vaginal spasm, included in the earlier definitions, has never been documented. The panelists specified that involuntary contractions mayoccur. They noted that vaginismus typically prevents the full entry of a penis (or other object), but that vaginal entry can occur and causes discomfort and pain (K. P. Jones, Kingsberg & Whipple, 2005). Vaginismus affects 15 to 17 percent of women who consult sex therapy clinics (Spector & Carey, 1990; Anastasiadis et al., 2002).

 

There have been very few controlled studies of dyspareunia or vaginismus. A multidisciplinary approach for sexual pain is recommended for women with these disorders, with attention to the experience of pain, the emotional/psychological profile, any past genital mutilation or sexual abuse, and examination of the mucous membrane and the pelvic floor (Basson, Althof, et al., 2004). Examination of the genitals should be approached with gentleness and constant interaction with the woman about painful areas.

 

It may be difficult or impossible to examine the vagina with a speculum. Vaginal estrogen and vaginal lubricants can be used to enhance comfort with penetration for women with vaginal atrophy. Beyond treatment of medical conditions, such as atrophic vaginitis and endometriosis, women suffering from sexual pain disorders may benefit from psychological counseling and education. Instruction in progressive muscle relaxation and the use of vaginal dilators may be helpful. Although many clinicians define vaginal penetration as the goal of therapy, we suggest sexual pleasure for the woman and her partner is a better measure.