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CHAPTER 19

Dening Female Sexual Dysfunction


Suzette E. Sutherland and Stanley E. Althof

INTRODUCTION
Following Masters and Johnsons groundbreaking work in the early 1970s there was a flurry of scientic inquiry into the etiology and treatment of female sexual dysfunction. This early excitement stalled in the late 1980s and early 1990s. It was not until after the introduction of sildenal for the treatment of erectile dysfunction that a second renewed wave of scientic enthusiasm regarding female sexual dysfunction evolved, leading to the advancement of new models and treatments. This chapter will present the major etiological and treatment models for female sexual dysfunction. It will address both the psychological and biological issues relevant to a holistic biopsychosocial model of female sexuality.

THE EARLY YEARS


William Masters and Virginia Johnson, in 1966, were recognized for providing the rst description of the human sexual response as it applies to both men and women.1 Through direct observations and physical measurements, they identied the gross physical and physiological reactions to sexual stimuli and proposed a linear model with four separate yet successive phases: excitement, plateau, orgasm, and resolution. Albeit arbitrary and inadequate for understanding the ne psychogenic aspects of the sexual response, these divisions provided a useful framework for future description and study. In addition to the development of their sexual response model, Masters and Johnson recognized gender-specic differences between the male and female sexual response. With the exception of variations in the duration of response, the male sexual response was described by a single cycle that can be represented graphically, as shown in Figure 19.1. This was in contrast to the female, where three different response patterns were noted, but also with the recognition that an innite variety of responses exist with variations in both intensity and duration of response (Fig. 19.2). The Masters and Johnson models for male and female sexuality were similar in that they were linear

and phasic; they began with arousal and ended with orgasm. By studying women having intercourse in a clinical research setting they documented the physiological parameters of female orgasm. They found there were variations in form but not separate clitoral or vaginal orgasms, as proposed by psychoanalytic theory. Helen Singer Kaplan24 and Harold Lief 5 expanded on Masters and Johnsons work by proposing the concept of desire to account for women and men who lacked the motivation to be sexual.They proposed desire as the initial phase, or the inciting factor responsible for triggering a three-phase sexual response cycle: desire, arousal, and orgasm. Desire, for both men and women, was thought to be a spontaneous event, which directly elicited the physiological responses of arousal and orgasm. A biphasic nature of these physiological responses to sexual stimulation was described: genital and generalized vasocongestion, seen as penile erection in the male and vaginal lubrication and labial/clitoral swelling in the female; and reflexive myotonic reactions resulting in ejaculation in the male and orgasm in both sexes. Desire, however, was thought to be the necessary precursor for initiating these physiological responses. Kaplan perpetuated the linear phasic models of Masters and Johnson, leading clinicians to think of female sexual dysfunctions as discrete entities with little overlap between dysfunctions.

Orgasm

Plateau Refractory period Excitement

Refractory period

Res

Figure 19.1 The male sexual response cycle. From Masters WH and Johnson VE. Human sexual response. Boston: Little Brown, 1966. By kind permission of Lippincott, Williams & Wilkins.

Res olut ion

io olut n

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Dening Female Sexual Dysfunction


Figure 19.2 The female sexual response cycle. From Masters WH and Johnson VE. Human sexual response. Boston: Little Brown, 1966. By kind permission of Lippincott, Williams & Wilkins.

Orgasm

Plateau
Re
ol Res

so

lut

ion

Resolution

Excitement

ution

(B)

A B C

(C)

(A)

Further investigation into sexual response patterns has led to a greater understanding of differing genderspecic responses. This has resulted in the development of alternate models for women. In 1991 Leonore Tiefer recognized the non-genital components of female sexual satisfaction respect, mutuality, emotional bonding, intimacy as the motivational forces for engaging in sexual activity.6 In her recent women-centered New View denitions of sexual problems among women, the psychobiosocial aspects emotional, physical, cultural, and relational of the sexual experience are emphasized.7,8 This concept, known as the demedicalization of sexuality, advocates a non-medical framework for sexuality theory which is meaning-centered rather than function-centered, and grounded in humanistic rather than in biological foundations.7 Unlike women, men exhibit a strong objective and physically visible correlation between subjective and objective (genital) sexual arousal and response.1,2 With sexual stimulation, genital vasocongestion leads to penile rigidity; continued stimulation leads to orgasm with ejaculation. In contrast to this, female sexual arousal and response are not only difcult to measure but are often not readily perceived as such by the woman.9 Furthermore, Laan and Everaerd noted a discrepancy between objective and subjective sexual arousal in women.10 A disconnection between objective and subjective (mental) arousal was observed in their laboratory studies. These ndings further support the notion that sexuality is more contextual for women as compared to men. Rosemary Basson recently put this contextcentered perspective into an elegant non-linear model of female sexual response (Fig. 19.3).11,12 The

emphasis is on the responsive nature of womens sexual desire (as opposed to spontaneous); arousal and desire occur simultaneously, each enhancing the other in an interactive pattern. Many women are sexually neutral and consciously decide to be sexual and/or receptive to sexual overtures that have been made. This decision is primarily in response to a greater need for a sense of emotional attachment. In Bassons model, a yearning for emotional and relational intimacy provides the motivational force for physical and sexual behavior.

PREVALENCE STUDIES ON FEMALE

SEXUAL PROBLEMS AND DYSFUNCTIONS

The National Health and Social Life Survey (NHSLS), conducted in the early 1990s, reported epidemiological data on sexual dysfunction in the USA.13 This population-based analysis was the rst of its kind in almost 50 years to shed light on the widespread nature of sexual problems in society, especially among women. The survey included 1749 women and 1410 men, aged 1859 years. A higher prevalence of sexual problems overall was reported among women (43%) as compared to men (31%). One-third of women identied problems with sexual interest and desire, one-fourth reported a lack of orgasmic experiences, and one-fth complained of difculties with vaginal lubrication. Overall, 20% of women reported sex as an unpleasant experience (Fig. 19.4). Due to the cross-sectional design of the NHSLS, conclusions about causality or risk factors for sexual dysfunction were not possible. However, subsequent multivariate analysis identied

Prevalence Studies on Female Sexual Problems and Dysfunctions


Figure 19.3 Alternative model of female sex response cycle. From Basson R. Using a different model for female sexual response to address womens problematic low sexual desire. J Sex Marit Ther 2001; 27:395403. Reproduced by permission of Taylor & Francis Inc.

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Intimacy needs

Seeking out and being receptive to

Enhanced intimacy More arousal and pleasure and positive outcome emotionally and physically

Sexual stimuli

Sexual desire To continue

Sexual arousal

Biological and psychological factors affect processing of stimuli

Experience pain during sex Sex not pleasurable Unable to achieve orgasm Lacked interest in sex Anxiety about performance Climax too early Men unable to keep an erection Women have trouble lubricating 0 5 10 15 20 25

Women Men

Figure 19.4 Male and female frequency of reported sexual problems. From Laumann EO, Gagnon JH, Michael RT, Michaels S. The social organization of sexuality. Sexual practices in the United States, Chicago. Copyright 1994 University of Chicago Press. Reproduced by permission of the University of Chicago Press.

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several independent predictors of female sexual dysfunction.14 Increasing age (especially postmenopausal), lower level of educational attainment, unmarried status, poor physical or emotional health, and prior negative sexual experiences were all associated with an increased incidence of sexual problems. For many women female sexual dysfunction caused profound physical, psychological, and emotional concerns, resulting in a signicant impairment in quality of life. Previous estimates of sexual dysfunction among healthy women vary widely. In a review of 23 studies on the incidence and prevalence of female sexual dysfunction by Spector and Carey, a 510% prevalence for lifelong inhibited orgasm among the community samples was reported, with 70% of these women anorgasmic with intercourse.15 The majority of womens complaints, however, were decreased sexual desire and arousal. Studies completed with community samples revealed difculties associated with sexual desire and

arousal in up to 50% of women, while analysis of the clinical samples noted these same complaints in up to 80% of women. In 1978 Frank et al. published a study on 100 ethnically homogenous happily married couples in which 63% of the women experienced dysfunction with sexual performance relating to arousal or orgasm.16 Sexual difculties were dened as those parameters relating to the emotional tone of the sexual relationship (inability to relax, lack of sexual interest or desire, insufcient foreplay before intercourse, insufcient tenderness after intercourse) and were reported by 77% of the women. The men in Franks study tended to underestimate the problems reported by their wives.While difculties with getting and maintaining excitement during sexual encounters was reported by one-third of the wives, only half of their husbands recognized this problem in their partner. For women, dysfunctions in sexual

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arousal, as well as the number of sexual difculties, most strongly correlated with overall sexual dissatisfaction. This nding supports the notion that women may have a greater need for the emotional intimacy associated with sexual behaviors, and are therefore disappointed when the physical encounter does not generate a greater sense of connection. Another survey study by Rosen et al. in 1993 identied a number of sexual problems among 329 healthy women (ages 1873 years) from an outpatient gynecology setting.17 Among these problems were sexual anxiety or inhibition (38%), lack of sexual pleasure (16%), orgasmic difculties (15%), lubrication difculties (13.5%), and dyspareunia (11%). Increasing age (especially postmenopausal women) and nonmarried status were signicant predictors of sexual dissatisfaction. In spite of these reported difculties, 68.6% of the women viewed their sexual relationship overall as satisfactory, reinforcing the multidimensional aspect of female sexuality and the importance of relationship factors for normal female sexual function. A renewed interest in female sexual dysfunction blossomed following the successful experience of oral pharmacotherapy with sildenal citrate (Viagra) for the treatment of male erectile dysfunction.18,19 With promising clinical research suggesting the importance of neurohemodynamic events in female sexual physiology, similar to those seen in males, the efcacy of a vascular medication for the treatment of female sexual dysfunction was hopeful.9,20,21 Preliminary data on the use of Viagra in women have not been optimistic, largely owing to a reported 50% placebo effect.22 This again points to the multifactorial nature of female sexual functioning, emphasizing the psychological and emotional, as opposed to purely physical, aspects.

CLASSIFICATION OF FEMALE SEXUAL

DYSFUNCTION

Classication systems for female sexual dysfunction are based on the linear and discrete model initially promulgated by Masters and Johnson1 and Kaplan2 that includes disorders of desire, arousal, orgasm, and sexual pain. Three major classication systems exist, including the World Health Organizations International Classication of Disease (ICD-10) system of 1992,23 the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association classications of 2000,24 and the more recent reclassication system developed by the American Foundation of Urologic Disease (AFUD) Consensus Panel in 2000.25 According to the ICD-10, sexual dysfunction is dened as the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish.23 Seven categories were devised, which include: (1) a lack or

loss of sexual desire (F52.0); (2) sexual aversion disorder (F52.1); (3) failure of genital response (F52.2); (4) orgasmic dysfunction (F52.3); (5) non-organic vaginismus (F52.5); (6) non-organic dyspareunia (F52.5); and (7) excessive sexual drive (F52.7). The DSM-IV-TR denes sexual dysfunction as disturbances in sexual desire and/or the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difculty.24 The dysfunctions listed in DSMIV-TR include: (1) hypoactive sexual desire disorder (302.71); (2) sexual aversion disorder (302.79); (3) female arousal disorder (302.72); (4) female orgasmic disorder (302.73); (5) dyspareunia (302.76); and (6) vaginismus (306.51). Additionally, in order to qualify for any of these diagnoses, the woman must also be personally, not just interpersonally, distressed by the dysfunction.A separate diagnostic category for sexual dysfunction due to a general medical condition24 was included for any sexual performance difculties secondary to the physiologic consequences of a medical condition. Criticism of the DSM-IV-TR stems from its excessive focus on genital response while minimizing the emotional and interpersonal aspects of sexual encounters, which seem to be of greater importance to women than the physical genital response.26 By separating psychogenic dysfunctions from medical or substance-related dysfunctions it perpetuates the psychogenicorganic dichotomy rather than reflecting a more holistic biopsychosocial model. It is also criticized for reflecting a heterosexual, phallocentric model, where intercourse is considered the gold standard or point of reference for many of the diagnoses.7,26 Furthermore, the DSM-IV-TR and ICD10 classications do not reflect the extensive overlap commonly seen among women presenting with sexual dysfunction.27 In an attempt to address many of the shortcomings of these previous classication systems for female sexual dysfunction, a multidisciplinary, international committee of experts and in the eld of female sexuality convened to evaluate and revise the existing denitions and classications.25 Their aim was to develop a new consensus-based system of diagnostic criteria that would include psychogenic- and organicbased disorders.They sought to make recommendations regarding guidelines for clinical evaluation, measurable endpoints and outcomes for therapy and clinical trials, and to identify and prioritize future areas for research. The nal consensus classication system that emerged maintained the same four major disorder categories of desire, arousal, orgasm, and sexual pain as previously used in both the ICD-10 and the DSMIV-TR. This was done in an effort to preserve some continuity in both the clinical and research settings.

Classification of Female Sexual Dysfunction

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The individual psychologically based denitions, however, have been redened to include medical risk factors and etiologies of female sexual dysfunction. This change reflects recent advances seen in basic and clinical research. In an attempt to move away from the previous phallocentric model of sex, a new category for non-coital sexual pain disorders was created. Enthusiasm about an additional new diagnostic category designated to reflect sexual satisfaction disorders was generated, but insufcient epidemiological and clinical data in this area prevented the panel from reaching a consensus for its inclusion. The AFUD Consensus Panel Classications and Denitions of Female Sexual Dysfunction follow:

I. Sexual desire disorders


A. Hypoactive sexual desire disorder: the persistent or recurrent deciency (or absence) of sexual fantasies/ thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress. B. Sexual aversion disorder: the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.

II. Sexual arousal disorder


The persistent or recurrent inability to attain or maintain sufcient sexual excitement, which causes personal distress, and may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses.

III. Orgasmic disorder


The persistent or recurrent difculty, delay in, or absence of attaining orgasm following sufcient sexual stimulation and arousal, which causes personal distress.

IV. Sexual pain disorders


A. Dyspareunia
The recurrent or persistent genital pain associated with sexual intercourse.

B. Vaginismus
The recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.

Each classication receives additional subtyping to describe the disorder as: A. Lifelong versus acquired type. B. Generalized versus situational type. C. Etiologic origin (organic, psychogenic, mixed, unknown). A criterion for personal distress as a quality-of-life measure was included for most of the diagnostic categories. This criterion emphasizes the subjective nature of female sexual dysfunction and thereby afrms the importance of relying on patient self-reports as a signicant endpoint in clinical trials, rather than focusing solely on physiological or anatomical (genital) data. Furthermore, the substitution of personal distress for interpersonal distress (included in DSM-IV-TR) was intended to focus on the womans concerns rather than those of her partner. Current validated self-report instruments, such as the Female Sexual Function Index (FSFI)28 and the Brief Index of Sexual Functioning for Women (BISF-W),29,30 do not incorporate an evaluation of personal distress. However, following the recent development and validation of the Female Sexual Distress Scale (FSDS), a measure of sexually related distress and its impact on quality of life is now possible.31 Hypoactive sexual desire disorder was broadened to include a lack of receptivity to sexual activity initiated by a sexual partner. The concept of receptivity, however, is left without specic denition. The new denition also includes the persistent lack or deciency of sexual desire, which therefore excludes situational fluctuations in desire or sexual interest. Sexual arousal disorder was expanded beyond the objective physiologic parameters of genital arousal to acknowledge the strong subjective component of normal female sexual function. The new denition for sexual arousal disorder now includes subjective and non-genital objective somatic excitement and arousal responses, or lack thereof. Orgasmic disorder was broadened to include difculty and delay in attaining orgasm, rather than just the absolute absence of orgasm. Sexual pain disorder was also broadened to include an additional category for pain associated with sexual stimulation that does not include vaginal penetration or coitus. Moving away from traditional phallocentric notions of normal sexual activity, this recognizes the importance and satisfaction of non-coital sexual activity for many women.

Commentary on the AFUD classication system


While the new AFUD classication system represents a signicant step forward in conceptualizing female sexual dysfunction, several authors have voiced

C. Other sexual pain disorders (non-coital)


The recurrent or persistent genital pain induced by non-coital sexual stimulation.

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concerns regarding the diagnosis, the criterion sets, and larger conceptual issues. A summary of the major modications of the DSM-IV-TR nosologies and the controversies regarding the revisions or lack thereof are summarized below:

Does it truly provide an international perspective?


Although introduced as an international group, the participants of the consensus panel were primarily Caucasian as well as North American and/or European. Representation from Eastern European, Asian, Pacic Islanders,Australian, and South American cultures was lacking.32 The cultural differences and attitudes towards sexuality vary vastly and the new system may not be sufciently culturally sensitive. For example, reports of sexual desire disorders in Asian females would indicate that the incidence is statistically lower than that seen in the USA. Such statistics, however, are undoubtedly affected by cultural practices, as fewer Asian women consider decreased sexual desire a problem, and therefore do not seek counsel.33

than a preferred diagnosis-oriented classication system.39 As a list of symptoms (which are not necessarily synonymous with diagnoses), this classication system may prove useful in the clinical setting, but may leave a functional void in the formation of distinct diagnoses, management schemes, or research endeavors. A fully functional diagnostic classication system would in theory have provided more therapeutic, prognostic, and scientic signicance.

Organic categories
Incorporation of the organic category into the specication of female sexual dysfunction was a useful alteration, which should inspire research on the etiology of sexual disorders in women.40 The inclusion of both organic and psychogenic causes of sexual dysfunction is in line with the generally accepted multifactorial or biopsychosocial view of female sexuality.38,41

Personal distress
The criterion for personal distress has been met with mixed reviews. For those who believe it is the extent to which a disorder subjectively impacts the patient that denes the dysfunction, it is a welcome addition.32,4143 Likewise, the removal of interpersonal difculty previously seen in the DSM-IV-TR has been applauded, as it takes the focus away from the couple, and any inherent or interpersonal problems associated with sexual incompatibility, and places it on the individual.40 Others, however, do not feel that the absence of distress nullies the presence of the disorder.38,44,45 This argument centers around the lack of a personal distress criterion for other non-sexual disorders in the DSMIV-TR such as obsessivecompulsive disorder, bipolar disorder, or substance abuse. Similarly, a personal distress criterion is not required for medical diagnoses such as hypertension, diabetes, and coronary artery disease. Because the patient does not experience personal distress about the dysfunction, does that mean it does not exist? If a problem is present, it should be identied as such and given a rightful diagnosis, regardless of the subjective degree of bother experienced by the patient. Distress should not guide a diagnosis, although clearly the womans subjective distress is one of the primary motivators for treatment.27 Perhaps this controversy could be bridged by adding a specier to the diagnosis, such as with or without personal distress or syntonic versus dystonic.44

The influence of commercial interests?


This endeavor was made possible by educational grants from various pharmaceutical companies who have a vested interest in developing pharmacological solutions for female sexual dysfunction. The nancial incentive to medicalize female sexual dysfunction and further research along a path that undoubtedly takes a predominantly physiological course has some mental health practitioners concerned.3437 However, in keeping with the biopsychosocial model of female sexual function, scientific advances in physiological and sociological domains are needed.

More of the same?


Overall, the Consensus Panel did not stray far from the classication system of the DSM-IV-TR, although the descriptions of each dysfunction were updated and broadened.27 Admittedly, this was done to maintain continuity for the sake of furthering research and clinical efforts. As there is no evidence-based research that supports the DSM-IV-TR system, maintaining the framework could possibly allow for the continuation of inherent problems within it, and the continuation of existing myths about female sexuality.38

Receptivity

Are the criterion sets a list of symptoms or distinct diagnoses?


Writers criticize the DSM-IV-TR, and therefore the Consensus Panel, as being a symptom-oriented, rather

The inclusion of receptivity to the category of hypoactive sexual desire disorder was another welcome addition. Traditionally, sexual desire has been dened by cognitive and/or psychological factors such as spontaneous sexual thoughts, fantasies, or urges. Many

Classification of Female Sexual Dysfunction


Non-coital pain
Moving away from an exclusively intercourse-focused classication system led to the introduction of a noncoital sexual pain category. This extension of the existing category addresses recurrent or persistent genital pain following non-coital stimulation.43 This new category acknowledges other non-phallocentric sexual behaviors that are not focused on intercourse.8

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women, however, may not have spontaneous feelings or expressions of desire, but are responsive or receptive to the sexual advances of a partner.41,46 This idea is in keeping with the alternative female sexual response cycle described by Basson, which is intimacy-based.11,12 In this model, sexual arousal is not spontaneous, but follows the cognitive and physical acceptance of sexual stimulation. This new model challenges the traditional linear model where a psychological state (i.e., sexual desire) leads to a physiological response (i.e., sexual arousal).13 A linear relationship between the psychological and physiological aspects of the sexual response pattern is more readily apparent in men than in women. It was the recognition of these gender-specic differences which led to the development of Bassons non-linear female sexual response model. Receptivity, however, is neither clearly explained nor dened.A woman may be receptive to the sexual advances of her partner, without being emotionally or physically invested in the activity.46 A receptive but reluctant woman may be engaging in sexual activity to appease or placate her partner in order to maintain harmony within the relationship. Would her receptiveness preclude her from classication within the new Consensus Panel classication system? Clearly sexual desire problems are not without context (i.e., when? how? with whom?), and the important subjective components cannot be ignored.47 A complete objective medical, physical, or physiological approach to a woman with decreased sexual desire would be deemed inappropriate. For many women, the motivational aspects associated with enhanced nurturing and intimacy provide the primary incentive for sexual contact. Likewise, intimacy, affection, and nurturing touch, rather than spontaneous sexual thoughts or desire, provoke arousal, which in turn generates desire. The desire category may benet from an expansion, which includes motivational aspects other than sexual fantasies/thoughts.39,41,46 In keeping with this idea, Levine recently proposed a tripartite motivational model of sexual desire comprised of wish, drive, and motive.48 Wish represents the cognitive aspirations of sexual desire, motive the psychological, and drive the more biological.

Sexual pain versus genital pain


A controversy exists regarding the labeling of pain disorders: sexual versus genital.50 Sexual pain denotes that it occurs during a specic behavior, while genital pain characterizes the pain by location rather than by activity. With the exception of dyspareunia and vaginismus, all other chronic pain syndromes in the DSMIV-TR are classied according to their anatomical location, not by the activity with which they interfere (i.e., intercourse). The reproducibility of pain on physical examination outside the context of sexual activity supports a nosological change from sexual pain to genital pain. With this in mind, Binik suggests dyspareunia should be classied according to the specic anatomical location or origin of pain (i.e., vestibule, vaginal vault, supercial, deep), which would further emphasize the physical nature of dyspareunia and vaginismus as opposed to the psychological.51 On the other hand, Basson advocates in favor of a sexual pain disorder category, but makes a recommendation for further subtyping of dyspareunia according to the stage of penile entry or penile movement that is associated with pain.41

Vaginismus versus penetration disorder


A close look at the current denition of vaginismus reveals that it does not actually require the presence of pain. The term vaginismus focuses on the interference of vaginal penetration or intercourse due to vaginal spasms. Objective data dening the etiology and exact location of the overactive muscular activity within the pelvis that inhibits penetration are however lacking. Furthermore, there are other painful conditions that prevent penetration, such as vulvar vestibulitis, which are not specically associated with vaginal spasms.With this in mind, a suggestion for substituting vaginismus with penetration disorders was introduced, which would include all physical conditions that discourage or prevent vaginal penetration.43,52 For those women who describe a purely psychological fear about penetration with minimal actual introital stimulation, the term PARVE phobic anxiety regarding vaginal entry has been proposed.41

Subjective mental excitement


The inclusion of subjective or mental excitement, as well as non-genital somatic responses to the denition of sexual arousal, was another welcome addition.Again the importance of the cognitive element of female sexual desire and arousal is acknowledged.40,41,49 And although physiological excitement in the form of genital swelling and lubrication is an important aspect of healthy sexual arousal, recent advances in basic and clinical science have revealed the concomitant importance of non-genital, somatic responses in women.9,20,21

Sexual satisfaction
Finally, the concept of a sexual satisfaction category was discussed, although ultimately not included in

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the new consensus conference report. According to McCabe, a sexual satisfaction disorder could be seen as a breakdown in the resolution phase of the sexual response cycle.40 For Tiefer, the issue of sexual satisfaction is central to a woman-centered classication system and should denitely be included.34 A disjunction between sexual function and sexual satisfaction has often been noted among women. Most womens perceptions of the quality of their sexual relations are heavily influenced by the affective tone of the relationship itself, as opposed to the quality of the sexual performance.16 Inclusion of a sexual satisfaction disorder would provide the incentive for further research in this area.

4. Kaplan HS. Hypoactive sexual desire. J Sex Marit Ther 1979; 3:3-9. 5. Leif H.Whats new in sex research? Inhibited sexual desire. Med Aspects Hum Sex 1977; 11:9495. 6. Tiefer L. Historical, scientic, clinical and feminist criticisms of the human sexual response cycle model. Annu Rev Sex Res 1991; 2:12. 7. Tiefer L. A new view of womens sexual problems: Why new? Why now? J Sex Res 2001; 38 (2):8996. 8. Tiefer L. Sex is not a natural act and other essays. Boulder, CO: Westview Press; 1995. 9. Shabsigh R. Female sexual function and dysfunction. In: Walsh PC, Retick AM, Vaughan ED et al., eds. Campbells urology, 8th edn. Philadelphia: WB Saunders; 2002:17101733. 10. Laan E, Everaerd W. Determinants of female sexual arousal: psychophysiological theory and data. Annu Rev Sex Res 1995; 6:3276. 11. Basson R. The female sexual response: a different model. J Sex Marit Ther 2000; 26:5165. 12. Basson R. Using a different model for female sexual response to address womens problematic low sexual desire. J Sex Marit Ther 2001; 27:395403. 13. Laumann EO, Gagnon JH, Michael RT et al. The social organization of sexuality. Sexual practices in the United States. Chicago: University of Chicago Press; 1994. 14. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281 (6):537544. 15. Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature. Arch Sex Behav 1990; 19 (4):389408. 16. Frank E, Anderson C, Rubenstein D. Frequency of sexual dysfunction in normal couples. N Engl J Med 1978; 299: 111115. 17. Rosen RC, Taylor JF, Leiblum SR et al. Prevalence of sexual dysfunction in women: results of a survey study of 329 women in an outpatient gynecological clinic. J Sex Marit Ther 1993; 19:171188. 18. Leland J. A pill for impotence? Newsweek 1997; 130 (20):6268. 19. NIH Consensus Development Panel on Impotence. NIH consensus conference. JAMA 1993; 2170:8390. 20. Berman JR, Berman L, Goldstein I. Female sexual dysfunction: incidence, pathophysiology, evaluation, and treatment options. Urology 1999; 54:385391. 21. Berman JR, Berman L, Lin H et al. Female sexual dysfunction: new perspectives on anatomy, physiology, evaluation and treatment. AUA Update Ser 2000; XIX, 34:266271. 22. Kaplan SA, Reis RB, Kohn IJ et al. Safety and efcacy of sildenal in postmenopausal women with sexual dysfunction. Urology 1999; 53 (3): 481486.

SUMMARY
Research into the nosology, etiology, and treatment of female sexual dysfunction is nally receiving attention and nancial support. It is evolving into a reenergized and exciting area of medicine. Once a eld limited to the discipline of mental health, recent advances in basic science and clinical research have uncovered important anatomical and physiological aspects that comprise normal and abnormal human sexual function, lending further credence to the need for a biopsychosocial model. The appropriateness of a multidisciplinary approach for the understanding and treatment of female sexual dysfunction is now acknowledged. Adequate evaluation and treatment, addressing both cognitive and physiologic aspects of female sexual function, would benet from input from both medical and mental health practitioners. The need for more research in the area of female sexual function is evident. First, however, strategic planning is necessary to assist academic centers and pharmaceutical centers to organize and prioritize their efforts and nancial resources.53 The importance of an appropriate nosological diagnostic system to further this goal has previously been emphasized. To this end, the Consensus Panel has provided the eld of female sexual dysfunction with an important step, as it provides a clear and functional nomenclature for clinical and scientic purposes. The next 10 years will surely prove exciting as we see the continued development of new models and treatments for female sexual dysfunction.

REFERENCES
1. Masters WH, Johnson VE. Human sexual response. Boston: Little, Brown; 1966. 2. Kaplan HS. The new sex therapy. New York: Brunner/ Mazel; 1974. 3. Kaplan HS. Disorders of sexual desire. New York: Brunner/ Mazel; 1979.

References

265

23. World Health Organization. ICD-10: International statistical classication of diseases and related health problems. Geneva: World Health Organization; 1992. 24. American Psychiatric Association. DSM-IV-TR: Diagnostic and statistical manual of mental disorders, 4th edn. Washington, DC: American Psychiatric Press; 2000. 25. Basson R, Berman J, Burnett A et al. Report of the international consensus development conference on female sexual dysfunction: denitions and classications. J Urol 2000; 163 (3):888893. 26. Leiblum SR. Critical overview of the new consensus-based denitions and classication of female sexual dysfunction. J Sex Marit Ther 2001; 27: 159167. 27. Bancroft J, Graham CA, McCord C. Conceptualizing womens sexual problems. J Sex Marit Ther 27: 95103. 28. Rosen RC, Brown C, Heiman J et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual dysfunction. J Sex Marit Ther. 2001; 26:191208. 29. Taylor JF, Rosen RC, Leiblum SR. Self-report assessment of female sexual functioning: psychometric evaluation of the Brief Index of Sexual Function for Women (BSFI). Arch Sex Behav 1994; 23:627. 30. Mazer NA, Leiblum SR, Rosen RC. The Brief Index of Sexual Functioning for Women (BISF-W): a new scoring algorithm and comparison of normative and surgically menopausal populations. Menopause 2000; 7:350363. 31. Derogatis LR, Rosen R, Leiblum S et al. The Female Sexual Distress Scale (FSDS): initial validation of a standardized scale for assessment of sexually related personal distress in women. J Sex Marit Ther 2002; 28:317330. 32. Conaglen HM. Report of the International Consensus Development Conference on female sexual dysfunction: a view from down under. J Sex Marit Ther 2001; 27:127130. 33. Kameya Y. How Japanese culture affects the sexual functions of normal females. J Sex Marit Ther 2001; 27:151152. 34. Tiefer L. The Consensus conference on female sexual dysfunction: conflicts of interest and hidden agendas. J Sex Marit Ther 2001; 27:227236. 35. Fagan PJ, Strand J. A call for non-proprietary peerreviewed research. J Sex Marit Ther 2001; 27:141143. 36. Hall M. Small print and conspicuous omissions: commentary on the FSD classication report. J Sex Marit Ther 2001; 27:149150. 37. Rosenthal R. Female sexuality comes out of the psychiatric closet. J Sex Marit Ther 2001; 26:203204.

38. Everaerd W, Both S. Ideal female sexual function. J Sex Marit Ther 2001; 27:137139. 39. Davis SR. An external perspective on the report of the International Development Conference on female sexual dysfunction: more work to be done. J Sex Marit Ther 2001; 27:131133. 40. McCabe M. Do we need a new classication system for female sexual dysfunction? A comment on the 1999 consensus classication system. J Sex Marit Ther 2001; 27:175178. 41. Basson R. Are the complexities of womens sexual function reflected in the new consensus denitions of dysfunction? J Sex Marit 2001; Ther 27:105112. 42. Burnett A. Physiologic applications of the new female sexual response classication system. J Sex Marit Ther 2001; 27:121122. 43. Kaneko K. Penetration disorders: dyspareunia exists on the extension of vaginismus. J Sex Marit Ther 2001; 27:153155. 44. Althof SE. My personal distress over the inclusion of personal distress. J Sex Marit Ther 2001; 27:123125. 45. Sipski M. A physiatrists views regarding the report of the International Consensus Conference on female sexual dysfunction: potential concerns regarding women with disabilities. J Sex Marit Ther 2001; 27:215216. 46. Meston CM. Receptivity and personal distress: considerations for redening female sexual dysfunction. J Sex Marit Ther 2001; 27:179182. 47. Lachowsky M.After reading the report of the International Consensus Conference on female sexual dysfunction. J Sex Marit Ther 2001; 27:157158. 48. Levine SB. Reexploring the concept of sexual desire. J Sex Marit Ther 2002; 28:3851. 49. Leif H. Satisfaction and distress: disjunctions in the components of sexual response. J Sex Marit Ther 2001; 27:169170. 50. Binik YM, Meana M, Berkley K et al. The sexual pain disorders: is the pain sexual or is the sex painful? Annu Rev Sex Res 1999; 10:210235. 51. Binik YM, Pukall CF, Reissing ED et al. The sexual pain disorders: a desexualized approach. J Sex Marit Ther 2001; 27:113116. 52. Ohkawa R. Vaginismus is better not included in sexual pain disorder. J Sex Marit Ther 2001; 27:191192. 53. Shabsigh R. Strategic planning in research and development is needed in female sexual dysfunction. J Sex Marit Ther 2001; 27:209210.

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