Sexual Dysfunction

September 26, 2011

Sexual function

The study of sexual function in women, while still in its infancy, has evolved beyond early conceptualizations that focused on mystery and possible associations with witchcraft to psychological explanations that developed in the 19th and 20th centuries. The psychiatric evolution came to fruition in the 20th century with Freudian theories where treatment centered on psychoanalysis. Scientific investigations into sexual function were carried out by Masters and Johnson in the 1960s and furthered by research by Kaplan into psychotherapy and behavioral exercises. In the 20th century, the ability to treat men with erectile dysfunction has increased interest in women’s sexual function, particularly in postmenopausal women. This has led to alternative theories of sexual function other than the traditional model as well as a reclassification of female sexual dysfunction.

The traditional model of sexual function for men and women, as proposed by Masters and Johnson, is linear and includes four phases: desire, arousal, climax, and resolution. Newer models describe a more circular relationship between satisfaction and intimacy (Figure 1). Norms for sexual function are difficult to characterize, as dysfunction should imply individual distress, not something that causes distress only in the partner. Although prevalence and incidence data are scarce for rates of sexual activity, the data available support the conclusion that women are sexually active throughout their life span. Data from the National Survey of Family Growth indicate that approximately 40% of women 15-19 years of age have had sexual intercourse within the last 3 months. Although rates of sexual activity decline with age, population-based studies indicate continued sexual activity in 47% of married women aged 66-71 and a third of women over 78.

Figure 1. The interrelatedness of intimacy, sexual arousal, desire, and satisfaction.

Norms of sexual activity are not well characterized for women. Although heterosexual practices are commonly reported among American women, up to 1.2% of women report having sex exclusively with women. Reported frequencies of sexual activity vary with one survey of women reporting sexual activity an average of six times per month. Even though vaginal intercourse is the most commonly reported sexual practice among American women, many women report inability to achieve orgasm with vaginal intercourse, and require direct clitoral stimulation. Additionally, unlike men, desire in women does not always precede arousal. Some women participate in intimacy out of affection for a partner, become aroused, and then experience desire. This response pattern underlines the importance to most women of the relationship that they are in as well as the interdependent nature of the sexual response cycle.

The physical manifestations of the normal female sexual response cycle are described in the four classical phases: excitement, plateau, orgasm, and resolution. The physical effects are all the result of changes in blood flow patterns (engorgement) and increased muscle tension. During the excitement phase, muscle fibers contract in the nipples and increased blood flow causes swelling of the breasts, clitoris, and results in increased vaginal lubrication. The plateau phase is relatively short and involves further engorgement of the breasts and tissue around the vagina as well as vasodilatation of the skin, which may appear as a temporary flush. Further muscle tension around the vagina creates an anatomic basin at the base of the cervix that helps retain any seminal fluid and the uterus begins rhythmic involuntary contractions. During the orgasmic phase, the uterine contractions continue and there may be involuntary contractions of the lower vagina before the release of the previously building muscle tension and blood engorgement. Resolution is quite variable in length and results in the return of muscle tension and blood flow to the unstimulated state.


Prevalence of sexual dysfunction is difficult to characterize, but from the few studies available appears to be common, with American women reporting rates ranging from 25% to 63%. Common sexual complaints include low sexual desire (22% prevalence), arousal disorders (14% prevalence), and sexual pain disorders (7% prevalence).

In 1998, an international multidisciplinary group met to define areas of sexual dysfunction. To be called a sexual dysfunction or disorder, currently, the symptoms must be recurring (persistent), of significance (pervasive), and cause distress to the woman in question. Symptoms that bother the woman’s partner but not the woman herself are not defined as her sexual dysfunction. Likewise, if a woman has no interest in sex and it is not distressing to her to have no interest, it is not classified as a sexual dysfunction.

Sexual dysfunctions are further described as being primary (the problem has always been there) or secondary (there was no sexual problem initially but now there is), situational (it only occurs in predictable circumstances) or generalized (the problem occurs in all variations of a situation). Dysfunctions can be psychogenic, having an emotional cause, organic, having a physical cause, or result from a mixture of the two. The current classification system (Figure 2) includes four general areas: (a) sexual desire disorders, (b) sexual arousal disorders, (c) orgasmic disorders, and (d) sexual pain disorders.

Sexual Desire Disorders  
Hypoactive sexual desire disorder Deficiency of sexual thought/ fantasies and/or desire for or receptivity to sexual activity
Sexual aversion disorder Phobic aversion to and avoidance of sexual contact with a sexual partner
Sexual Arousal Disorder Inability to attain or maintain sufficient sexual excitement, which may be expressed as a lack of subjective excitement, or genital or other somatic responses
Orgasmic Disorder Difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal
Sexual Pain Disorders  
Dyspareunia Genital pain associated with sexual intercourse
Vaginismus Involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration
Noncoital sexual pain disorder Genital pain induced by noncoital sexual stimulation
Figure 2. Classification of female sexual dysfunction.

Although the types of sexual dysfunction are defined in order to differentiate one from the other, in actuality, women often have symptoms that fall into more than one dysfunction category. The causes of dysfunction are often a combination of physical, emotional, and interpersonal issues, which results in multifactorial etiologies for many of the dysfunctions.

Sexual Desire Disorders

These are further divided into two subcategories, hypoactive sexual desire disorders and sexual aversion disorders. A hypoactive sexual desire disorder is defined as a lack of desire for sexual activity, and/or a deficiency or absence of sexual thoughts and fantasies. This manifests by the absence of sexual thoughts, fantasies, or interest in sexual activity. Debilitating physical or emotional conditions and medical treatments or medications may cause hypoactive sexual desire disorder.

A sexual aversion disorder refers to fear and avoidance of sexual thoughts and situations. In aversion disorder there may be fear and phobic avoidance in response to any sexually suggestive situation. Aversion disorders may result from traumatic life events such as sexual assault or serious anxiety illnesses such as obsessive-compulsive disorders or phobias.

Example A 32-year-old woman developed a major depression. She tells her physician that the most distressing depression symptom is her utter lack of sexual desire. Molested as a child, she overcame an active fear of sexual intimacy in the context of her supportive relationship. Recovery from her initial sexual aversion makes this recent loss of sexual desire secondary to depression doubly distressing.

Sexual Arousal Disorders

These are defined as the persistent or recurrent inability to attain or maintain sexual excitement. Arousal disorders may be reported as an emotional lessening of excitement or sensation, and can be evident in the physical manifestations of lack of excitement, vaginal lubrication, decreased nipple sensitivity, and decreased clitoral engorgement and swelling. Decreased arousal can be caused by injury or illness that affects pelvic innervation and blood flow and by emotional illnesses that impair interest and enjoyment.

Example A 42-year-old woman recently started a new medication for her chronic medical illness. Since starting the medication, she reports that her genitals feel numb. She wants to have sex, but it is as if the physical responses have been disconnected from her desire. Stopping the medication is likely to reverse these sexual arousal disorder symptoms.

Orgasmic Disorder

This is defined as the difficulty or inability to reach orgasm after sufficient sexual stimulation and arousal. The dysfunction may be primary, never having the ability to achieve orgasm, or secondary, having lost the ability to achieve orgasm. Orgasmic disorders may be evident as a diminished intensity of orgasm, or the inability to achieve orgasm. Emotional or physical abuse can cause inability to achieve orgasm, but it can also be caused by medical illnesses or surgery that damages the nerves or blood flow to the pelvis.

Example A 55-year-old woman complains of difficulty achieving orgasm since undergoing total abdominal hysterectomy with bilateral salpingo-oophorectomy for leiomyomata. Her cause of anorgasmia is multifactorial including abrupt disruption of pelvic blood flow, coupled with castration. Both contributed to her inability to achieve orgasm.

Sexual Pain Disorders

Sexual pain disorders are further divided into three subcategories: dyspareunia, vaginismus, and noncoital sexual pain disorders. Dyspareunia refers to genital pain that occurs with sexual intercourse. Dyspareunia commonly manifests as pain with penile penetration or deep thrusting.

Vaginismus is the involuntary spasm of the lower third of the vagina making sexual intercourse impossible. These women are incapable of vaginal intercourse, pelvic exams, or wearing tampons.

Noncoital sexual pain disorders refer to pain that occurs with any type of sexual stimulation other than intercourse. Noncoital sexual pain disorders include genital pain that is initiated by sexual stimulation that does not involve intercourse. Pain disorders are usually multifactorial in etiology. Causes include atrophic vaginitis, or thinning of the vaginal wall that occurs during menopause, vaginal infections or inflammatory processes, or emotional or relationship problems.

Example A 65-year-old woman presents with pain with vaginal intercourse since discontinuing hormone replacement therapy. The cessation of hormonal therapy caused vaginal atrophy that in turn caused dyspareunia.


Just as the causes of dysfunction are often a combination of physical, emotional, and interpersonal issues, treatments are also multifactorial. For this reason, treatments for all the sexual dysfunctions are discussed in general.

Treatment recommendations are best tailored to an individual after a careful diagnostic evaluation. The evaluation begins by taking a history to determine if sexual symptoms are new or longstanding, and if they developed acutely, perhaps in relation to a surgery or starting a medication, or if the onset was insidious over time. A careful health maintenance history, including tobacco, alcohol, and drug use, as well as recreation practices like bicycling, which has been associated with increased risk of sexual dysfunction, is also gathered. A thorough health, surgical, and medication history is in order.

Once the diagnostic possibilities have been gathered and sorted, several treatment approaches are often indicated. The first treatment intervention is often to provide accurate information and education. Medications causing sexual side effects are common and if an equivalent medication that does not cause sexual side effects is available, the solution may be simple. Sometimes sexual activity can be scheduled right before or after taking the offending medication so that sex occurs when the least medication is in the bloodstream. Some medications and devices can be prescribed and used to specifically increase sexual responsiveness. Use of vibrators to increase clitoral stimulation, as well as medications or devices that can increase genital blood flow can also be helpful. Hormonal therapy, including estrogen to increase vaginal lubrication and blood flow, as well as testosterone, which increases desire, can also be used in women to address sexual dysfunction disorders.

Psychotherapy of various types and medication for emotional disorders such as anxiety and depression are frequently recommended. Central to treatment of sexual dysfunction is the need to address partner-related issues, as often the dysfunction is shared between a couple and is causing both distress.

In conclusion, interest in the diagnosis and treatment of female sexual dysfunction has increased in importance to care providers and their patients. As research in this area expands, newer therapies and treatments will become available for women who suffer from these disorders.

See Also: Dyspareunia

Suggested Reading

  • Anonymous. (1995). ACOG technical bulletin. Sexual dysfunction. Number 211—September 1995. American College of Obstetricians and Gynecologists [Educational Review]. International Journal of Gynecology and Obstetrics, 51, 265—277.
  • Basson, R. (2001). Are the complexities of women’s sexual function reflected in the new consensus definitions of dysfunction? Journal of Sex and Marital Therapy, 27, 105—112.
  • Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., et al. (2001). Report of the international consensus development conference on female sexual dysfunction: Definitions and classifications. Journal of Sex and Marital Therapy, 27, 83—94.
  • Kaplan, H. S. (1979). Disorders of sexual desire. New York: Brunner/Mazel.
  • Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States. Journal of the American Medical Association, 281, 537-544.
  • Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown.


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