1. Female sexual dysfunctions
WALID SARHAN

2. A Brief History
Rise of behavioral techniques involving systematic desensitization pairing relaxation & exposure methods
Psychoanalytic approach -sexual problems were linked to unresolved, unconscious conflicts during specific developmental periods
Masters & Johnson initiated a more biopsychosocial model consisting of physical examinations, history of dysfunction, education, behavioral & cognitive tasks, interpersonal issues; proposed brief, problem focused solutions

3. A Brief History continued
Helen Singer Kaplan’s The New Sex Therapy integrating M&J approach with psychodynamic methods
current
Mid-1980’s dawned the medicalization era; including combined CBT & pharmaceutical treatments; but has not had as significant an impact on female sexual dysfunction
Neo-Masters & Johnson Era

4. Healthy Sexuality Women’s sexuality is complex
It is less studied, understood than male sexuality
Many theories, beliefs about female sexuality are inaccurate or outdated
Clinicians may find topic difficult to address
Lack of training
Time
Personal issues
The health care profession has entered a new era of interest in sexuality, particularly for women.
Although everyone is talking about sex, healthy sexuality and sexual problems remain areas of controversy, especially in regard to midlife and older women. The reasons include: – an early, incorrect assumption by Masters and Johnson that female sexual response proceeds in much the same linear way as male sexual response; – a dearth of data; – extrapolation of many of the existing data from research findings in men; – the absence of objective, sensitive, and reliable criteria for evaluating female sexual response; and – a prevailing belief that older adults lose their interest in sex.
Clinicians may not bring up sexual issues with midlife and older women for a variety of reasons, including personal issues and because they believe they lack the skills or time.
Sources:
Berman L, Berman J, Felder S, et al. Seeking help for sexual function complaints: what gynecologists need to know about the female patient’s experience. Fertil Steril 2003;79:572–576.
Kingsberg S. Just ask! Talking to patients about sexual function. Sexuality, Reproduction & Menopause 2004;2(4):199–203.
Berman Fertil Steril 2003 Kingsberg Sexuality, Reproduction & Menopause 2004
Women’s Sexual Health in Midlife and Beyond

5. Phases of the Sexual Response
As a function of “normal” sexual responding:
Desire: Defined by an interest in being sexual and in having sexual relations by oneself or with an appropriate partner
Arousal: Refers to the physiological, cognitive & affective changes that serve to prepare an individual for sexual activity (vaginal lubrication, expansion & swelling of vulva)
Orgasm: Refers to climatic phase with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs:
Contractions in the outer third of the vagina
Resolution: Refers to sense of muscular relaxation and general well-being; men are physiologically refractor while women may respond to further stimulation
(APA, 2000)

6. Linear Model of Female Sexual Response
Resolution
A B C
(C)
(A)
(B)
Orgasm
Plateau
Excitement
In 1966, Masters and Johnson created a linear model of sexual response for both men and women composed of four stages: excitement, plateau, orgasm, and resolution. In 1979, Helen Singer Kaplan added the concept of desire to the model and condensed it into three phases: desire, arousal, and orgasm.
Excitement can last for a few minutes to several hours and is characterized by a variety of physical changes that prepare a woman’s body for orgasm. Plateau is characterized by the intensification of the changes begun during the excitement phase; this phase extends to the brink of orgasm. Orgasm is the peak of sexual excitement and begins the reversal of the changes begun during the excitement phase. Resolution is the final phase when the body returns to an unexcited state.
This diagram reflects the responses different women can have or an individual woman can have on different occasions. For instance, Woman A has a smooth transition from excitement to plateau to orgasm to resolution and has multiple orgasms on this occasion. Woman B (or Woman A on a different occasion) has a smooth transition up to plateau but doesn’t experience orgasm. This is not a problem if it is an occasional occurrence (e.g., it is Woman A who sometimes experiences orgasm) but would be diagnosed as a sexual disorder if this occurs every time Woman B has a sexual experience. Woman C has a different pattern of transition from excitement through orgasm and resolution than either A or B—again possibly reflecting the same woman on another occasion or three different women. Pattern C usually occurs with masturbation.
Sources:
Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little Brown, 1966.
Kaplan HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. New York, NY: Brunner/Hazel Publications, 1979.
Masters and Johnson Human Sexual Response 1966 Kaplan Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy 1979
Women’s Sexual Health in Midlife and Beyond

7. Circular Model of Female Sexual Response
Emotional Intimacy
Seeking Out
and Being Receptive to
Emotional and
Physical Satisfaction
Spontaneous
Sexual Drive
Sexual Stimuli
Dr. Rosemary Basson of the University of British Columbia has constructed a new circular model of female sexual response that incorporates the importance of emotional intimacy, sexual stimuli, and relationship satisfaction. This model acknowledges that female sexual functioning proceeds in a more complex and circuitous manner than male sexual functioning and is affected by numerous psychosocial issues (e.g., satisfaction with relationship, self-image, previous sexual experiences, etc.).
According to Basson, women have many reasons for engaging in sexual activity other than sexual hunger or drive. Many midlife women in long-term relationships do not have a great deal of spontaneous desire and interest, but engage in sex due to a desire for increased emotional intimacy with their partner. They start from a position of sexuality neutrality, where they are responsive to engaging in sexual activity if their partners approach them but don’t initiate sexual activity. Once aroused, sexual desire emerges and motivates them to continue the activity.
This model clarifies how vulnerable a woman’s sexual response is and that the goal of sexual activity for women is not necessarily orgasm, but rather personal satisfaction.
Source:
Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001;98:350–353.
Arousal and
Sexual Desire
Sexual Arousal
Biologic
Psychological
Basson Obstet Gynecol 2001
Women’s Sexual Health in Midlife and Beyond

8. Variables Affecting Female Sexual Response: Physiologic & Psychosocial
Past sexual experiences or
sexual abuse
Sexual self-image
and/or
body image
Relationship with sexual partner (male or female)
Sexuality for women extends far beyond the release of neurotransmitters, the influence of sex hormones, and vasocongestion of the genitals. A number of psychological and sociological variables can affect female sexual function.
Among the psychosocial variables, perhaps the most important is the relationship with the sexual partner. According to Basson, emotions and thoughts have a stronger impact on a woman’s assessment of whether or not she is aroused than does genital vasocongestion.
Source:
Basson R. Recent advances in women’s sexual function and dysfunction. Menopause 2004;11(6 suppl):714–725.
Basson Menopause 2004
Women’s Sexual Health in Midlife and Beyond

9. Female Sexual Response Cycle
Masters and Johnson characterized cycle with four phases:
Excitement
Plateau
Orgasmic
Resolution
Kaplan proposed idea of “desire” and a three-phase model.
Desire
Arousal
Orgasm
W SARHAN

10. Female Sexual Response
Physiological indicators of arousal
Vasocongestion in the pelvis
Vaginal lubrication
Labia minora may darken
Clitoris hardens leading the vaginal hood (prepuce of clit) to appear enlarged
Causing the vulva to lengthen and widen
Areola hardens & nipples become erect
Breast tumescence

11. Female Sexual Response
Experts on female anatomy contend that there is an area in the outer third of the vagina, also responsible for orgasm, the Grafenberg or the G-spot
Located in the front of the body, 2” from entrance of the vagina
Clitoral vs. vaginal orgasm??

12. Female sexual disorders include:
Sexual desire disorders:
Hypoactive sexual desire disorder
Sexual aversion disorder
Sexual arousal disorder
Orgasmic disorder
Sexual pain disorders:
Dyspareunia
Vaginismus

13. Sexual Desire Disorders: Hypoactive sexual desire disorder
Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life. 
The disturbance causes marked distress or interpersonal difficulty. 
The sexual dysfunction is not better accounted for by another disorder
It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 
W SARHAN

14. Sexual Desire Disorders: Sexual aversion disorder
Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. 
The disturbance causes marked distress or interpersonal difficulty. 
W SARHAN

15. Sexual Arousal Disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. 
The disturbance causes marked distress or interpersonal difficulty. 
The sexual dysfunction is not better accounted for by another disorder
It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 
W SARHAN

16. Orgasmic Disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm.
The disturbance causes marked distress or interpersonal difficulty. 
The orgasmic dysfunction is not better accounted for by disorder
It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 
W SARHAN

17. Sexual Pain Disorders: Dyspareunia
Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female. 
The disturbance causes marked distress or interpersonal difficulty. 
The disturbance is not caused exclusively by Vaginismus or lack of lubrication,
It is not better accounted for by another disorder
it is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
W SARHAN

18. Sexual Pain Disorders: Vaginimus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. 
The disturbance causes marked distress or interpersonal difficulty. 
The disturbance is not better accounted for by another disorder
It is not due exclusively to the direct physiological effects of a general medical condition.
W SARHAN

19. Populations who may experience female sexual dysfunction (FSD):
Abused
Perimenopausal
Pregnancy
Multiple sclerosis
Childhood sex abuse
Chemotherapy
Genital mutation
Post menopausal
Lack of sensitivity
Gynecological cancer
Radiation
Battered
Nuerogenic disease
Sexual trauma
Spinal cord injury
Vascualr disease
Post-hysterectomy
Post-partum
W SARHAN

20. Etiology
“The etiologies of female sexual dysfunction affect a variety of populations and may be caused by psychological, emotional, or physiological reasons. Often, the etiology is multifactorial And interrelated.”
W SARHAN

21. Psychological Causes
As with most disorders, female sexual dysfunction can be caused and aggravated by psychological causes.

22. There are five main Psychological Causes to FSD.
Sexual or Emotional Abuse
Depression
Relationship Issues
Stress
Self Esteem
Cultural factors in the Arabic society
W SARHAN

23. Depression
Depression is a prevalent cause of sexual dysfunction in both men and women.
Most women, when grieving, experience a loss of sexual desire.
Depression can be a double edged sword for some, due to the increase of sexual dysfunction caused by anti-depressants.

24. Relationship
A healthy relationship is based on trust, intimacy, and communication.
sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being.
W SARHAN

25. Relationship (cont.)
Other factors that can affect the sexual health of a relationship are conflicts about cultural, social or religious beliefs.
These can invoke feelings of guilt during sexual activity and affect the ability of a women to be aroused, obtain an orgasm, or have any desire to have sex.

26. Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013
Female Orgasmic Disorder
Delay, infrequency or absence of orgasm or reduced intensity of orgasm sensations lasting more than 6 months
Wide estimates of prevalence: 10%-42%
10% of women do not report experience of orgasm
Lifelong vs. acquired; generalized v. situational, also never; mild, moderate or severe

27. Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013
Female Sexual Interest/Arousal Disorder
Absent/reduced interest/arousal related to sexual activities, thoughts, encounters, cues, etc.
Becomes persistent problem for relationships
Lifelong vs. acquired; generalized v. situational; mild, moderate or severe

28. Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013
Genito-Pelvic Pain/Penetration Disorder
Difficulties with 1vaginal penetration during intercourse, 2 pain during intercourse, 3 fear or anxiety about pain or penetration, or contraction of pelvic floor muscles during sex
lasting more than 6 months
15% of women report some pain during intercourse
Lifelong vs. acquired; mild, moderate or severe

29. How common is sexual dysfunction?
Laumann, Paik,& Rosen 1999 estimate
about 43% of women
and about 31% of men
have experienced sexual dysfunction based on a national survey of Americans.
This makes sexual dysfunction the most common
psychological problem in US.

30. How Common is Inadequate Lubrication?
Approximately 40% of females in the United States have reported inadequate lubrication during sexual activity, making it the second most common sexual difficulty reported by females after low arousal.
Inadequate lubrication is a physiological sign that a female is insufficiently sexually aroused. Sexual arousal is both a psychological and physiological response.
Without proper vaginal lubrication, intercourse can be painful and can result in bodily injuries, such as chaffing or tearing of the vaginal mucosa (inner vaginal wall)

31. Female Sexual Disorders: Prevalence
Interest
Lubrication/Arousal
Orgasm
Total
Laumann
31.6%
20.6%
25.7%
43%
Bancroft
7.2%
31.2%
9.3%
45%
Geiss
28.8%
23.0%
17.8%
48%
Nazareth
16.8%
3.6%
18.9%
39.6%
This slide lists prevalence data we have available on women’s sexual disorders.
Sources:
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537–544.
Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003;32:193–208.
Geiss IM, Umek WH, Dungl A, et al. Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the international consensus classification. Urology 2003;62:514–518.
Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: cross sectional study. BMJ 2003;327:423–428.
Bancroft Arch Sex Behav Geiss Urology Laumann JAMA Nazareth BMJ 2003
Women’s Sexual Health in Midlife and Beyond

32. National Health and Social Life Survey (NHSLS)
100
In-person survey
sexually active
18-59 years
Asked if problems in any one of seven areas of sexual function 90 80 70
% of respondents 60 50
43% 40
31%
The National Health and Social Life Survey, conducted in 1992, was a study of adult sexual behavior in the United States. It was the first population-based assessment of sexual dysfunction since the Kinsey study 50 years prior.
It included 1,749 women and 1,410 men.
Respondents were asked if they had problems in any one of seven areas of sexual function in past 12 months.
It found that 43 percent of women and 31 percent of men had sexual difficulty within the past year. These statistics are widely quoted.
The study found that for women, the prevalence of sexual problems tends to decrease with increasing age, except for those who report trouble with vaginal lubrication. Unmarried women and younger women experienced more sexual problems than married and older women. Black women tend to have higher rates of low sexual desire and experience less pleasure compared with white women; white women reported more sexual pain than black women. Hispanic women had consistently lower rates of sexual problems.
Source:
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537–544. 30 20 10
Women
Men
Laumann JAMA 1999
Women’s Sexual Health in Midlife and Beyond

33. Distress About Sex: Kinsey 2000 Survey
Women reporting marked distress 10 20 30 40 50 60 70 80 90
100
Telephone survey
987 white and black ♀
20–65 years old
Best predictors of distress:
General emotional well-being
Emotional relationship with partner during sexual activity
% of respondents
24.4%
One of the issues with female sexual function has been the difficulty of determining when a sexual behavior becomes a sexual problem. Most experts agree that a critical attribute of any sexual function diagnosis is dependent on whether the condition actually causes the woman distress. Without distress, a diagnosis and treatment are not required.
In 1999–2000, the Kinsey Institute conducted a telephone survey of 987 women aged 20 to 65 who had been in a heterosexual relationship for 6 months or more. A quarter of women (24.4%) surveyed reported marked distress about their sexual relationship, their own sexuality, or both.
The most reliable predictors of sexual distress were markers of general emotional well-being (depression, tiredness, general unhappiness) and the emotional relationship with their partner while engaged in sexual activity. Poor predictors of distress were physical aspects of sexual response in women, such as arousal, vaginal lubrication, and orgasm.
Sexual problems were defined as no sexual thoughts, no orgasm, lubrication problems, impaired physical response, and pain. Sexual thoughts occurred less frequently as women aged. Lubrication problems increased as women aged, but not significantly over the level reported by younger women. Overall, the authors noted that reduced sexual interest or response were less a cause of distress to older women than to younger women.
Source:
Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003;32:193–208.
Bancroft Arch Sex Behav 2003
Women’s Sexual Health in Midlife and Beyond

34. Patients, physicians, and asking about sex
25% of primary care physicians take a sex history (Jonassen, et al 2002)
75% patients believe that their physicians would dismiss their sexual health concerns or embarrass the physician (Marwick 1999)
Over 90% of patients believe it is physician’s role to address sexual health concerns and are grateful when this happens (Ende, et al 1984)

35. Reluctance to seek help
Studies show that over 50 % of individuals with sexual problems do not ask for help from health care provider
Studies indicate that of those seeking help (from any health care provider), less than 50% found the assistance helpful

36. Patient Perceptions
Although 85% of adults want to discuss sexual functioning with their physicians…
71% believe their physicians doesn’t have the time
68% don’t want to embarrass their physician
76% thought no treatment was available for their problems
They also report…
Non-empathic and/or judgmental responses
Physician discomfort
Concern about privacy and/or confidentiality
Lack of cultural sensitivity
Marwick C. JAMA 1993; 281:
Maurice WI, Bowman MA, Sexual Medicine in Primary Care 1999:1-41

37. Treatment Approaches Sex Therapy (CBT + Master’s & Johnson)
Pharmacotherapy & Medical Devices
A Systemic Approach
Bibliotherapy

38. Bibliography
Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., Fourcroy, J., Goldstein, I., Graziottin, A., Heiman, J., Laan, E., Leiblum, S., Padma-Nathan, H., Rosen, R., Segraves, K., Segraves, R. T., Shabsigh, R., Sipski, M., Wagner, G., & Whipple, B. (2001). Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and classifications. Journal of Sex & Marital Therapy, 27,
Berman, J.R., Berman, L., and Goldstein, I. (1999). Female Sexual Dysfunction: incidence, Pathophysiology, evaluation, and treatment options.Urology, 45,
Brassil, D.F, Keller, M. (2002). Female Sexual Dysfunction: Definitions, Causes, and Treatment. Urologic Nursing, 22,
Laumann, E.O, Paik, A., Rosen, R.C. (1999). Sexual Dysfunction in the United States. Journal of the American Medical Association, 281,
Sarwer, D.B, Durlak, J.A. (1996). Childhood Sexual Abuse as a Predictor of Female Sexual Dysfunction: A Study of Couples Seeking Sex Therapy. Child Abuse & Neglect, 20,
Segraves, R.T. (2002). Female Sexual Disorders: Psychiatric Aspects. Canadian Journal of Psychiatry, Retrieved April 6, 2004 from Ebsco host.
Tiefer, L., Hall, M., & Travis, C. (2002). Beyond dysfunction: A new view of women’s sexual problems. Journal of Sex & Marital Therapy, 28,
(2004). Behavenet Clinical Capsule: DSM-IV-TR (Text Revision). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000).

39. Thank you