Beyond Female Sexual Dysfunction

 Women are in the most comfortable sexual position in history. Notions of sexual activity have shifted further away from a sole reproductive purpose than any time in history as women (at least in the Western paradigm) are given a license to enjoy sex and be as selfish about their own orgasms as their partner’s pleasure. Women are choosing to have sex on their own terms, whether as part of a relationship, ongoing friendship or casual encounter. Sex and sexual pleasure is part of everyday parlance with happy sexualised women visible everywhere, from your local burlesque show to the latest advertisement for perfume. But what if you don't feel like having sex or have difficulties during sex? How do you work out if you have a problem, and if so, what does it mean and how do you treat it? Cate Lawrence interviews three women about their sex lives and various health professionals to find out.

What sexual problems are experienced by women? 

The types of sexual problems experienced by women commonly involve libido, arousal and orgasmic functioning and tend to cross over between mental and physiological spheres.  A woman may be experiencing a decreased interest in sex, an absence of feeling ‘turned on’ or difficulty achieving orgasms or something more complex. Josephine linked her absence of libido to sport:

 “I just didn’t think about sex at all. It was like not being interested it sport, the notion of it just passed me by completely”. 

By comparison Katy experienced ongoing difficulties with orgasms. “I would try to consciously think about sex and get myself aroused and into it.  I tried porn, while that sometimes would get me a bit aroused, I couldn't have an orgasm!  It was exasperating.  I tried this for a long, long time.  Maybe 1 out of 10 times I'd be able to have an orgasm [but] the orgasms were weak, unsatisfying and just generally frustrating.  Probably after a year of trying to stimulate interest in sex, I just gave in and gave up”

Anne had experienced a long history of sexual difficulties:

Mine's a low sex-drive mostly, although I did have difficulty reaching orgasm during intercourse originally (long time ago). I have always been able to masturbate to orgasm.I turned out to be suffering from vaginismus and sex during my short (2.5 years) marriage was bloody awful, to be honest”.

Defining sexual problems is an important factor in determining the cause and treatment of sexual difficulties. The study of sexual difficulties has long been framed in psychoanalytic and psychological theories. Currently, the 4th edition of the Diagnostic Standards Manual (the primary system used to classify and diagnose mental disorders) uses the term sexual dysfunction to encapsulate sexual difficulties which cannot be explained by a medical disorder: hypoactive sexual disorder, sexual aversion disorder, female sexual arousal disorder,  female orgasmic disorder, dyspareunia , vaginismus , substance-induced sexual dysfunction, and sexual dysfunction not otherwise specified[1].

The notion of classifying sexual difficulties within a psychiatric framework is problematic and raises as many questions as it attempts to answer. Firstly the diagnosis of sexual dysfunction is problematic considered that there is an absence of a baseline definition of ‘normal’ sexual functioning in women.  Does an orgasm as a physical response define 'functional' sex in woman, as an erection and ejaculation in men? Many women would contend they experience normal (if less pleasurable) sex sans orgasm. Secondly, positioning sexual difficulties within a psychiatric school of thought is to neglect the role of social and relationship factors in sexual functioning[2], suggested the difficulties are connected to faulty thinking or faulty brain functioning.  Thirdly, equating sexual difficulties to a medically diagnosed model suggests that treatment must involve medical intervention. Researchers critical of the notion of ‘female sexual dysfunction’ have turned their attention to the eagerness of pharamaceutical companies to play a role in developing medical treatments for women's sexual problems as a consequence of profits made from prescribing treatment to treat men’s sexual problems[3][4]. This suggests that women themselves are the best determinant of what is normal for them and what is not, bearing in mind that notions of normal sex may have shifted with

How common are sexual problems in women?

It is difficult to determine the extent of sexual problems in women. Most women have simply never been asked if they have experienced sexual difficulties, much less considered whether it was something that could be treated by medical intervention, thus being under the radar of research studies. One study posited sexual difficulties in women at a rate of 43%[5] but the data has been discredited for its lack of academic rigour[6][7]. I contacted Dr. Lynne Glover, Specialist in Psychosexual Medicine and Co-editor, IPM journal to find out about the incidence of sexual difficulties in her practice.  She received a total of 94 referrals in 2008 to her psychosexual medicine clinic in a town in the south west of England. Of those, 24 were for problems with libido, most of them with loss of libido or low sex drive. The total subdivided into: 21 women with loss of libido; 2 men with loss of libido and 1 couple in difficulties because of their different libidos. This suggests that women are entitled to seek help for their sexual difficulties whether they are common or not.

What causes sexual problems?

According to Dr Glover sexual problems may have a variety of causes:

·       Memories of past events which are perceived in a negative light

·       Opinions of others, most usually parents and partners

·       Experiences related to pregnancy & labour or being a parent

·       Experience of infertility

·       Losses e.g. death of a loved one, experience of marital loss or the loss of a job

·       Illness or anxiety about the possibility of illness.

·       Religious or cultural beliefs

·       Anxieties about oneself or others.

On an interpersonal level, sexual compatability, sexual techniques, and the strength of a relationship may all be contributing factors. Further, an inhibition of sexual desire is in many situations a healthy and functional response for women faced with stress, tiredness, or threatening patterns of behaviour from their partners.

But what if you consider yourself emotionally healthy and have had a healthy sex life until recently? What you swallow may be the answer. Consumer feedback has motivated researchers to examine the role of The Contraceptive Pill to explain reduced libido in women. But results are inconclusive depending on which research you access.  Found that the majority of studies into Oral Contraception (OC) were retrospective and uncontrolled, used un-standardised methods to measure libido and were conducted decades when much higher OCs were in use[8]. The results of these studies suggest OC use was associated with increased rather than decreased libido.

By comparison other research has found that women using the birth control pill showed markedly-decreased levels of sexual desire than those women who do not use the birth control pill[9]. It also found that women who had discontinued use of the pill continued to suffer side effects in the long-term. found that a chemical produced by the pill to stop ovulation continues to suppress testosterone levels, responsible for arousing desire in men and women, for up to a year after women stop taking it Currently, Australian researchers are trialing a new contraceptive pill which uses a natural form of the female hormone oestrogen, called Estradil as a means to counteract decreases in libido attributed to the OC.

"It is believed the reduced libido is caused by a reduction in free bioactive testestorone. The new pill had undergone an earlier clinical trial in which it appears to have a reduced impact on free and total testosterone levels[10]." 

Many researchers have indicated that treatment with selective serotonin reuptake inhibitors (SSRIs) may lead to sexual dysfunction of with varying degrees[11].[12] Dr Glover comments:

 "Drugs may influence mood and libido also, but it is unusual for the effects of medication to be the sole cause of an individual’s low sex drive. It is important to note that depression itself is often associated with diminished libido". The difficulty experienced by a woman with depression

 Katy struggled with sexual difficulties due to taking antidepressants admitting that she found her doctor unsympathetic, conceding “This only added to my depression”.

Fortunately she found that changing her doctor and anti-depressant enabled the return of her sex drive.

“… Wellbutrin seems to be helping depression-wise so far and is ok libido-wise so I'm very relieved (and enjoying it!)….  I'm also a bit angry that I had to endure that for so long” This highlights the need for women taking medication for depression to have a health care professional with whom they have a good rapport to ensure that their complaints are taken seriously.

How to have a relationship despite sexual difficulties.

Maintaining a happy relationship with a low libido is something all women I interviewed struggled with.

Josephine recalls…. “I’d get into bed at night and my husband would have this hopeful look on his face and I’d just tense up. I couldn’t kiss him or hold him without him getting hard and all I wanted was to go to sleep or read a book. It was incredibly frustrating for us both. He felt rejected and I felt irritated that all he wanted to do was have sex all the time.”

 Similarily, Anne had contend with the affect of her sexual difficulties on her primary partner, commenting that her partner has “struggled with feeling unloved and unwanted when I want so little sex. He doesn't want me to engage if I don't actually want to, but he really wishes I wanted to more and he feels a bit distanced without sexual contact”. She found it vital to keep talking to her partner about their sex life and look at ways to compromise. “We have worked to the point where I'm able to engage in more play and what I call 'passive sex'  (where I don't even attempt to orgasm), enough to maintain the sense of connection and intimacy between us.

The impact on sense of self

Given the prevalence of sex and sexual expression in popular culture, all women I interviewed struggle with the idea of having different sexual experiences to other women.

Katy recalls “it made me feel like I was somehow on the outside looking in, like a vital piece of me had been removed.  Sex and sensuality was a huge part of my life, even when I didn't have a partner, and to not have that was devastating.  I was even starting to feel shame around issues of sex and that was never a problem/issue for me and it made me feel extremely conflicted. I couldn't tell what was me and what was the meds…..I felt as if I wasn't quite connected to the rest of the human race anymore in a way. 

Josephine agrees, explaining “I felt that everyone else was in the most amazing sexual relationships, shagging several times a week and having sex on the kitchen table every night. I felt like I was boring and restrained and it was terribly lonely”.

Anne recounts struggling with the sense of a partner's sexual expectations or needs. “Being polyamorous means I'm not obliged to meet my partner's sexual needs (thank god!) but I have experienced again and again the sense of - hope? expectation? in a new potential sexual contact, and watched it slowly die, and watched people slowly turn their intimacy focus elsewhere. So the impact on intimacy and the feeling of failing both myself and other people are some of the hardest things in terms of impact on sense of self”.

What treatment or cures are available for sexual difficulties?

Treatments for sexual difficulties are being keenly persued by pharmaeceutical companies, keen to cash on in demand for sexual desire. Yet a female Viagra is not in the works with Pfizer  after several years of research revealed inconclusive resulted with the president of Pzifer conceeding in 2004 “Diagnosing FSAD involves assessing physical, emotional, and relationship factors, and these complex and interdependent factors make measuring a medicine’s effect very difficult[13]." Josephine confesses she tried Viagra once, acquired at a party, which left her with the most becoming flushed (facial) cheeks and a tingle in her loins but no real orgasms.

However research into hormonal treatment is ongoing by many. Currently the only drug approved medically in the UK is Intrinsa, a series of testosterone patches that are available only for women who have experienced menopause due to surgery such as hysterectomy. However research has been undertaken to examine the use of testosterone spray and found that that on average, women who used the spray recorded two more satisfactory sexual experiences a month than before taking the hormone[14]. Whether this is any great improvement is subjective. Similarly, research into the role of androgen in premenopausal loss of libido in a small sample of women has suggested that a loss of libido cannot be attributed to androgen status[15]. Indeed, there appears to be a lack of large cross-sectional and longitudinal studies into the role of hormones and sexual difficulties

But what about natural supplements? I spoke to Naturopath and Family Therapist Nicole Tracey who suggests that supplements may be an option and it is worth considering a consultation with a qualified naturopath. She comments “It is really important to have an adequate intake of B vitamins, along with minerals and trace elements…. I will often recommend herbs that support the reproductive system and act as aphrodisiacs and tonics. Shatavari and Damiana are two herbs that I find particularly successful”.   

What else can I do?

Deciding whether there is a problem and deciding what to do about it is ultimately the responsibility of women themselves, as all women are unique individual in different life stages and situations. Unsurprisingly there is no ‘one fits all solution’. The best thing women can do is take an active part in improving their sex lives.

Talk to your partner:

Anne explains, “Clearly stating where I'm at to my partner(s) is vital - disappointing a partner's expectations has been one of the hardest things about the whole experience. Giving myself permission just to do what I feel like and not feel obliged to achieve either my own or my partner's orgasm helps relax the inner anxiety that often of itself will interrupt sexual pleasure”. Communication is an important part of any meaningful intimate relationship and the support of your partner is vital.

Seek professional help:

You can visit your GP (General Practitioner, or doctor) and ask them to refer you to a Sexual and Relationship Therapy clinic in your area. Look for a therapist who is a member of the Institute of Psychosexual Medicine or the British Association for Sexual and Relationship Therapy. Anne undertook extensive treatment for Vagiminus but contends it talking to a good therapist about the emotional and historical sources of her issues was an integral part of recovery.

Dr Lynne Glover provided some insight into the benefits of professional therapy which addresses both the physiological and emotional factors, an approach which would be absent within conventional ‘talk’ therapy explaining, “as doctors, we are able to examine physical concerns through examination as well as listening to the feelings of the patient; this is often termed the ‘body-mind’ approach. It is particularly relevant when dealing with sexual problems but also equally valuable when dealing with other problems that have both physical and emotional aspects. In a patient presenting with a low sex drive examination may not be necessary if no physical concerns are expressed, whether one is offered will depend upon what comes out of the initial assessment following discussion.

Become your own advocate:

Think about what’s normal for you and your body and what problems you are having. Research your symptoms and possible causes of sexual problems to enable you to be informed. Don’t be afraid to seek a second opinion and a doctor you can build an open communication with. Katy agrees. “I finally found a doctor who I felt took me seriously. I guess I would caution people they if they really haven’t tried everything, and your libido is suffering seriously, consider trying a new medicine”.

Embrace the sensual:

Sensuality is defined as relating the gratification of the senses or the indulgence of appetite. Touch, tactility, good food and engaging music can all help awake the senses
 In particular, ways of expressing yourself sexually can be beneficial, such as eating chocolate, writing or reading erotic fiction, wearing clothing of fabric that pleases you (itchy lingerie is a turn off for many!). Josephine found a sense of sexual self within the Kink/BDSM community where dressing up and role playing took away the focus of orgasms. By comparison Anne reveals: Touch really helps. Snuggles, snogs (I'm a snog-slut!), cuddle puddles, sandwich hugs - these all help me feel intimately connected to other people and comfortable in my body”

All three women I interviewed are still working through their experiences. Josephine admits “I still can’t say I’m all that into sex, but I do enjoy the intimacy and the closeness and the kissing as I love my husband very much.  I make sure that we have sex at least once a week, and once we get going I usually enjoy it, even if I don’t orgasm. I consider having sex to still be an important part of a relationship”.

Resources

British Association of Sex and Relationship Therapy

http://www.basrt.org.uk/

Relate UK

http://www.relate.org.uk/

Institute of Psychosexual Medicine

http://www.ipm.org.uk

Sexual Dysfunction Association

http://www.sda.uk.net/

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[1] American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, Fourth Edition, American Psychiatric Association , Washington, DC

[2] Balon,A “The DSM Criteria of Sexual Dysfunction: Need for a Change”, Journal of Sex & Marital Therapy, Volume 34, Issue 3 May 2008 , pages 186 - 197

[3] Tiefer L (2006) Female Sexual Dysfunction: A Case Study of Disease Mongering and Activist Resistance. PLoS Med 3(4): e178 doi:10.1371/journal.pmed.0030178

[4] Moynihan R (2003) The making of a disease: Female sexual dysfunction. BMJ 326:45–47.

[5] Laumann, E. O.,  Paik, A. and Rosen, R. C. (1999) Sexual dysfunction in the United States. Prevalence and predictors. Journal of American Medical Association 281 , pp. 537-544.

[6] Moynihan R (2003) The making of a disease: Female sexual dysfunction. BMJ 326:45–47.

[7] Balon,A “The DSM Criteria of Sexual Dysfunction: Need for a Change”, Journal of Sex & Marital Therapy, Volume 34, Issue 3 May 2008 , pages 186 - 197

[8]Davis, Anne R and Castano, Paula M “Oral Contraceptives and Libido in Women”, Annual Review of Sex Research; 2004, Vol. 15, p305-328, 24p.

[9] Panzer, C. Journal of Sexual Medicine, January 2006; vol 3: pp 104-113.

[10] http://www.theage.com.au/news/lifeandstyle/lifematters/new-contraceptive-pill/2009/01/22/1232471502991.html

      

[11] Rosen, Raymond C. PhD; Lane, Roger M. MD; Menza, Matthew MD “Effects of SSRIs on Sexual Function: A Critical Review”.Journal of Clinical Psychopharmacology. 19(1):67-85, February 1999.

[12] Montejo-gonzàlez, Angel L., Llorca, G., Izquierdo, J. A., Ledesma, A., Bousono, M., Calcedo, A., Carrasco, J. L.,Ciudad, J., Daniel, E., De LA Gandara, J., Derecho, J., Franco, M., Gomez, M. J., Macias, J. A., Martin, T., Perez, V., Sanchez, J. M.,Sanchez, S. and Vicens, E.(1997)'Fluoxetine, paroxetine, sertraline, and fluvoxamine in a prospective, multicenter, and descriptive

clinical study of 344 patients',Journal of Sex & Marital Therapy,23:3,176 — 194

[13] March 2004, http://www.pfizer.com

[14] Davis S, Papalia MA, Norman RJ, et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women: a randomized trial. Annals of Internal Medicine 2008;148:569-577

[15]

Authors: Nyunt, A.; Stephen, G; Gibbin, J.; Durgan, L.; Fielding, A.; Wheeler, M.; Price, D. “Androgen Status in Healthy Premenopausal Women with Loss of Libido”Journal of Sex and Marital Therapy, Volume 31, Number 1, January-February 2005 , pp. 73-80(8)

This article was originally published in an abridged version in Filament, 2011.