Definition of female sexual dysfunction:
Female sexual dysfunction is considered the collective
term for the various disorders of the sexual process in
women. Female sexual dysfunctions are currently classified
as discrete individual disorders in one of the phases of
the sexual response cycle – desire, arousal, orgasm,
resolution / satisfaction, or pain related to sexual activity
– however, it is seldom that one of these disorders
occurs in isolation from another.
Lack or loss of sexual desire:
It is estimated that 30% of women with sexual dysfunction
problems have no sex drive (the “biological”
force which makes a person seek out or accept sex). Affected
women have no need for sex (unless the wish to have a baby).
New evidence indicates that lack of sex drive is likely
to have biological or physical causes such as insufficient
blood flow to the clitoris or vagina; neurological impairment
(possible after pelvic or gynaecological surgery); low testosterone
levels or maybe a consequence of an organic disease such
as raised blood pressure.
Inhibited sexual desire (ISD):
Reduced sexual desire is the most frequent complaint among
women attending sex therapy clinics in the UK – affecting
nearly 80% of women who seek help. Symptoms include: loss
of sexual “spark”; little desire to initiate
sex (although if stimulated sufficiently can still achieve
orgasm); aversion to “sexual overtures”; pain
on intercourse; emotional upset; inability to respond to
stimulation or maintain lubrication. Possible causes can
include; extreme tiredness, depression, use of antidepressants,
psychological blocks, stress, general unhappiness in relationship.
Female sexual arousal disorder (FSAD):
Female sexual arousal disorder can occur on its own or
in conjunction with inhibited sexual desire and lack of
sexual drive disorders. It is defined as the persistent
or recurrent inability to attain, or to maintain until completion
of sexual activity, an adequate lubrication – swelling
response of sexual excitement. According to new research
FSAD may be due to factors such as vascular and clitoral
erectile insufficiency syndrome which means there is insufficient
blood flow to the female sexual tissues (clitoris, vagina,
urethra) to enable the necessary lubrication and engorgement
for satisfactory sexual activity. Possible causes can include:
physiological complications such as impaired blood flow
or nerve damage to the sexual tissue, or it may be secondary
to a disease or may be lack of adequate stimulation from
Female orgasmic disorder (FOD):
Female orgasmic disorder is defined as the 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 diagnosis of FOD should be based on the clinician’s
judgement that woman’s orgasmic capacity is less than
would be reasonable for her age, sexual experience and the
adequacy of sexual stimulation she receives. There is probably
a significant physiological element in orgasmic disorders.
Female androgen deficiency syndrome (FADS):
Testosterone (the male sex hormone) is an androgen hormone,
which is also secreted, in smaller amounts by the ovaries
and adrenal glands in women. It is thought to be the hormone
of desire because of its positive influence on the sex drive.
As women age their levels of testosterone fall considerably
(but not dramatically like oestrogen levels at menopause).
Dr Susan Davies of the Jean Haile Research Institute in
Australia has discovered that many older women who complain
of a lack of sexual desire are in fact suffering from androgen
Possible causes of female sexual dysfunction:
“Female sexual desire has a strong psychological
and emotional input than male desire”. C. Kalamis,
“Women without sex”, published in 1999.
1) Psychological problems:
The sexual circuitry (which orchestrates the sexual response)
is strongly influenced by what goes on in the mind and in
the emotions. Sexual arousal can be compared to an electrical
circuit, which can be subject to breakdowns at many different
junctions along the route to sexual fulfilment. Such breakpoints
- Pain – which can cancel out sexual response
- Emotional interference with the sexual response (such
as anxiety, sadness, anger, grief and bereavement).
- Distraction – negative memories, uncertainty
of how to behave (too much emphasis on watching self rather
than focusing on what is being felt) fear of pregnancy,
fear of contracting a sexually transmitted disease.
- Another important psychological issue is BODY IMAGE
DISORDER. How women feel about their bodies has a profound
impact on their sexuality. Poor body image can lead to
the entire sexual response cycle becoming dysfunctional.
Key psychological problems:
Anxiety. Mood. Anger.
Other psychological influences (which can be temporary,
episodic or enduring) are depression, overbearing family
responsibilities, money worries, miscarriage, bereavement,
rape, child abuse and paternal or religious influences.
Growing up in a family with strong sexual taboos can lead
to diminished sexuality, sexual dysfunction and problems
with orgasm. This can lead to feelings of distress through
the perception of being unable to please a partner resulting
in a vicious circle of anxiety to decreased lubrication
and pain on intercourse leading to avoidance of sex and
eventual (in some cases) relationship breakdown. Depression
(or drugs given for treatment of depression) may also play
a part, along with a loss of self – confidence and
self – esteem.
A UK study has found that 6% of women questioned about
their sexual difficulties were depressed. Historically,
women who have lost their self – confidence or self
– esteem or suffer from depression may be able to
reach orgasm because something switches off before orgasm
is reached – perhaps associated with a fear of letting
go and losing control.
2) Possible physiological causes of FSD:
Apart from the considerable impact of psyche on female
sexuality, there are now believed to be a number of physical
causes of FSD:
- Hormone imbalance (Oestrogen / progesterone / testosterone)
- Underlying inefficiency of vital chemical messengers
- Smaller clitoral size
- Reduced or inadequate numbers of sensory receptors
in the sexual tissues
- Configuration of the sexual tissues
- Feedback loops evolving from pain on intercourse (Dyspareunia)
3) Possible risk factors for female sexual dysfunction:
Many of the following (except those that are female gender
– specific) are risk factors for male (erectile) dysfunction
- Raised blood pressure. A 1987 study showed that 78%
of women being treated for raised blood pressure, had
difficulty in becoming sexually aroused.
- Heart disease / narrowing / hardening of the arteries
and raised cholesterol. More women are being diagnosed
with cardiovascular disease nowadays. Oestrogen protects
women from heart disease until the menopause. Narrowing
or hardening of pelvic arteries due to heart disease may
affect blood flow to sexual tissues in women as it does
- Diabetes a known cause of ED in men, affects nerves
and blood vessels and therefore, nerve conduction and
blood circulation throughout the body, which may affect
nervous and vascular feed to the sexual tissue.
- Thyroid problems (particularly for women over 40).
Hypo – (Lowered) and hyper (raised) thyroidism can
influence sexual feelings. Thyroid hormone can affect
body weight, energy levels, skin condition, mental condition,
reproductive organs and sexual functioning.
- Nerve or blood vessel damage due to abdominal or pelvic
surgery (e.g. hysterectomy) and surgical intervention
of some gynaecological cancers. Having surgery or radiation
therapy in the pelvic area can result in vaginal discomfort.
Hysterectomy compromises the production of oestrogen,
progesterone and androgen (like testosterone), which are
all important for sex drive and arousal. Sexual problems
are also common among women who have had hysterectomies
frequently report a reduction in their sexual feelings
and response after radical surgery. Some women report
that their orgasms are not as strong as before surgery
– this may be due to nerve damage during the operation.
- Multiple sclerosis. A variably progressive disease of
the nervous system in which patchy, degenerative changes
occur in the nerve sheaths of the brain, spinal cord and
optical nerves, will affect sexual functioning.
- Pre – menstrual syndrome (PMS). Where hormonal changes
can cause irritability and depressive states as well as
causing dramatic mood swings in some women.
- Childbirth (due to strong hormonal influence) can reduce
sexuality. This is often temporary. Where the affect is
prolonged, there may be damage to nerve and blood vessels
incurred during the birth.
- Endometriosis. Conditions such as endometriosis (inflammation
of the lining of the womb and – in some severe cases
– within the visceral cavity) can result in pain and
discomfort on intercourse and intimacy. Severe endometriosis
can confer infertility on some sufferers.
- Infertility. Infertility due to gynaecological problems
(such as endometriosis) or via menopause can also cause
associated feelings of lack of esteem and self – worth
and loss of “femininity” and loss of sexuality.
- Menopause. Falling oestrogen and androgen circulating
in the body can produce effects such as dry vagina (often
resulting in pain on intercourse), reduced capacity or mental
“arousal” and reduced sex drive. These factors
combined with low self – esteem due to changing body
image (greater tendency to weight gain, reduction in breast
size, loss of pubic hair, etc). plus the realisation of
loss of fertility (femininity), health concerns, insomnia,
anxiety, stress and depression confer FSD on previously
normally functioning women.
- Obesity. Obesity has been shown to be associated with
lack of self – esteem and a greater tendency to blood
vessel, heart disease and diabetes.
- Smoking and alcoholism. Well known causes of ED in men,
there is evidence to suggest that smoking and excessive
alcohol intake can adversely affect sexual function in women.
Smoking can severely affect the circulatory system and excess
alcohol, the nervous system. Alcohol can also adversely
affect sexual arousal.
- Diagnosed psychological problems. (e.g. depression) As
female sexuality is highly influenced by “state of
mind”, women who are suffering from depression are
less likely to have normal sexual function. On top of this,
certain prescription antidepressants have a dramatic affect
on sexuality. One report in the US suggests that 33% of
women taking antidepressants will experience a loss of libido
and difficulty achieving orgasm.
- Other prescription drugs. Antihistamines, anti –
hypertensives, antidepressants, antipsychotics, anti –
oestrogens, some contraceptive pills, central nervous system
stimulants and narcotics adversely affect sexual arousal.
The Kinsey institute in the US is currently studying the
effects of combined oral contraceptives on mood and sexuality
following earlier findings that suggests they may have an
adverse effect on sexuality. A 1990 study of the effects
of a commonly prescribed anti – hypertensive / anti
– anginal showed it significantly affected sexual
arousal in 9 healthy young women.
However, Dr Roy Levin of Sheffield University, UK, who’s
work on the female sexual response spans 30 years, suggests
that many women suffer sexually because they are simply not
being stimulated sufficiently or effectively by their partners
– due to:
- Lack of awareness of the female genital anatomy (by both
- Ignorance of what happens during arousal.
- Lack of knowledge of where the important sexually arousal
zones are positioned. And for many women sexual satisfaction
includes affection, communication with their partner and
Women consider that attraction, passion, trust and intimacy
are more significant than their genital response. Some women
find that specific problems can easily put them off sex and
cause them to lose their desire for sex.
Diagnosis of female sexual dysfunction:
Only a small proportion of women come forward to have their
sexual problems diagnosed and even fewer accept treatment.
The first full population study of the extent and nature of
sexual problems in the UK has reinforced the finding that
4 in 10 women are affected by sexual problems. Of 789 men
and 979 women from 4 GP practises, the following findings
- Sexual intercourse was never or rarely a pleasant experience
for 110 of the women
- 68% reported having some sort of sexual problem at sometime
- Only 4% of the women had received help.
The nature of a woman’s FSD can be diagnosed by combining
sexual and clinical history, a physical examination, laboratory
tests (such as oestrogen, progesterone and testosterone levels;
Doppler ultra sonography, vaginal photo – plethysmography
or vaginal thermal clearance) and / or filling out a simple
There has been a recent breakthrough in research into women’s
sexual problems with the development of
A) Equipment with the ability to monitor vaginal blood flow
(biofeedback information is given on the changes in the engorgement
of the vagina, labia and clitoris – the physiological
state of arousal) and:
B) The development of clinical questionnaires in which women
self report their problems.
However, because environment, etc. have such a strong influence
on female sexuality, these measuring devices are often not
as accurate as they would be in a “real” sexual
situation at home and some women self report lack of arousal
when in fact the physiological status reports the opposite.
Treatment of female sexual dysfunction:
The problem of female sexual dysfunction is widespread, yet
very little is being done for affected women, partly due to
the fact that so few women seek help and perhaps, partly because
they are unsure of where to go for help. Apart from GP, Gyanecologist,
Sexual & Marriage therapists (who mostly take a psychological
approach), there are few clinics offering specific sexual
help for women from a medical perspective. Also, little attention
is focused on the fact that a woman may be more prepared to
talk to another woman about her sexual difficulties.
Possible treatments for female sexual dysfunction:
- Psychosexual counselling
- Stimulation of the sympathetic nervous system –
through exercises which raises blood pressure and heart
- Change in diet
- Vitamin, mineral or herbal supplement
- Relaxation and exercise therapy
- Change in sexual techniques to re – stimulate interest
- A change in type and hormonal content of contraceptive
- Possible alcohol / drug counselling or weight loss plan
if obesity / body image is a factor.
- Use of artificial lubricants
- Treatment for an underlying condition such as thyroid
dysfunction or diabetes.
- Use of hormonal creams. Topical vaginal oestrogen for
peri – and post menopausal women.
- Combined testosterone and oestrogen therapy
- Testosterone implant therapy
- Use of oxytocin – more common as the hormone which
causes contractions in childbirth, researchers are investigating
whether oxytocin has a role in promoting sexuality.
- Viagra and other pharmaceutical drugs.
Counselling has an important role if there is a psychological
or behavioural basis for the sexual dysfunction. It is also
important where there are relationship difficulties. But medical
intervention may be necessary if there is a physiological
How to find a therapist?
SASHA – Southern African Sexual Health Association
0860 100 262
SAASECT – South African Association of Sex
educators, Counsellors and Therapists (011) 787 - 1222