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 are:

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.

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 a partner.

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 deficiency.

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.

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 (e.g. neurotransmitters)
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 too:
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 in men.
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 partners)
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 sensual touching.
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 were uncovered:

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 questionnaire.

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 rate.
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 pill
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.

Psychosexual counselling:

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 cause.

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

1) Psychological problems:

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.

Definition of female sexual dysfunction:

Lack or loss of sexual desire:

Inhibited sexual desire (ISD):

Female sexual arousal disorder (FSAD):

Female orgasmic disorder (FOD):

Female androgen deficiency syndrome (FADS):

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.

Key psychological problems:

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 (e.g. neurotransmitters)

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 too:

Raised blood pressure. A 1987 study showed that 78% of women being treated for raised blood pressure, had difficulty in becoming sexually aroused.

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.

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.

Obesity. Obesity has been shown to be associated with lack of self – esteem and a greater tendency to blood vessel, heart disease and diabetes.

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 partners)

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 sensual touching.

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:

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.

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:

Possible treatments for female sexual dysfunction:

Psychosexual counselling

Stimulation of the sympathetic nervous system – through exercises which raises blood pressure and heart rate.

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 pill

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.

Psychosexual counselling:

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 cause.

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