Female Sexual Interest/Arousal Disorder

Female Sexual Interest/Arousal Disorder

Sexual Arousal Disorder

Over the past century the world of female sexuality has dramatically changed. Women are now living longer than ever before and many are enjoying sexual experiences well into their later years. Post-menopausal women want to continue to be sexually active and the focus now is on greater sexual realisation, understanding and sexual satisfaction. Women are now more open in seeking help to increase sexual satisfaction and for the treatment of sexual issues.

The practice of sex therapy is becoming an integral part of individual and couple therapy. More women than ever are presenting with the issue of low libido or difficulty feeling adequate levels of arousal.

The definition:

The DSM-5 (diagnostic manual) outlines³⁴:

The term: Female Sexual Interest / Arousal Disorder

Criteria: Lack of, or significantly reduced, sexual interest / arousal, must meet at least three of the following. Absent / reduced:

  1. Interest in sexual activity
  2. Sexual / erotic thoughts or fantasies
  3. Sexual excitement / pleasure during sexual activity in approx. 75%-100% of sexual encounters (in identified situational contexts, or if the condition is generalised, in all contexts)
  4. Sexual interest / arousal in response to any internal or external sexual / erotic cues
  5. Genital or non-genital sensations during sexual activity approx. 75%-100% of sexual encounters (in identified situational contexts, or if the condition is generalised, in all contexts)
  6. Initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate

The symptoms have persisted for a minimum of approximately six months, and cause the individual significant distress. In addition, that the dysfunction is not better explained by other conditions – for more information see DSM-5, 302.72 (F52.22).

The issue can be categorised as either:

  • Lifelong: the problem has always existed from the first sexual experience
  • Acquired: acquired at some point in the lifespan after a period of normal sexual functioning
  • Generalised: occurs in all situations and with all partners
  • Situational: occurs in only certain situations / partners
  • Mild: causing a mild level of distress
  • Moderate: causing moderate distress
  • Severe: causing severe distress

When is the low libido or low arousal a problem or a disorder?

What constitutes a disorder versus a problem? Sexual dysfunction implies that normal sexual functioning is impaired and that the impairment is causing personal or interpersonal distress⁶. Some individuals present to therapy deeply distressed about the sexual issue but others have relatively low or no distress.

It’s important for each individual to determine how much distress the issue is causing and what the reasons and motivations are for change. For example, is it for the person concerned, the partner or the relationship itself?

Female sexual interest / arousal disorder has also been known as hypoactive (underactive) sexual desire and appears to be the most common of all the female sexual disorders⁷˒⁸.  A study of 1,489 women in the United Kingdom by Burri & Spector (2011)¹⁰, indicated that the most prevalent sexual dysfunction for women was a lack of sexual desire (17.3%), followed by satisfaction (14.6%), orgasm (13.5%), arousal (13.3%), lubrication and pain (both at 11.5%). In their study, Mercer et al. (2003)¹¹, discovered that 53.8% of heterosexual women aged 16-44 in the UK had a least one sexual difficulty lasting for a least a month and that the most common was lack of interest in sexual activity.

Researchers caution however, that accurate statistics are difficult to obtain as data varies based on the criteria used. In a study involving 741 women across Australia, Asia, the Americas and Europe, McCabe & Goldhammer (2013)⁷ evidenced that, depending on the criteria used to measure low sexual desire, results varied considerably from 3 to 31%. It’s important to consider how a person subjectively evaluates the low sexual desire or if the level of desire falls into the low but normative range⁷.

Causes

There are many potential causes of low libido and low arousal. The issue may be caused by one or a combination of many driving factors. Many of these are explored below:

Early Trauma

Early trauma may impact significantly on the adult life of the individual, especially within the realms of sexual functioning. In the US National Health and Social Life Survey of 1,749 women, Laumann, Paik & Rosen, (1999)¹⁴ evidenced that for women, early traumatic sexual experiences later predicted negative attitudes to sexual experiences. Some of these women were twice as likely to develop issues with sexual functioning. Along with a history of sexual abuse, physical abuse was also found to correlate with female sexual dysfunction¹⁵. These traumatic events have long-lasting effects and may last decades beyond the original experience¹⁶.

Cultural influences

There cannot be enough emphasis placed on the question of what normal sexual functioning is and what is not. The more one examines sexuality the more one appreciates there is no correct answer to this question. In Western society intercourse is placed in a particularly privileged position and taken for granted as a ‘normal’ sexual course of action²⁴ – the be-all-and-end-all, the Holy Grail, and this sets the foundation of how women and men make sense of sex within a Western culture²⁵. Consideration should include aspects of the persons, and the couple’s sexual expectations and cultural norms as these form how sex is viewed and desired.

Distress

Several studies have investigated the association between sexual distress and female sexual dysfunction and there appears to be a significant correlation between a woman’s level of sexual stress and her motivation to engage in sexual activity²⁷˒¹⁸. A UK study of 1489 women reported that 26.6% had recent sexual distress and 25.9% of women felt they had lifelong sexual distress¹⁰. These results were similar to a Finnish study²⁸, and a British female twin study of 319 women with sexual problems recorded that 36.5% of women reported distress compared to 16.5% of sexually functional women²⁹.  It is clear that the level of distress one feels around sexuality highly impacts on sexual satisfaction and/or the development of sexual issues.

Relationship Quality

There has been greater emphasis recently placed on looking at the quality of the interpersonal relationship as a predictor of female sexual issues. Relationship dissatisfaction, marital conflict and extramarital affairs, poor communication and lack of trust and emotional closeness are all known contributors to reduced sexual desire¹˒²˒³. In particular, a woman’s anger towards her partner⁴ and a woman’s irritability⁵ were strong predictors of both lack of sexual desire and reduced subjective and physiological sexual response. There appears to be significant reciprocity between relationship satisfaction and sexual functioning. Problems in the current relationship are more likely to occur among women with sexual dysfunction⁶, and Regan (1999) offers that sexual desire predicts the quality of the relationship.

Sexual Assertiveness

In a sample of 1,755 women and 1,619 men, Santos-Iglesias et al., (2013)³² found that having a high level of sexual assertiveness was predicted by many factors. These include: higher sexual desire for the couple unit; less guilt about sex; an ability to talk about sex more openly; held more positive attitudes toward sexually explicit material; and had higher sexual arousal. Sexual assertiveness involves being assertive about sexual situations and being able to display assertive behaviours in a sexual context in terms of communicating sexual preferences and unwanted sexual behaviours³². Note that a person who is assertive about initiation of sexual contact may not also be assertive in these areas. Evidence suggests that sexual assertiveness relates to greater sexual functioning, lower sexual victimization, lower participation in risky sexual behaviours and increased satisfaction.

 

Attitudes Toward Sex

If we have experienced previous sexual encounters as not enjoyable, anxiety provoking or linked with negative emotions, we are more likely to expect that future sexual encounters will be the same. We then form negative attitudes towards sex and these can be long lasting if they remain unchallenged or unchanged. Moreover, these attitudes may have been formed through real events or through perceptions of how the sexual encounters have been. Our attitudes are likely to have substantial influence over our libido and whether or not we feel adequate arousal levels.

The issues of low libido and low sexual arousal can be woven into a complex fabric of psychological, emotional, physical, situational and environmental factors. It will only be through thorough investigation that each factor can be isolated and the best treatment pathways can be formulated.

References:

¹ Leiblum, S.R. & Rosen (1988). Sexual desire disorders. New York, NY: Guilford Press.

² Basson, R. (2006). Sexual desire and arousal disorders in women. The New England Journal of Medicine, 354 (14), 1497-1506.

³ Burri, A. & Spector, T. (2011). Recent and lifelong sexual dysfunction in a female UK population sample: Prevalence and risk factors. Journal of Sexual Medicine (8), 2420-2430.

⁴ Robinson, B., Munns, R.A., Weber-Main, A.M., Lowe, M.A. & Raymond, N.C.  (2011). Application of the sexual health model in the long-term treatment of hypoactive sexual desire and female orgasmic disorder. Archives of Sexual Behavior, 40,       469-478.

⁵ ter Kuile, M. M., Vigeveno, D., & Laan, E. (2007). Preliminary evidence that acute and chronic daily psychological stress affect sexual arousal in sexually functional women. Behaviour Research and Therapy, 45, 2078–2089.

⁶ McCabe, M.P. (2005). The role of performance anxiety in the development and maintenance of sexual dysfunction in men and women. International Journal of Stress Management, 12, (4) 379–388.

⁶ Hertlein, K.M., Weeks, G.R. & Sendak, S.K. (2009). A clinician’s guide to systemic sex therapy. New York, USA: Taylor Francis Group.

⁷ McCabe, M.P. & Goldhammer, D.L. (2013). Prevalence of women’s sexual desire problems: What criteria do we use? Archives of Sexual Behavior, 42, 1073-1078.

⁸ Hurlbert, D.F., Apt., C., Hurlbert, M.K. & Pierce, A.P. (2000). Sexual compatibility and the sexual desire-motivation relation in female hypoactive sexual desire disorder. Behaviour Modification (24), 325-327.

¹⁰ Burri, A. & Spector, T. (2011). Recent and Lifelong Sexual Dysfunction in a Female UK Population Sample: Prevalence and Risk Factors. Journal of Sexual Medicine (8), 2420-2430.

¹¹ Mercer, C.H, Fenton, K.A., Johnson, A.M., Wellings, K. Macdowall, W. McManus, S. et al. (2003). Sexual function problems and help seeking behaviour in Britain: National probability sample survey. British Medical Journal, 327, 426-427.

¹⁴ Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281, 537–544.

¹⁵ Ishak, I.H., Low, W.Y. & Othman, S. (2010). Prevalence, risk factors and predictors of female sexual dysfunction in a primary care setting: A survey finding. Journal of Sexual Medicine (7), 3080-3087.

¹⁶ Barlow, G. H. & Durand, V. M. (2009). Abnormal psychology: An integrative approach (5th ed.). Belmont,USA: Wadsworth.

¹⁸ Basson, R. (2006). Sexual desire and arousal disorders in women. The New England Journal of Medicine, 354 (14), 1497-1506.

²⁴ Ayling, K. & Ussher, J.M. (2008). “If sex hurts, am I still a women?” The subjective experience of vulvodyndia in heterosexual  women. Archives of Sexual Behavior, 37, 294-304.

²⁵ Potts, A. (2002). The science/fiction of sex: Feminist deconstruction and the vocabularies of heterosex. East Sussex, United Kingdom: Routledge.

²⁷ Hurlbert, D.F., Fertel, E.R., Singh, D. & Ferdinand, F. Et al. (2005). The role of sexual functioning in the sexual desire adjustment and psychosocial adaptation of women with hypoactive sexual desire. The Canadian Journal of Human Sexuality (14), 15-30.

²⁸ Witting, K., Santtila, P., Varjonen, M., Jern, P., Johansson, A., von der Pahlen, B. & Sandnabba, K., (2008). Female sexual dysfunction, sexual distress and compatibility with partner. Journal of Sexual Medicine (5), 2587-2599.

²⁹ Burri, A., Rahman, Q. & Spector, T. (2011). Genetic and environmental risk factors for sexual distress and its association with female sexual dysfunction. Psychological Medicine, (41), 11, 2435-2445.

³⁴ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.), (DSM-5).    Washington, USA: American Psychiatric Publishing.

References:

¹ Leiblum, S.R. & Rosen (1988). Sexual desire disorders. New York, NY: Guilford Press.

² Basson, R. (2006). Sexual desire and arousal disorders in women. The New England Journal of Medicine, 354 (14), 1497-1506.

³ Burri, A. & Spector, T. (2011). Recent and lifelong sexual dysfunction in a female UK population sample: Prevalence and risk factors. Journal of Sexual Medicine (8), 2420-2430.

⁴ Robinson, B., Munns, R.A., Weber-Main, A.M., Lowe, M.A. & Raymond, N.C.  (2011). Application of the sexual health model in the long-term treatment of hypoactive sexual desire and female orgasmic disorder. Archives of Sexual Behavior, 40,       469-478.

⁵ ter Kuile, M. M., Vigeveno, D., & Laan, E. (2007). Preliminary evidence that acute and chronic daily psychological stress affect sexual arousal in sexually functional women. Behaviour Research and Therapy, 45, 2078–2089.

⁶ McCabe, M.P. (2005). The role of performance anxiety in the development and maintenance of sexual dysfunction in men and  women. International Journal of Stress Management, 12, (4) 379–388.

 

⁶ Hertlein, K.M., Weeks, G.R. & Sendak, S.K. (2009). A clinician’s guide to systemic sex therapy. New York, USA: Taylor Francis Group.

⁷ McCabe, M.P. & Goldhammer, D.L. (2013). Prevalence of women’s sexual desire problems: What criteria do we use? Archive of Sexual Behavior, 42, 1073-1078.

⁸ Hurlbert, D.F., Apt., C., Hurlbert, M.K. & Pierce, A.P. (2000). Sexual compatibility and the sexual desire-motivation relation in female hypoactive sexual desire disorder. Behaviour Modification (24), 325-327.

¹⁰ Burri, A. & Spector, T. (2011). Recent and Lifelong Sexual Dysfunction in a Female UK Population Sample: Prevalence and Risk Factors. Journal of Sexual Medicine (8), 2420-2430.

¹¹ Mercer, C.H, Fenton, K.A., Johnson, A.M., Wellings, K. Macdowall, W. McManus, S. et al. (2003). Sexual function problems and help seeking behaviour in Britain: National probability sample survey. British Medical Journal, 327, 426-427.

¹⁴ Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281, 537–544.

¹⁵ Ishak, I.H., Low, W.Y. & Othman, S. (2010). Prevalence, risk factors and predictors of female sexual dysfunction in a primary care setting: A survey finding. Journal of Sexual Medicine (7), 3080-3087

¹⁶ Barlow, G. H. & Durand, V. M. (2009). Abnormal psychology: An integrative approach (5th ed.). Belmont, USA: Wadsworth.

¹⁸ Basson, R. (2006). Sexual desire and arousal disorders in women. The New England Journal of Medicine, 354 (14), 1497-1506.

²⁴ Ayling, K. & Ussher, J.M. (2008). “If sex hurts, am I still a women?” The subjective experience of vulvodyndia in heterosexual  women. Archives of Sexual Behavior, 37, 294-304.

²⁵ Potts, A. (2002). The science/fiction of sex: Feminist deconstruction and the vocabularies of heterosex. East Sussex, United Kingdom: Routledge.

²⁷ Hurlbert, D.F., Fertel, E.R., Singh, D. & Ferdinand, F. Et al. (2005). The role of sexual functioning in the sexual desire adjustment and psychosocial adaptation of women with hypoactive sexual desire. The Canadian Journal of Human Sexuality (14),     15-30.

²⁸ Witting, K., Santtila, P., Varjonen, M., Jern, P., Johansson, A., von der Pahlen, B. & Sandnabba, K., (2008). Female sexual dysfunction, sexual distress and compatibility with partner. Journal of Sexual Medicine (5), 2587-2599.

²⁹ Burri, A., Rahman, Q. & Spector, T. (2011). Genetic and environmental risk factors for sexual distress and its association with female sexual dysfunction. Psychological Medicine, (41), 11, 2435-2445.

³⁴ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.), (DSM-5). Washington, USA: American Psychiatric Publishing.

 

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