Annamaria Giraldi MD, PhD, Alessandra H. Rellini PhD, James Pfaus PhD, Ellen Laan PhD
ONLINE: September 13, 2012 – The Journal of Sexual Medicine,
Past definitions of sexual arousal have focused only on the physiological aspects of arousal, such as genital lubrication, congestion, swelling, and sensation. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) uses this focus in its definition of Female Sexual Arousal Disorder (FSAD) and includes “marked distress or interpersonal difficulty.”
However, this approach to FSAD has been criticized because it does not account for subjective aspects of sexual arousal, which may be situational and do not always coincide with physiological aspects. For some women, such as postmenopausal women, problems with the physiological aspects of arousal (like vaginal dryness) cause distress.
Also, adequate arousal is different among women. Some need both physical and subjective aspects. Some need more stimulation – or more intense stimulation – than others.
To address the discrepancy in the DSM-IV-TR definition of arousal and the empirical evidence on the subject, an international committee was formed by the American Urological Association in 2002. This committee proposed three different subtypes of FSAD:
Genital Sexual Arousal Disorder: Genital sexual arousal is absent or impaired, but “subjective sexual excitement still occurs from non-genital sexual stimuli.”
Subjective Arousal Disorder: Physical arousal occurs, but there is “absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation.”
Combined Genital and Subjective Arousal Disorder: Genital arousal is “absent or impaired” and subjective arousal is absent or “markedly diminished.”
While these subtypes better encompass women’s experiences, they have not yet been accepted as nomenclature and little research has addressed their validity and clinical usefulness. Research would be helpful, but it is unclear whether the application of these subtypes would result in a different diagnosis or treatment. One research dilemma is the questionable accuracy of self-reported data. Also, only two studies have examined the distinction between the subtypes and those results would need to be replicated before Genital FSAD could be distinguished from Subjective FSAD.
It has been proposed that women’s sexual desire and arousal disorders be combined in the revision of the DSM-5. This paper does not aim to critique this idea. However, it should be noted that scholars are not sure whether women can tell the difference between sexual desire and subjective states of sexual arousal. It is also unknown what future definitions of arousal will be.
FSAD can be classified in the following ways:
- Primary. The woman has never experienced sufficient arousal, even when she has had sufficient desire and sexual stimulation.
- Secondary. The woman has been sufficiently aroused in the past, but currently experiences decreased arousal.
- Generalized. The problem occurs in all sexual situations.
- Situational. The problem occurs only in some sexual situations.
Women with FSAD often have other sexual dysfunctions.
Prevalence and Risk Factors
Most epidemiological studies have used the conventional definitions of sexual arousal and have not included distress as a factor. Therefore, these studies reflect arousal problems and not clinically defined FSAD.
Most studies report a prevalence of 13% and 24%, with a range of 6% to 28% of women. Several studies have shown that prevalence increases with increasing age. When adjusted for distress, prevalence has been reduced to 3.3% for women aged 18 to 44 years and 7.5% for women aged 45 to 64 years. It appears that women experience more arousal problems as they get older, but also become less distressed by them.
The duration of arousal problems varies, with one review reporting that 10% of women have problems for one month, 60% have problems lasting between one and six months, and 30% have problems lasting longer than six months.
The prevalence of arousal problems are influenced by transcultural differences and suggest that healthcare providers should consider ethnicity when assessing sexual arousal problems.
Biological Risk Factors
Automatic sexual responses are largely governed by the autonomic nervous system, intact nerve-medication, vascular function, and hormonal factors. For example, estrogen helps with blood flow to the genitals and vaginal lubrication. Issues with any of these functions can result in problems with genital arousal.
Some examples of risk factors for FSAD include decreases of estrogens and androgens; diabetes; vaginal and urinary tract infections; surgery, radiation, and medication; and psychological factors such as depression and anxiety.
The authors pointed out the following:
- Studies examining the link between estrogen decline and FSAD have been inconclusive.
- The effects of age and menopause can be difficult to separate.
- As women age, androgen levels decline. Testosterone may play a role in genital arousal.
- Medical diseases involving the autonomic nervous system and the vascular system are known risk factors for FSAD. Examples include diabetes, multiple sclerosis, and spinal cord injuries.
- Other medical conditions can indirectly affect arousal. Examples include conditions treated by surgery or radiation therapy on the pelvis or genitals, urinary tract infections, and recurrent vaginal infections. Anti-estrogenic treatment for hormone sensitive breast cancer is also a risk factor.
Psychological, Intra- and Interpersonal Risk Factors
- Cognitions and Affect. Cognitive-affective mechanisms, such as negative sexual attitudes or negative expectations about sex, can affect how people respond to sexual stimuli.
- Depression. Depression can lead to arousal problems in women and may be paired with desire problems as well. It may be helpful to address mood when diagnosing and treating sexual arousal disorder.
- Anxiety. Studies have found higher levels of anxiety in women with sexual problems and higher rates of sexual dysfunction in women with anxiety.
- Personality Variables. Personality features such as low/fragile self-regulation and self-esteem, as well as histrionic personality can impair sexual response.
- Sexual Abuse. Sexual abuse is associated with lower physiological sexual arousal responses and higher rates of FSAD. How this happens is still unclear, but biological factors such as the Hypothalamic-Pituitary-Adrenal (HPA) axis and psychological factors like post-traumatic stress disorder, may be involved. The authors note that not all women who have been sexually abused develop sexual dysfunction. Also, if a woman has been sexually abused, sexual problems may not necessarily be related to the abuse. Other types of childhood abuse may also affect sexual arousal later. Women with major depressive disorder or post-traumatic stress disorder resulting from abuse should be treated for those disorders before, or along with, the sexual arousal disorder.
- Relationship quality. Relationships can also affect sexual arousal, especially if a woman cannot tell her partner how she prefers to be stimulated.
- Distraction and Self-Focused Attention. Sexual arousal may be inhibited if a woman is distracted by nonsexual thoughts or by evaluating herself during sexual activities (spectatoring).
- Perceived Stress. Psychological stressors may reduce genital and subjective arousal.
- Body Image. Female sexual function may be negatively affected by body image self-consciousness.
- Partner’s Sexual Dysfunction. If a male partner has a sexual problem, such as erectile dysfunction or premature ejaculation, that may affect female sexual function, including arousal.
A biopsychosocial approach that explores “predisposing, precipitating, and maintaining factors” is recommended to assess arousal and arousal problems. A full assessment involves a medical and sexological history and medical examination, along with determining the degree of distress the woman feels. The authors offer the following “questions of importance” for clinical assessment along with suggestions for various responses:
- Can you describe the problem in your own words?
- Has the problem always been there?
- Are you sexually active? With or without a partner?
- Is the problem limited to your partner and/or to a special context/situation?
- Does your partner have a sexual problem?
- What does the problem mean to you?
- What does the problem mean to your partner and to the relationship?
Clinicians should take a detailed history of the arousal problems and the conditions under which they occur. It is helpful if the woman’s partner is involved in this process. Important considerations include the following:
- Is the woman mentally sexually excited?
- Is she aware of a genital response during sexual stimulation, such as tingling or lubrication?
- Is there vaginal dryness or dyspareunia?
- Does she receive adequate sexual stimulation?
- Does she have other sexual disorders, such as problems with pain, desire, or orgasm?
- Is she distressed by the problem? Is it causing distress to her relationship?
Psychological and Relational History
To evaluate cognitive and affective factors, the following suggestions are offered:
- Clarify the woman’s thoughts before, during, and after the sexual experience. Does she feel distracted, sexually substandard, unsafe, etc.?
- Clarify her emotions. Does she feel sadness, guilt, etc. at any point during the sexual activity?
- Assess for depression, post-traumatic stress disorder, and anxiety disorders.
The following questions can help evaluate relational factors:
- Does the partner have sexual dysfunction?
- Are there relational problems, such as lack of attraction, or conflicts?
- Has the woman ever experienced an unwanted sexual experience?
- Was she physically or emotional abused while growing up?
- How have her past experiences affected the way she sees herself?
Medical and Gynecological History
The following areas should be addressed:
- Menstrual cycle, menopause, pregnancy, or breast feeding
- Somatic problems. Are there diseases known to cause lubrication problems, such as diabetes, or recurrent vaginal infections?
- Iatrogenic causes, such as surgery, radiation therapy, and/or medication
A gynecological exam is always recommended and should focus on the following:
- Any changes or abnormalities in vulvar anatomy
- Signs of inflammation
- Skin color and quality
- Appearance of vaginal mucosa (estrogenized and moistened or atrophic?)
- Signs of myogenic or referred pain or associated urogenital and rectal pain
- Inspection of pelvic floor trophism, muscular tone and strength
- Determination of pH
- Sampling and culture of discharge, if infection is suspected
Decisions on laboratory tests may be made based on the results of the physical examination. The following tests may be warranted, depending on the woman’s situation:
- Testosterone status [including free testosterone and sex hormone binding globulin (SHBG)]
- Plasma levels of estrogens
- Prolactin levels
- Thyroid-stimulating hormone (TSH)
Principles of Treatment of Sexual Arousal Disorder
Ideally, treatment should focus on the cause of the disorder, keeping biological, psychological, and relational factors in mind. If other disorders appear to be causing problems with arousal, those should be addressed.
Women with subjective arousal problems may find cognitive-behavioral techniques and/or traditional sex therapy helpful, as these strategies may help them become aware of genital responses and what it means to be subjectively aroused.
Women with genital arousal disorder may find pharmacological treatment that improves lubrication and focus on adequate sexual stimulation helpful.
Psychosexual Treatment of FSAD
Non-pharmacological treatment of FSAD has not been widely studied, but some women benefit from traditional sex therapy.
Studies on mindfulness-based treatment for FSAD have had encouraging results, but larger studies are needed before mindfulness can be considered effective.
Pharmacological Treatment of FSAD
Pharmacological treatment of FSAD may be hormonal or nonhormonal.
Hormonal treatment options include the following:
- Topical or systemic estrogen therapy. Studies have shown that this approach may improve vaginal lubrication and decrease vaginal dryness and irritation. However, it is important to individualize systemic estrogen therapy because of concerns over long-term effects.
- Tibolone. Tibolone is a synthetic steroid with estrogen, progesterone, and some androgenic effect that lowers SHBG. It has been shown to improve lubrication, but may not necessarily be more effective than estrogen. Because of its weak androgenic effect, it may benefit women with decreased desire and arousal problems, but more research is needed.
- Topical vaginal DHEA. This treatment has been shown to reverse symptoms and signs of vaginal atrophy.
Nonhormonal treatment could include phosphodiesterase type 5 inhibitors (PDEs), but studies have shown mixed results on their effectiveness. Studies of PDE use in smaller populations of women with specific medical conditions, such as diabetes and multiple sclerosis have been more encouraging.
Suggestions include the following:
- Vaginal lubricants. These may be water, oil, and silicone based, although oil-based lubricants should not be used with latex products.
- Vaginal moistures. These may reduce symptoms of vaginal atrophy and improve the maturity of the vaginal epithelium.
- EROS-CTD device. A few studies have investigated this small, battery-powered device used to increase blood flow to the clitoris. No studies have examined the long-term effects of the device.
In contrast to a lack of sexual arousal, some women experience persistent genital arousal disorder (PGAD), also called restless genital syndrome (ReGS). This condition is characterized by increased genital blood flow in non-sexual situations. The feeling is persistent, unwanted, and distressing.
Five criteria are used to diagnose ReGS/PGAD:
- Involuntary genital and clitoral arousal may last for hours, days, or months.
- The arousal is not relieved by orgasm(s).
- The genital arousal is not related to subjective feelings of sexual desire.
- The persistent feelings of genital arousal are intrusive and unwanted.
- The persistent arousal causes distress.
ReGS/PGAD is not recognized as a clinical disorder in the DSM-IV-TR or the International Classification of Diseases (ICD-10). The DSM Work Group on Sexual and Gender Identity Disorders has not proposed including ReGS/PGAD in the DSM-5.
ReGS/PGAD has not been widely researched. It is thought to be associated with psychological-related pathophysiologies like depression and anxiety. Stress tends to worsen symptoms; distraction and relaxation tends to relieve them. ReGS/PGAD may also be associated with biological pathophysiologies such as vascular, neurologic, pharmacologic, and hormonal causes.
Potential Intervention Regimens
Strategies for treating ReGS/PGAD have been found primarily in case reports. Double-blind, placebo-controlled studies on the topic have not been published as of yet. However, psychological strategies include treatment for depression and increasing relaxation. Biological interventions include ice or topical anesthetics. Discontinuing the use of some medications or herbal products help some women.
Other strategies have included selective embolization, embolization of the incompetent ovarian vein, electroconvulsive therapy, surgical release of pudendal nerve entrapment, and use of tricyclic or SSRI antidepressants.
As yet, there is “a lack of consensus on whether ReGS/PGAD is a hyperarousal disorder per se, or a syndrome secondary to pelvic/pudendal/hypogastic sensory neuropathy.”