Women's sexual dysfunction: Revised and expanded definitions

Abstract

Acceptance of an evidence-based conceptualization of women's sexual response combining interpersonal, contextual, personal psychological and biological factors has led to recently published recommendations for revision of definitions of women's sexual disorders found in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV-TR). DSM-IV definitions have focused on absence of sexual fantasies and sexual desire prior to sexual activity and arousal, even though the frequency of this type of desire is known to vary greatly among women without sexual complaints. DSM-IV definitions also focus on genital swelling and lubrication, entities known to correlate poorly with subjective sexual arousal and pleasure. The revised definitions consider the many reasons women agree to or instigate sexual activity, and reflect the importance of subjective sexual arousal. The underlying conceptualization of a circular sex-response cycle of overlapping phases in a variable order may facilitate not only the assessment but also the management of dysfunction, the principles of which are briefly recounted.

Full text

Review
Synthèse
Sexual difficulties are common among women, but
whether a problem causing distress is a “dysfunction”
as opposed to a normal or logical response to difficult
circumstances (e.g., a problem with the relationship, sexual
context or cultural factors) remains controversial. Surveys
of patients in physicians’ offices suggest that each year,
family practitioners will see several women or couples who
present with sexual problems, and even more if the physi-
cian inquires about patients’ sexual health.1
Sexual difficulties are particularly prevalent among
women seeking routine gynecological care.2In population
surveys, some 30%–35% of women aged 18–70 have repor-
ted a lack of sexual desire during the previous 1–12 months.3,4
Research into women’s sexual function over the past 2
decades has brought into question previous views, defini-
tions and diagnostic labels such as those still found in
DSM–IV-TR.5Previous definitions of women’s sexual dys-
function were based on the linear model of human sex re-
sponse of Masters and Johnson,6as revised by Kaplan.7The
model assumes a linear progression from an initial aware-
ness of sexual desire to one of arousal with a focus on geni-
tal swelling and lubrication, to orgasmic release and resolu-
tion. The resulting diagnostic categories such as hypoactive
sexual desire disorder, female sexual arousal disorder and
female orgasmic disorder reflected this linear and rather
genitally focused model of sexual function. Thus, relatively
discrete, non-overlapping phases of sexual response were
portrayed and discrete dysfunctions defined.
The evidence to date shows that many facets of women’s
sexual function are at variance with this model. This review
is based on the recent report of an international committee
convened by the American Foundation of Urological Dis-
ease to revise and expand definitions of women’s sexual
dysfunction.8The committee relied on empirical and clini-
cal research as well as clinical experience. Literature sear-
ches provided the background to extensive collaboration
from September 2002 to February 2003. Informal pilot
testing of the committee’s conclusions in clinical practice,
plus presentation to a large international audience, led to
further revisions over the next 6 months, acceptance by the
Second International Consensus of Sexual Medicine9and
subsequent publication.9,10
After a review of normal characteristics of women’s sex-
ual motivation and interest, sexual arousability and re-
sponse, this article presents recommended expanded and
revised definitions of women’s sexual dysfunction, along
with suggested approaches to diagnosis and treatment.
Normal sexual function in women
Clinical and empirical studies, mainly of North Ameri-
can and European adult women without sexual complaints,
have clarified sexual response cycles that are different from
the linear progression of discrete phases already men-
tioned. Women describe overlapping phases of sexual re-
sponse in a variable sequence that blends the responses of
mind and body (Fig. 1).11–14 That women have many reasons
for initiating or agreeing to sex with their partners is an im-
portant finding.15 Women’s sexual motivation is far more
complex than simply the presence or absence of sexual de-
sire (defined as thinking or fantasizing about sex and yearn-
ing for sex between actual sexual encounters).
Recent baseline data from a longitudinal study15 of 3300
multi-ethnic, premenopausal North American women aged
42–52 who had not recently received medication affecting
reproductive hormones and who had engaged in sexual ac-
tivity with a partner during the past 6 months clarified their
reasons both to engage sexually (to express love, for plea-
Women’s sexual dysfunction:
revised and expanded definitions
Rosemary Basson
Abstract
ACCEPTANCE OF AN EVIDENCE-BASED CONCEPTUALIZATION OF WOMEN’S
SEXUAL RESPONSE combining interpersonal, contextual, personal
psychological and biological factors has led to recently published
recommendations for revision of definitions of women’s sexual
disorders found in the
American Psychiatric Association’s Diag-
nostic and Statistical Manual
(DSM–IV-TR). DSM-IV definitions
have focused on absence of sexual fantasies and sexual desire
prior to sexual activity and arousal, even though the frequency of
this type of desire is known to vary greatly among women with-
out sexual complaints. DSM-IV definitions also focus on genital
swelling and lubrication, entities known to correlate poorly with
subjective sexual arousal and pleasure. The revised definitions
consider the many reasons women agree to or instigate sexual ac-
tivity, and reflect the importance of subjective sexual arousal. The
underlying conceptualization of a circular sex-response cycle of
overlapping phases in a variable order may facilitate not only the
assessment but also the management of dysfunction, the princi-
ples of which are briefly recounted.
CMAJ
2005;172(10):1327-33
DOI:10.1503/cmaj.1020174
CMAJ • MAY 10, 2005; 172 (10) 1327
© 2005 CMA Media Inc. or its licensors

sure, because the partner wanted to, to relieve tension) and
to refrain (lack of interest, tiredness or physical problems
[their own or their partner’s], or no current partner).15
These findings and those from other studies are in keeping
with the sexual response cycle illustrated in Fig. 1.
At the beginning of a given sexual experience, a woman
may well sense no sexual desire per se. Her motivations to
be sexual are complex and include increasing emotional
closeness with her partner (emotional intimacy) and often
increasing her own well-being and self-image (sense of
feeling attractive, feminine, appreciated, loved and/or de-
sired, or to reduce her feelings of anxiety or guilt about sex-
ual infrequency).15–21
When a woman is willing to become aroused and enjoy
a sexual experience, she focuses on the sexual stimulation
she and her partner supply. If the stimulation is as she
wishes, sufficient time is available and she can stay focused,
her sexual excitement and pleasure intensify. Clearly, the
type of stimulation, the time needed and the context (both
erotic and interpersonal) are all highly individual. Emo-
tionally and physically positive outcomes will increase sub-
sequent motivation.
Some women report desire that appears to be spontaneous
(also shown in Fig. 1), leading to arousal or to more enthusi-
asm to find or be receptive to sexual stimuli. This type of de-
sire has a broad spectrum across women and may be related
to the menstrual cycle.22 It decreases with age,23 and at any
age commonly increases with a new relationship.12,21
Previous definitions of women’s sexual dysfunctions un-
fortunately assumed that the cycle of a woman’s sexual re-
sponse always began with sexual desire, sexual thoughts and
fantasies, and that their absence was evidence of a disorder.
Basson
1328 JAMC • 10 MAI 2005; 172 (10)
Fig. 1: Sex response cycle, showing responsive desire experienced during the
sexual experience as well as variable initial (spontaneous) desire. At the “initial”
stage (left) there is sexual neutrality, but with positive motivation. A woman’s rea-
sons for instigating or agreeing to sex include a desire to express love, to receive
and share physical pleasure, to feel emotionally closer, to please the partner and
to increase her own well-being. This leads to a willingness to find and con-
sciously focus on sexual stimuli. These stimuli are processed in the mind, influ-
enced by biological and psychological factors. The resulting state is one of sub-
jective sexual arousal. Continued stimulation allows sexual excitement and
pleasure to become more intense, triggering desire for sex itself: sexual desire,
absent initially, is now present. Sexual satisfaction, with or without orgasm, re-
sults when the stimulation continues sufficiently long and the woman can stay fo-
cused, enjoys the sensation of sexual arousal and is free from any negative out-
come such as pain. (Modified from Basson 2001,14 and published with the
permission of the American College of Obstetricians and Gynecologists.)
Sexual satisfaction
with or without
orgasm(s)
psychological
and biological
processing
Subjective
arousal
Sexual stimuli
with appropriate
context
Arousal and
responsive
sexual desire
Nonsexual rewards:
emotional intimacy, well-being,
lack of negative effects from
sexual avoidance
Willingness to
become receptive
motivation
Spontaneous
“innate” desire
Multiple reasons
and incentives
for instigating or
agreeing to sex

In a 1992 survey of American adults,4the most common
sexual dysfunction among women 18–59 years of age was
low desire, reported by just under a third of those surveyed,
with little variation by age. Such results have remained
consistent across studies.3,24,25 It is unclear how many of
these women are simply reporting low or absent sponta-
neous desire but do experience triggered desire during sex.
Moreover, women report that sexual fantasies can be delib-
erate — a means to stay focused on the sexual stimulus,
rather than an indication of sexual desire.26
Another important finding is that the robust correlation
seen in men between subjective arousal and genital conges-
tion (erection) is not seen in women.27–30 Rather, sexual
arousal in women is more strongly modulated by thoughts
and emotions triggered by the state of sexual excitement.31
In women, photoplethysmography can be used to measure
vaginal vasocongestion and hence to gauge physiological
arousal. Female study participants subjected to erotic (usu-
ally visual) stimuli can meanwhile report their subjective re-
sponses (sexual arousal and positive and negative emotions)
by using a Likert scale or a lever that can be moved from
left (low arousal) to right (high arousal). In psychophysio-
logical response studies,32,33 women with arousal disorders
(as per DSM–IV-TR definitions), despite a lack of subjec-
tive arousal and perception of “lack of lubrication/swelling
response” while watching erotic videos, showed increases in
vasocongestion comparable to those in control participants
without such disorders. Only the women in the control
group reported subjective arousal while watching the
videos.32 Previous definitions of arousal disorder focused
only on genital lubrication and/or swelling response —
ignoring 25 years of research showing the poor correlation
of genital engorgement with the woman’s subjective arou-
sal and excitement in response to sexual stimulation.
Causes of women’s sexual dysfunctions
The model in Fig. 1 clarifies the importance of women
being able to become subjectively aroused. Many psycho-
logical and biological factors may negatively influence this
sexual arousability.
Interpersonal and contextual factors
In a recent national probability sample of American
women 20–65 years of age,24 their emotional relationship
with the partner during sexual activity and general emo-
tional well-being were the 2 strongest predictors of absence
of distress about sex. Women who defined themselves (us-
ing standard psychological instruments) to be in good men-
tal health were much less likely than women with lower
self-rated mental health to report distress about their sexual
relationship (odds ratio 0.41, 95% confidence interval 0.29–
0.59). The healthier women were therefore 59% less likely
to report distress about their sexual relationship. Feeling
emotionally close to their partner during sexual activity de-
creased the odds of “slight distress” by 33% relative to “no
distress,” and “marked distress” by 43%; in other words,
the stronger the emotional intimacy with the partner, the
less distress. Other contextual factors reported to reduce
arousability included concerns about safety (risks of un-
wanted pregnancy and STDs, for example, or emotional or
physical safety), appropriateness or privacy, or simply that
the situation is insufficiently erotic, too hurried, or too late
in the day.
Personal psychological factors
Frequently a woman’s arousal is precluded by the non-
sexual distractions of daily life, but also sometimes by sex-
ual distractions (e.g., worry about not becoming sufficiently
aroused, reaching orgasm, a male partner’s delayed or pre-
mature ejaculation or a female partner’s lack of orgasm).
Empirical studies have shown a high correlation of desire
complaints with measures of low self-image, mood instabil-
ity and tendency toward worry and anxiety (without meet-
ing the clinical definition of a mood disorder).34 Differences
between a group of 46 consecutive women with a diagnosis
of desire disorder without clinical depression and a control
group of 100 healthy women were significant for 6 out of 8
scales in the Narcissism Inventory (a standardized self-ad-
ministered instrument).34 The scales indicated that the
women with desire disorder had self-esteem that was weak
or even fragile, emotional instability, anxiety and neuroti-
cism.34 Sexual arousal and orgasm, especially in a partner’s
presence, necessitates a certain degree of vulnerability,
which is impossible for some women who cannot tolerate
feelings of loss of control generally, and loss of control
specifically of their body’s reactions.
Further inhibiting psychological factors include memo-
ries of past negative sexual experiences, including those that
have been coercive or abusive, and expectations of negative
outcomes to the sexual experience (e.g., from dyspareunia
or partner sexual dysfunction).13
Biological factors
The biological and pathophysiological underpinnings of
normal and abnormal female sexual response are only re-
cently receiving attention. Most of the basic science and
animal experiments in this area are beyond the scope of this
review. Some promising attempts are noted, however, in
part because they relate attempts to ameliorate sexual dys-
function by means of off-label use of available drugs and to
avoid the negative sexual side-effects of medications such as
antidepressants.
Depression is strongly associated with reduced sexual
function. Of 79 women with major depression surveyed be-
fore treatment with medication,35 50% reported decreased
sex drive; 50%, more difficulty obtaining vaginal lubrica-
tion; and 50%, far less sexual arousal when engaging in sex.
Only 50% had been sexually active during the previous
Female sexual response
CMAJ • MAY 10, 2005; 172 (10) 1329

month. In addition, sexual dysfunction can constitute an
adverse event of antidepressant use, especially among pa-
tients who had low levels of sexual enjoyment before the
onset of their depression.36 When patients are specifically
asked about sexual side-effects, they are acknowledged by
as many as 70%.37
Sexual dysfunction is also a common side-effect of treat-
ment with antidepressants. Among women being treated, it
has been found to be more common in those who are
older, married, without postsecondary education, without
full-time work, or taking concomitant medication (any
type); those who have a comorbid illness that might affect
sexual functioning, or a history of antidepressant-associated
sexual dysfunction; those who deem sexual function un-
important; and those whose previous sexual engagements
had afforded little pleasure.36
Currently under scrutiny is the role of dopamine and
other neurotransmitters in influencing sex hormone recep-
tors and how the neurotransmitters are, in turn, influenced
by sex hormones. Estrogenized female animals change their
sexual behaviour when administered progesterone; stu-
dies38,39 have shown that the same changes can result from
dopamine or the presence of a male animal. Among 75
non-depressed women with a DSM-IV diagnosis of hypo-
active sexual desire disorder who received bupropion (a
dopaminergic drug; average dose 389 mg/d) or placebo,40
improvements in pleasure, arousal and orgasm were statis-
tically significant for those administered the active drug.
Interestingly, these changes were unaccompanied by in-
creased desire.
Testosterone itself is being investigated as to its role in
sexual function and dysfunction. About half of daily testos-
terone production in women is from the ovary. Some
women with sudden loss of all ovarian production of andro-
gens lose their sexual arousability. Supplementation to high
physiological (as opposed to pharmacologically evident)
levels of testosterone recently has led to increased arousa-
bility and more intense orgasmic experiences, but not to in-
creased sexual thinking, fantasizing or spontaneous desire.41
Of 75 surgically menopausal women aged 31–56 participat-
ing in a randomized clinical trial of testosterone versus
placebo, those given testosterone (300 µg transdermally) in
addition to estrogen reported increased frequency of sexual
activity, sexual pleasure and intensity of orgasm.41,42 So,
reminiscent of the animal model, supplementation with a
dopaminergic drug or testosterone can increase some
women’s sexual arousability; but so too, as in the animal
model, can environmental change (a new partner).12
Definitions and prevalences
Based on the recent work of the International Commit-
tee of the American Foundation of Urological Disease,85
major categories of dysfunction can be defined (Table 1).
Prevalences of the recently defined categories are largely
unknown, mainly because subjective arousal received little
attention. It was included under the broader term of
“hypoactive sexual desire disorder,” an older term used to
describe women reporting an absence of spontaneous or
initial desire, the lack of which does not constitute, by it-
self, female sexual dysfunction in the new definitions. Thus,
estimated prevalences of hypoactive sexual disorder among
women of 30%–40% may be wrong and misleading. When
(or if) it becomes widely known that lack of spontaneous or
initial desire does not by itself constitute disorder, the
numbers of women diagnosed with a sexual disorder are ex-
pected to decline.
Previous figures for “female arousal disorder” were low,
but as explained, they represented the numbers of women
noting “lack of lubrication or swelling response” without
reference to subjective arousal. The prevalence of genital
arousal disorder (complaints of “genital deadness” tending
to occur in midlife) is also unknown, given the previous
failure to ask whether nongenital stimuli remain effective
despite the loss of genital responsivity. Even the figures for
women’s orgasmic disorder are uncertain, as it is often
stated to be comorbid with arousal disorder: DSM–IV-TR
stated that an anorgasmic woman’s capacity for sexual
arousal had to be high or normal to fit the definition of
orgasmic disorder.
Figures for the prevalence of dyspareunia and vaginis-
mus vary markedly from study to study. A population-
based assessment of 5000 women aged 18–65 recently
identified about 16% reporting histories of unexplained
chronic, burning, knife-like vulvar pain lasting longer than
3 months, including 8% experiencing the problem at the
time of the survey.43 Although there are other causes of vul-
val burning (vulvodynia), vulvar vestibulitis is thought to
account for the great majority. This poorly understood
condition involves neurogenic inflammation in specific
sites around the hymenal margin, producing areas of in-
tense allodynia (pain from touch stimulus) typically around
the lower edge of the introitus, but may involve the whole
introital rim. Vulvodynia may occur spontaneously, or
symptoms may be limited to introital dyspareunia and post-
coital vulvodynia. The overall cumulative incidence of
those who reported inability to have sexual intercourse be-
cause of the pain was 10%.
Publications about persistent sexual arousal and Internet
surveys of its prevalence are only very recent. Most clini-
cians have seen very few (mostly older) women with this
highly distressing syndrome.
Diagnosis and management
Given that a woman’s sexual function is a consequence
of her current psychosocial and interpersonal context,
which is determined to some degree by her sexual and
medical history and medications, the international commit-
tee8recommends that physicians recognize 3 factors that
contribute to sexual dysfunction: past psychosexual devel-
opment; current life context; and medical factors, including
Basson
1330 JAMC • 10 MAI 2005; 172 (10)

Female sexual response
CMAJ • MAY 10, 2005; 172 (10) 1331
T
able 1: Major categories of women’s sexual dysfunction
Dia
g
nosis and definition Comments Management
Sexual desire/interest disorder
Feelin
g
s of sexual interest or desire, sex-
ual thou
g
hts or fantasies, and responsive
desire are absent (or diminished). Motiv-
atin
g
reasons or incentives for attemptin
g
t
o become sexually aroused are scarce
or absent. The lack of interest is beyond
t
he normative lessenin
g
that may occur
w
ith life cycle and relationship duration.
Lack of responsive desire is key to the dia
g
-
nosis. Minimal spontaneous sexual thinkin
g
,
f
antasizin
g
or desire ahead of sexual activity
does not necessarily constitute disorder.
W
hen motivation to be sexual for any reason
is minimal, or sexual stimulation does not
cause arousal and concurrent desire to
continue, then disorder is present.
Combined sexual arousal disorder
A
ddress the various phases in patient’s sex response cycle (Fi
g
. 1):
her sexual motivations; the couple’s emotional intimacy; their
sexual skills; sexual stimuli and context, including interactions in
t
he precedin
g
hours; psycholo
g
ical factors, includin
g
distractions;
and biolo
g
ical factors such as fati
g
ue, depression or medications.
A
ddress abnormal loss of andro
g
en activit
y
* (e.
g
., from bilateral
oophorectomy or in postmenopausal women takin
g
oral estro
g
en,
w
hich increases SHBG, which in turn reduces bioavailable
t
estosterone). Address any ne
g
ative outcome(s), such as pain.
A
bsent or markedly reduced sub
j
ective
sexual arousal (feelin
g
s of excitement,
pleasure) from any type of stimulation,
and absent or impaired
g
enital sexual
arousal (vulval swellin
g
, lubrication).
Sexual excitement from any type of stimula-
t
ion (erotic material, stimulatin
g
the partner,
breast or
g
enital stimulation) is lackin
g
.
A
lthou
g
h no ob
j
ective measure is made
(these dia
g
noses are clinical), there is no
awareness of reflex
g
enital vasocon
g
estion.
A
s for sexual desire/interest disorder.
Sub
j
ective sexual arousal disorder
A
bsent or markedly reduced sub
j
ective
sexual arousal (feelin
g
s of excitement,
pleasure) from any type of stimulation.
V
a
g
inal lubrication and other si
g
ns of
physical response still occur.
Despite lack of sub
j
ective sexual arousal,
external lubricants are not required fo
r
comfortable intercourse. The woman or he
r
partner may observe lubrication in response
t
o stimulation.
A
s for sexual desire/interest disorder.
Genital arousal disorder
A
bsent or impaired
g
enital sexual
arousal: minimal vulval swellin
g
or
v
a
g
inal lubrication from any type of
sexual stimulation, and reduced sexual
sensation from caress of the
g
enitalia.
Sub
j
ective sexual excitement still
occurs from non
g
enital sexual stimuli.
Continued sub
j
ective sexual arousal from
non
g
enital stimuli (erotica, stimulatin
g
the
partner, kissin
g
, receivin
g
breast stimulation)
is key to this dia
g
nosis. Early studies have
shown that
g
enital con
g
estion upon stimu-
lation is demonstrably reduced in only some
of these women. Others appear to have los
t
sexual sensitivity of the con
g
ested
g
enital
t
issues; the congestion nonetheless develops
t
o a normal de
g
ree.
Phosphodiesterase inhibitors may be of benefit if vasocon
g
estion
is reduced (demonstrable by va
g
inal photoplethysmo
g
raph
y
, when
available); otherwise, simply by trial.
A
ndro
g
en therapy may be indicated in women with known
andro
g
en reduction (alon
g
with estrogen therapy).
Persistent sexual arousal disorder
Spontaneous, intrusive and unwanted
g
enital arousal (tin
g
lin
g
, throbbin
g
)
w
hen sexual interest or desire is absent.
A
ny awareness of sub
j
ective arousal is
t
ypically but not invariably unpleasant.
T
he arousal is unrelieved by or
g
asm(s),
and the feelin
g
s persist for hours or days.
Recurrent
g
enital sensations of arousal can
constitute a seizure disorder; brain ima
g
in
g
may therefore be necessary.
Mana
g
ement is unclear.
A
necdotal reports include benefit from hi
g
h-dose SSRIs.
Self-stimulation affords very temporary relief only.
Older women particularly feel extremely abnormal and are hi
g
hly
embarrassed; simple knowled
g
e that the physician is aware of this
condition is of help.
Or
g
asmic disorder
Despite self-report of hi
g
h sexual
arousal, or
g
asm from any kind of stim-
ulation is lackin
g
, markedly diminished
in intensity or considerably delayed.
Differential dia
g
nosis can be confounded
by women with arousal disorders, who also
t
ypically do not experience or
g
asm.
Mana
g
ement includes addressin
g
issues of trust, safet
y
, attraction
t
o partner and the type, skill and duration of stimulation.
Encoura
g
ement of self-stimulation may be appropriate.
Stimulation with a vibrator may allow or
g
asms such that oral,
f
in
g
er or penile stimulation then becomes effective.
V
a
g
inismus
Persistent or recurrent difficulties in
allowin
g
va
g
inal entry of a penis, fin
g
e
r
or any ob
j
ect, despite the woman’s
expressed wish to do so. There is often
(phobic) avoidance; anticipation, fear
or experience of pain; and variable in-
v
oluntary contraction of pelvic muscles.
Structural or other physical abnormal-
ities must be ruled out or addressed.
T
his dia
g
nosis is presumptive initiall
y
, as
confirmation must follow therapy sufficien
t
t
o allow a careful introital and va
g
inal exam.
Clinicians report that their patients’ male
partners are typically unassertive, with
lower-than-avera
g
e sexual desire. Despite
some frustration from lack of intercourse,
t
hey more than tolerate only nonpenetrative
sex. Partner’s sexual hesitancy may need to
be addressed durin
g
therap
y
.
A
ddress fears of intimacy identified in the developmental history;
possibly refer for psychotherapy. The behavioural component
allows the woman to feel in control of her va
g
ina and introitus.
Initially she is encoura
g
ed to self-touch daily in a nonsexual
manner for a few minutes, as close to the introitus as possible,
movin
g
on to insertion of her fin
g
er, a small tampon-like ob
j
ec
t
and then a series of va
g
inal inserts of increasin
g
diameter. Shared
placement of the inserts with her partner is helpful before shared
placement of his penis. The sex therapy component includes
encoura
g
in
g
nonpenetrative sex.
Dyspareunia
Persistent or recurrent pain with
attempted or complete va
g
inal entry
or penile–vaginal intercourse
T
here are many causes, includin
g
vulvar
v
estibulitis, vulval atrophy from estro
g
en
deficiency, hypertonicity of the pelvic
muscles, interstitial cystitis, endometriosis,
lack of arousal.
T
reat the underlyin
g
condition (e.
g
., local or systemic estrogen for
v
ulval atrophy; co
g
nitive behavioural therapy with or without a tri-
cyclic antidepressant, with or without pelvic-muscle physiotherapy;
anticonvulsant for vestibulitis; referral for endometriosis).
Encoura
g
e nonpenetrative sex in the interim.
Note: SHBG = sex hormone–binding globulin; SSRIs = selective serotonin reuptake inhibitors.
*Testosterone supplementation is investigational, and recommended only to older women receiving estrogen supplementation, given that (short-term only) safety and efficacy data
are from postmenopausal estrogenized women exclusively.41

comorbid illness, drugs and previous surgery. Sexual dys-
function can be a symptom of an underlying disorder, or
have causes outside the patient herself. It is important to
avoid “pathologizing” women by diagnosing a sexual disor-
der based on a normal response, such as tiredness or the
side effect of a drug. Simultaneously, it is essential not to
imply that dysfunction is absent or discredited simply be-
cause the cause is external to the patient. A simple analogy
is the woman with neck strain and tension headaches from
persistent work at a computer with poor desk height.
Clearly, the solution is to adjust her working environment;
nevertheless, she is given a medical diagnosis, even though
there is almost certainly nothing intrinsically wrong with
her cervical spine.
This has consequences for case management. The
woman who has poor emotional intimacy with her partner,
has possibly many distractions from her children, is tired
from her job and is attempting to be sexual perhaps without
the required context and needed specific sexual stimulation
is reacting normally by not becoming aroused, being de-
sirous or experiencing any orgasm. There may well be
nothing wrong with her sex response system per se. Never-
theless, if she reports and suffers from dysfunction, her
problems should be addressed, the underlying conditions
identified and changes recommended.
Based on a careful history in which the physician helps
the patient construct her sex response cycle (Fig. 1), prob-
lem areas will be identified.11 Thus the physician provides
insight and direction to the many changes that need to be
made by the woman and her partner. Having clarified the
problems, the physician may be able to assist with some. For
example, a partner’s premature ejaculation can be addressed,
the sexual context improved, depression treated, local estro-
gen prescribed, the couple referred for relationship therapy,
and either or both partners can be referred for psychother-
apy to address learned patterns of thinking and behaviour
stemming from childhood traumas and experiences.
Approach to history and diagnosis
During the general systems enquiry, sexual function can
be assessed after the enquiries about menstruation, dys-
menorrhea or postmenopausal symptoms. When the an-
swer to the question “Do you have any sexual concerns?” is
positive, a separate visit may be necessary to fully assess and
outline management. It is usually necessary to interview the
couple, as well as each partner separately: Box 144 and Box 2
outline key questions to ask in either case.
Distress from any given dysfunction is highly variable.
Indications of distress (at minimum, notations indicating
severe, moderate or mild distress) are needed, in addition
to qualitative descriptors such as lifelong/acquired and situ-
ational/generalized.8
Conclusion
Newly published revised, expanded definitions of
women’s sexual dysfunctions attempt to acknowledge the
highly contextual nature of women’s sexuality. To aid clini-
cal management of these dysfunctions, these definitions
now emphasize assessment of the context of women’s prob-
lematic sexual experiences. Definitions of dysfunction con-
tinue to reflect phases of sexual response, but they now
clarify the tendency of the phases to overlap (especially de-
sire, arousal and expectation, which usually contribute to
dysfunctions). The new focus is away from spontaneous or
initial desire and toward triggered desire accompanying
arousal. Appropriate attention is now paid to the poor cor-
relation between subjective sexual arousal or excitement and
objective measures of increases in genital vasocongestion.
Basson
1332 JAMC • 10 MAI 2005; 172 (10)
Box 1: Seven key questions for the couple44
1. Ask the couple to explain their sexual problem(s) in their
own words. Clarify details with direct questions, giving
options rather than leading questions.
2. Establish the duration of their problems; whether they are
generalized or situational; and which one(s) have priority.
3. Determine the context of the sexual problems. How is their
emotional intimacy? How useful are the sexual stimuli?
4. How erotic is the context? Are attempts restricted to bedtime,
when 1 or both partners need to sleep? What frequency of
sex is expected or attempted? Are there concerns about birth
control, safety from STDs or privacy? Are the sexual skills of
the partners adequate? Is their mutual communication about
their sexual needs problematic?
5. Determine the rest of the sexual response for each partner.
(For example, she presents with dyspareunia but currently
rarely becomes aroused or attains any sexual desire during
the experience, and is progressively losing her motivation
to be receptive to sex.) If these problems have developed
during the current relationship, check each partner’s earlier
response(s) when together.
6. Enquire how each partner has reacted to the problem(s).
7. Note any previous treatment(s), their compliance and benefit.
Clarify why the couple is seeking help now, and assess their
motivation to make changes.
Box 2: Interview each partner alone*
•Clarify this partner’s view of the problem(s) and how this
partner thinks they are coping.
•Review this partner’s sexual response to self-stimulation.
oAsk about the interviewee’s past partnered sexual experiences
and their positive and negative aspects.
oDetermine a developmental history: relationships with parents
or caregivers, any losses or traumas, and how he or she coped.
oInquire if the partner ever experienced sexual, emotional or
physical abuse, whether as a child or as an adult.
*Questions marked with open bullets ( o) may be omitted in some cases, e.g.,
for a recently developed problem after decades of healthy sexual function.

These new expanded and revised definitions form part
of the Second International Consultation on Sexual Medicine:
Men and Women’s Sexual Dysfunctions,42,45 available later this
year on the Web. The ultimate validity and reliability of
these revisions must, of course, be tested formally in both
clinical and research settings.
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Female sexual response
CMAJ • MAY 10, 2005; 172 (10) 1333
Correspondence to: Dr. Rosemary Basson, B.C. Centre for Sexual
Medicine, Vancouver General Hospital, 855 W 12th Ave.,
Vancouver BC V5Z 1M9; fax 604 875-8249;
sexmed@interchange.ubc.ca
This article has been peer reviewed.
From the Departments of Psychiatry and of Obstetrics and Gynaecology, Univer-
sity of British Columbia and the B.C. Centre for Sexual Medicine, Vancouver
General Hospital, Vancouver, BC
Competing interests:
Rosemary Basson received an honorarium from the Min-
nesota University Human Sexuality Group for a presentation on Oct. 9, 2004, on
“Revised definitions of women’s sensual dysfunction.”
Acknowledgements
:My sincere thanks to Dr. Peter Rees for his helpful review of
the manuscript and to Mrs. Maureen Piper for her excellent secretarial skills.