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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.
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exual 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.
Sexual difficulties are particularly prevalent among
women seeking routine gynecological care.
In population
surveys, some 30%–35% of women aged 18–70 have repor-
ted a lack of sexual desire during the previous 1–12 months.
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
Previous definitions of women’s sexual dys-
function were based on the linear model of human sex re-
sponse of Masters and Johnson,
as revised by Kaplan.
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
The 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 Medicine
subsequent publication.
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).
That women have many reasons
for initiating or agreeing to sex with their partners is an im-
portant finding.
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 study
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
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 • 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).
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).
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.
It decreases with age,
and at any
age commonly increases with a new relationship.
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.
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,
and published with the
permission of the American College of Obstetricians and Gynecologists.)
Sexual satisfaction
with or without
and biological
Sexual stimuli
with appropriate
Arousal and
sexual desire
Nonsexual rewards:
emotional intimacy, well-being,
lack of negative effects from
sexual avoidance
Willingness to
become receptive
innate desire
Multiple reasons
and incentives
for instigating or
agreeing to sex
In a 1992 survey of American adults,
the 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.
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.
Another important finding is that the robust correlation
seen in men between subjective arousal and genital conges-
tion (erection) is not seen in women.
Rather, sexual
arousal in women is more strongly modulated by thoughts
and emotions triggered by the state of sexual excitement.
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,
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
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,
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).
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).
The scales indicated that the
women with desire disorder had self-esteem that was weak
or even fragile, emotional instability, anxiety and neuroti-
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).
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
Depression is strongly associated with reduced sexual
function. Of 79 women with major depression surveyed be-
fore treatment with medication,
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.
When patients are specifically
asked about sexual side-effects, they are acknowledged by
as many as 70%.
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.
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-
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,
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.
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.
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).
Definitions and prevalences
Based on the recent work of the International Commit-
tee of the American Foundation of Urological Disease,
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.
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-
recommends that physicians recognize 3 factors that
contribute to sexual dysfunction: past psychosexual devel-
opment; current life context; and medical factors, including
1330 JAMC 10 MAI 2005; 172 (10)
Female sexual response
CMAJ MAY 10, 2005; 172 (10) 1331
able 1: Major categories of womens sexual dysfunction
nosis and definition Comments Management
Sexual desire/interest disorder
s of sexual interest or desire, sex-
ual thou
hts or fantasies, and responsive
desire are absent (or diminished). Motiv-
reasons or incentives for attemptin
o become sexually aroused are scarce
or absent. The lack of interest is beyond
he normative lessenin
that may occur
ith life cycle and relationship duration.
Lack of responsive desire is key to the dia
nosis. Minimal spontaneous sexual thinkin
or desire ahead of sexual activity
does not necessarily constitute disorder.
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
ddress the various phases in patients sex response cycle (Fi
. 1):
her sexual motivations; the couples emotional intimacy; their
sexual skills; sexual stimuli and context, including interactions in
he precedin
hours; psycholo
ical factors, includin
and biolo
ical factors such as fati
ue, depression or medications.
ddress abnormal loss of andro
en activit
* (e.
., from bilateral
oophorectomy or in postmenopausal women takin
oral estro
hich increases SHBG, which in turn reduces bioavailable
estosterone). Address any ne
ative outcome(s), such as pain.
bsent or markedly reduced sub
sexual arousal (feelin
s of excitement,
pleasure) from any type of stimulation,
and absent or impaired
enital sexual
arousal (vulval swellin
, lubrication).
Sexual excitement from any type of stimula-
ion (erotic material, stimulatin
the partner,
breast or
enital stimulation) is lackin
h no ob
ective measure is made
(these dia
noses are clinical), there is no
awareness of reflex
enital vasocon
s for sexual desire/interest disorder.
ective sexual arousal disorder
bsent or markedly reduced sub
sexual arousal (feelin
s of excitement,
pleasure) from any type of stimulation.
inal lubrication and other si
ns of
physical response still occur.
Despite lack of sub
ective sexual arousal,
external lubricants are not required fo
comfortable intercourse. The woman or he
partner may observe lubrication in response
o stimulation.
s for sexual desire/interest disorder.
Genital arousal disorder
bsent or impaired
enital sexual
arousal: minimal vulval swellin
inal lubrication from any type of
sexual stimulation, and reduced sexual
sensation from caress of the
ective sexual excitement still
occurs from non
enital sexual stimuli.
Continued sub
ective sexual arousal from
enital stimuli (erotica, stimulatin
partner, kissin
, receivin
breast stimulation)
is key to this dia
nosis. Early studies have
shown that
enital con
estion upon stimu-
lation is demonstrably reduced in only some
of these women. Others appear to have los
sexual sensitivity of the con
issues; the congestion nonetheless develops
o a normal de
Phosphodiesterase inhibitors may be of benefit if vasocon
is reduced (demonstrable by va
inal photoplethysmo
, when
available); otherwise, simply by trial.
en therapy may be indicated in women with known
en reduction (alon
with estrogen therapy).
Persistent sexual arousal disorder
Spontaneous, intrusive and unwanted
enital arousal (tin
, throbbin
hen sexual interest or desire is absent.
ny awareness of sub
ective arousal is
ypically but not invariably unpleasant.
he arousal is unrelieved by or
and the feelin
s persist for hours or days.
enital sensations of arousal can
constitute a seizure disorder; brain ima
may therefore be necessary.
ement is unclear.
necdotal reports include benefit from hi
h-dose SSRIs.
Self-stimulation affords very temporary relief only.
Older women particularly feel extremely abnormal and are hi
embarrassed; simple knowled
e that the physician is aware of this
condition is of help.
asmic disorder
Despite self-report of hi
h sexual
arousal, or
asm from any kind of stim-
ulation is lackin
, markedly diminished
in intensity or considerably delayed.
Differential dia
nosis can be confounded
by women with arousal disorders, who also
ypically do not experience or
ement includes addressin
issues of trust, safet
, attraction
o partner and the type, skill and duration of stimulation.
ement of self-stimulation may be appropriate.
Stimulation with a vibrator may allow or
asms such that oral,
er or penile stimulation then becomes effective.
Persistent or recurrent difficulties in
inal entry of a penis, fin
or any ob
ect, despite the womans
expressed wish to do so. There is often
(phobic) avoidance; anticipation, fear
or experience of pain; and variable in-
oluntary contraction of pelvic muscles.
Structural or other physical abnormal-
ities must be ruled out or addressed.
his dia
nosis is presumptive initiall
, as
confirmation must follow therapy sufficien
o allow a careful introital and va
inal exam.
Clinicians report that their patients male
partners are typically unassertive, with
e sexual desire. Despite
some frustration from lack of intercourse,
hey more than tolerate only nonpenetrative
sex. Partners sexual hesitancy may need to
be addressed durin
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
ina and introitus.
Initially she is encoura
ed to self-touch daily in a nonsexual
manner for a few minutes, as close to the introitus as possible,
on to insertion of her fin
er, a small tampon-like ob
and then a series of va
inal inserts of increasin
diameter. Shared
placement of the inserts with her partner is helpful before shared
placement of his penis. The sex therapy component includes
nonpenetrative sex.
Persistent or recurrent pain with
attempted or complete va
inal entry
or penilevaginal intercourse
here are many causes, includin
estibulitis, vulval atrophy from estro
deficiency, hypertonicity of the pelvic
muscles, interstitial cystitis, endometriosis,
lack of arousal.
reat the underlyin
condition (e.
., local or systemic estrogen for
ulval atrophy; co
nitive behavioural therapy with or without a tri-
cyclic antidepressant, with or without pelvic-muscle physiotherapy;
anticonvulsant for vestibulitis; referral for endometriosis).
e nonpenetrative sex in the interim.
Note: SHBG = sex hormonebinding 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.
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.
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 1
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-
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.
1332 JAMC 10 MAI 2005; 172 (10)
Box 1: Seven key questions for the couple
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 partners 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 partners view of the problem(s) and how this
partner thinks they are coping.
Review this partners sexual response to self-stimulation.
Ask about the interviewees past partnered sexual experiences
and their positive and negative aspects.
Determine a developmental history: relationships with parents
or caregivers, any losses or traumas, and how he or she coped.
Inquire if the partner ever experienced sexual, emotional or
physical abuse, whether as a child or as an adult.
*Questions marked with open bullets (
) 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,
available later this
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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;
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.”
: My sincere thanks to Dr. Peter Rees for his helpful review of
the manuscript and to Mrs. Maureen Piper for her excellent secretarial skills.
... The limited available studies report greater prevalence of SD in women with Type 1 diabetes compared with women with Type 2 diabetes and women without diabetes. [2][3][4] The majority of these studies have been epidemiological studies based on questionnaire surveys. Hence, limited evidence is available about the lived experiences of SD and its effect on the quality of life of women with Type 1 diabetes. ...
... Whilst there are no standard diagnostic criteria for SD, 3 it is generally defined in terms of deficits in sexual desire, arousal and the ability to orgasm. 4,5 It has also been suggested that SD involves psychological and sociocultural processes. 6 Hence, SD is a complex and multifaceted problem, and its aetiology in women with Type 1 diabetes incorporates both biological and psychosocial factors. ...
Full-text available
Background: Survey data suggest that women with Type 1 diabetes mellitus have a higher prevalence of sexual dysfunction (SD) compared with women with Type 2 diabetes or without diabetes. However, little is known about how women with Type 1 diabetes experience SD or its impact on their lives. This exploratory study sought to elicit women with Type 1 diabetes’s experiences of SD and identify their ideas on how SD could be better addressed in diabetes care. Method: A qualitative study using semi-structured interviews was conducted at a diabetes centre in South West of England hospital. A purposeful sample of six women with Type 1 diabetes (<50 years of age) and experience of SD were interviewed. The interviews lasted 20–30 min and were analysed using Interpretive Phenomenological Analysis. Findings: The study identified four superordinate themes: barriers to sex, impact of SD, personal support and ideas for improving support with SD. The majority of the themes were underpinned by diabetes specific factor such as hypoglycaemia, body image and diabetes management (technology and glucose regulation). This study found that women’s perspectives on their sexual identities and behaviours were mediated by emotional and interpersonal issues. This study also highlighted the lack of support provided by healthcare professionals (HCPs) in addressing SD. Conclusion: The findings indicate that SD is a complex issue that needs to be given more attention by HCPs, so that the women can approach sex positively in their lives. HCPs need to be enabled to initiate conversations around SD in their consultations.
... The third factor is "satisfaction with sex organs appearance and function". Normal sexual function is assessed based on the sexual response cycle, which is a combination of mind and body responses (21) . As body image affects all aspects of female sexual function (22) , the items of the third facto are related to the body and sexual self-image. ...
... In the third factor, not only female sexual function but also a spouse's sexual function is assessed from the women's viewpoint. In sexual dysfunction assessment, it is strongly recommended to evaluate sex partner-related factors regularly (18,21) . It is worthy to mention that as sex and sexual desire are considered undesirable for women in the most conservative cultures and communities, such as Iran, especially in the post-reproductive years, thus questioning straight about sexuality may be seemed unfair or accompanied by feelings of shame. ...
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Purpose: This study aimed to develop and psychometrically validate the Sexual Health Scale for Middle-Aged sexually active women (SHIMA). Methods: This study was a sequential exploratory study consisting of two phases. In phase one, we interviewed 19 middle-aged women and reviewed the existing instruments to generate an item pool. Then, a panel of experts (n = 16) examined the items. In the second phase, the psychometric properties of the scale were assessed. For content and face validity, a panel of experts (n = 8) and a group of middle-aged women (n = 10) reviewed the items. For construct validity, a cross-sectional study was carried out on a sample of 427 married women. Finally, SHIMA's reliability was assessed. Results: In the first phase, the sexual health concept was explored, and a provisional scale including 60 items was generated. Next, 21 items were removed based on content and face validity. Accordingly, the results obtained from the exploratory factor analysis (EFA) indicated acceptable loading for 34 items tapping into six factors that jointly explained 48.67% of the total variance observed. The internal consistency evaluation revealed that Cronbach's alpha and McDonald's omega were greater than 0.7, and the average inter-item correlation was greater than 0.4, except for one factor that showed borderline results. Test-retest reliability over a 2-weeks interval was 0.90, indicating its high stability. Conclusion: The SHIMA is a reliable and valid scale for measuring sexual health in middle-aged married women. It can be used as a sexual health screening scale by healthcare professionals and for research purposes.
... Moreover, as they reduce lubrication, they can be considered as psychological factors of Female Sexual Interest/Arousal Disorder (40). Sexual satisfaction is a substantial aspect of female sexual function (41), which is experienced with or without orgasm when the women can stay concentrated, and stimulation remains sufficiently long (42). Research documents the bidirectional correlation between relationships and sexual satisfaction, meaning that they are longitudinally and dynamically interconnected (43). ...
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Objective: Perfectaionism is a common personality trait that can affect various aspects of life, especially sexual relationships. The purpose of this systematic review was to summarize the existing evidence for the relationship between perfectionism and sexual function in studies conducted in Iran and the world. Method: A comprehensive search of databases such as Scopus, PubMed, Cochrane, Science Direct, ProQuest, PsychINFO, IranPsych, Irandoc, SID, and Google Scholar search engine was performed until December 2021 without a time limit. To find studies, we searched for the keywords perfectionism and sexual function in both Persian and English and combined these words with the AND operator. Studies that scored above 15 according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria were included. Data analysis was performed qualitatively. Results: From the total of 878 articles found in databases, six articles met the inclusion criteria and had moderate quality. Reviewing studies corroborated that, notwithstanding the positive association between general/sexual perfectionism and sexual desire, specific dimensions such as socially prescribed perfectionism, partner-prescribed, and socially prescribed sexual perfectionism, have the utmost unfavorable effect on female sexual function, which means that a higher level of perfectionism ultimately decreases the rate of sexual function in women. In addition, studies suggested that by increasing sexual anxiety and distress levels, perfectionism deteriorates sexual function. Conclusion: Perfectionism may cause a variety of problems regarding sexual function. However, to clarify the precise role of each dimension of perfectionism on different areas of sexual function, more research must be conducted in this area in various communities and on age groups other than females of reproductive ages.
... This points to the need for better methods for approaching sexual health-related discussions with HT patients, which should consider not only organic issues such as vaginal dryness but also psychic aspects such as depression, self-image, and counseling. [42][43][44][45][46][47][48] Our study had limitations such as small number of patients (41 in total); bigger amostrage in Tamoxifen group (46,35%); the majority of patients were postmenopausal (68%) which could enhance the impact on sexual life as we have seen in some studies cited above; and almost 20% of patients were at a stage IV or recurrent disease, which could lead to a bigger impact not only in sexual quality but also in general quality of life, leading to misunderstanding results. ...
Full-text available
Objectives: To evaluate how hormonal therapy can impact breast cancer patients sexual quality of life and compare two widely used therapeutic agents: anastrozole and tamoxifen. Studies so far have evaluated the side effects of such therapy on patients general quality of life, but literature remains scarce regarding the impact it has on sexual aspects. We believe there is a demand for a detailed view of these aspects since most patients undergo these treatments for at least five years. Material and Methods: Transverse observational study evaluated in 2019, 41 women with a history of breast cancer, all of them undergoing hormonal therapy. Group presented a mean age of 55.4 years (35 to 77 years); those in menopause with a mean time of menopause of 10.92 years (2 to 28 years). Thirty-eight women lived maritally and/or were sexually active. The mean duration of treatment was 36.84 months. We analyzed data in pre-and postmenopausal women, evaluating the results of questionnaires with general parameters (age, treatment time, general quality of life, adaptation to therapy) as well as specific instruments for evaluation of sexual dysfunction (FSDS-R) and quality of life with specific aspects for breast cancer (FACT-B). The results were placed in 2×2 contingency tables comparing the group receiving tamoxifen versus anastrozole. Results and Conclusion: Tamoxifen compared to anastrozole is a drug with apparent less impact on most common sexual dysfunctions (orgasm, dyspareunia, and feeling good quality of sex life), following those already published in international literature. We found no impact on physical, socio-familiar, and emotional well-being. Finally, we conclude that the results of this study significantly contribute to the choice of adequate therapeutic agent and highlight the need to bring this topic during routine consults and to the decision with the patient for the best suited treatment option.
... In various studies, the pattern of relationship satisfaction predicting infidelity is stronger for women than men (Allen et al., 2008;Blow & Hartnett, 2005;Glass & Wright, 1985;Mark et al., 2011;Prins et al., 1993;Wiggins & Lederer, 1984), and relationship variables, such as satisfaction, are particularly important to women's sexual functioning and overall satisfaction (Basson, 2005;Dennerstein et al., 2005;Prins et al., 1993). For example, among people who engage in extramarital infidelity, women report being less satisfied in their marriage than are men (Blow & Hartnett, 2005;Glass & Wright, 1985). ...
Infidelity is often defined as perceived as a violation of relationship exclusivity rules, and many view infidelities as immoral. Thus, one can imagine the importance of understanding why up to a fifth of research samples report cheating in their current relationships. There is considerable literature regarding what factors predict infidelity. Although individual characteristics associated with infidelity do exist, relationship-based variables tend to be the most consistent and robust factors. This chapter will discuss various theories and research findings that suggested different relationship-based factors and frameworks with which to consider and predict why some people engage in infidelity. This chapter reviews some major ideas and research through the lens of the investment model of commitment (i.e., satisfaction, investment, quality of alternatives, commitment), as well as other relationship-based variables (e.g., opportunities and boredom, relationship type and length) that have received empirical support. Finally, the chapter ends with a nod to future directions in this area, and a notion of what researchers should expect from the literature in the future.
Tıbbi söylemde, bir kadın cinsel işlev bozukluğu olarak tanımlanan vajinismus, günümüzde genellikle DSM, ICD gibi tıbbi sınıflandırma sistemlerinin kriterlerine göre biyomedikal bakış açısıyla ele alınmaktadır. Bu çalışmanın amacı, vajinismusun tıbbileştirilmesini, Türkiye’de vajinismus yaşayan kadınların deneyimleri üzerinden, sosyal hizmet bağlamında değerlendirmektir. Çalışma kapsamında nitel araştırma yaklaşımı kullanılmış ve vajinismus deneyimine sahip 22 kadınla derinlemesine görüşmeler gerçekleştirilmiştir. Yapılan analiz sonucunda, katılımcıların vajinismusu fiziksel ya da psikolojik bir hastalık olarak görmedikleri, toplumsal cinsiyet eşitsizliği ve kadın cinselliğinin tabu olarak görülmesinden etkilenen bir durum olarak algıladıkları anlaşılmıştır. Kadınlığa dair sosyal inşalar, partnerlerin çeşitli tutumları ve sosyo-ekonomik faktörler vajinismus sürecini etkilemektedir. Toplumsal cinsiyet eşitsizliğinin giderilmesi, cinselliğin konuşulabilir hale getirilmesi, cinsellik eğitimleri, ücretsiz ve kolay ulaşılabilir destek alma mekanizmalarının sağlanması vajinismus bağlamında önemli görülmektedir. Vajinismusun, yalnızca heteronormativite odağında cinsel birleşme işlevinin sağlatılmasına indirgenen tıbbi çözümlerinin, kadınların gerçek sorunlarına çözüm olmada yeterli olmadığı düşünülmektedir. Geniş mesleki zenginliğiyle sosyal hizmetin, vajinismusta deneyimleri bütüncül ele alma, kadınları anlama, kadınlara kendi kaderlerini tayin etmede yardımcı olma ve takip etmek istedikleri yolda pek çok açıdan destek verme gibi uygulamalarla önemli bir mekanizma olduğu düşünülmektedir. Kadın cinsel sorunlarının ele alınması sürecine sosyal hizmet uzmanlarının dahil olması önemli görülmektedir.
Purpose: The most a set of illnesses that impact both men, as well as women; include sexual aversion disorder (S.A.D) and hypoactive sexual desire disorder (H.S.D.D). Nevertheless being common, those same two illnesses are frequently ignored by medical professionals as well as clients owing to their private and more intimate character. In order to accurately handle our clients' sexual difficulties and execute effective therapy, we as clinicians must go over our own discomfort and in this paper, common sexual disorders will be addressed with the touch of their neuropsychological etiology. Objective: The major objective of this article is to describe numerous sexual desire issues and how they relate to the brain. Erectile dysfunction and a few other sexually transmitted diseases are at least known to people (STDs). In addition to having a limited understanding of sexual problems brought on by viruses and other microbes, society also has little to no awareness of those brought on by brain injury or the dysfunction of certain brain areas. Therefore, one of the primary goals of this essay is to clarify popular and widespread diseases of sexual desire and their relationship to illnesses of the brain or other pathologies. Design/Methodology/Approach: The scientific and secondary clinical data for this work were gathered from reliable sources like Google Scholar, Academia, Researchgate, and others. The results of national and international studies on the topic issue have been assembled methodically and scientifically. In order to make this document more scientifically sound, reliable, and accurate, each scientific journal research result underwent a thorough, methodical, and scientific assessment. To increase this paper's uniqueness and reliability, we gathered the thoughts of a variety of experienced experts. Findings/Result: According to emerging knowledge, the temporal areas play a critical role in the regulation of erotic functioning. The amygdala is assumed to play a major role in managing human sexual impulses. This approach emphasizes the need for more study into the neural mechanisms behind this fundamental and permanent aspect of human nature. It is hoped that such an examination would lead to more studies, particularly through key brain regions that have already been identified by researchers. Another viewpoint is that sexual arousal disorders are poorly understood and treated, which leads to significant comorbidity as well as mortality in romantic relationships. Originality and Value: An innovative attempt has been made to provide information on a number of common sexual desire problems and how they may be treated with psychotherapy and psychopharmacology. Information is gathered from researchers and subject-matter specialists to make the paper vibrant and precise. The report was written so that everyone who read it, regardless of academic background, could grasp this clinical problem. A fresh attempt has been undertaken to spread a clinical understanding of sexual desire problems and their relationship to the brain in a more straightforward manner. This paper was created in the hopes that readers will be able to comprehend problems of sexual desire by bearing in mind how they relate to the brain. Paper Type: Clinical analysis paper
Full-text available
A construct consisting of eight dispositional sexual motives was proposed to expand upon and integrate earlier theory and research. The eight motives are desire for (a) feeling valued by one's partner, (b) showing value for one's partner, (c) obtaining relief from stress, (d) providing nurturance to one's partner, (e) enhancing feelings of personal power, (f) experiencing the power of one's partner, (g) experiencing pleasure, and (h) procreating. Based on this formulation, a self‐report questionnaire was developed to measure stable interest in the eight incentives hypothesized to influence sexual motivation and behavior. Initial factor analyses supported the proposed model in that items clustered predominantly into the theoretically proposed dimensions. The questionnaire was revised, and two subsequent factor analyses supported the earlier factor structure. AMORE scales were moderately correlated with erotophobic versus erotophilic attitudes, attitudes about uncommitted sex, sensation‐seeking tendencies, and need for attention. The Value For Partner and Nurturance scales were correlated with a personality measure of interpersonal warmth, and the Power and Partner Power scales were correlated with aggression tendencies. All AMORE scales were correlated with a measure of general sexual desire. Many AMORE scales were also correlated with self‐reports of sexual behavior and contraception/protection use. The distinction among sexual motives provides a more complete understanding of sexual motivation and is likely to improve prediction of sexual behavior.
Objectives: To assess sexual behaviour, prevalence of ICD-10 diagnosed sexual dysfunction, associations between sexual and psychological problems, and help seeking for sexual problems in people attending general practice; to assess predictors of ICD-10 diagnosis of sexual dysfunction. Design: Cross sectional study. Setting: 13 general practices in London. Participants: 1065 women and 447 men attending general practices. Main outcome measure: Prevalence and predictors of ICD-10 diagnoses of sexual dysfunction. Results: 97 (22%, 95% confidence interval 18% to 25%) men and 422 (40%, 37% to 43%) women received at least one ICD-10 diagnosis, but only 3-4% had an entry relating to sexual problems in their general practice notes. The most common problems were erectile failure and lack or loss of sexual desire in men and lack or loss of sexual desire and failure of orgasmic response in women. Increasing age and being unemployed predicted sexual problems in women, and bisexual orientation, being non-white, and being unemployed were demographic predictors in men. No practice note factors predicted sexual problems in women, but high consulting rate predicted problems in men. The main clinical predictors were poor physical function and dissatisfaction with current sex life in both sexes and higher psychological morbidity in women. When all factors were considered, increasing age (odds ratio 1.01, 1.00 to 1.02), physical subscale score on the SF-12 (0.98, 0.97 to 0.99), sexual dissatisfaction (1.9, 1.5 to 2.4), and scoring over a 3/ 4 threshold score on the general health questionnaire (1.5, 1.1 to 1.9) independently predicted an ICD-10 sexual dysfunction diagnosis in women. Being bisexual (4.1, 1.3 to 12.8) was the only independent predictor of an ICD-10 diagnosis in men. Conclusions: Sexual difficulties are common in people attending general practitioners, and many people are prepared to talk about them with their doctors.
The sex therapy literature has concentrated on disorders of the excitement and orgasm phases of the sexual response. However, disorders of sexual desire have been virtually neglected, although low-libido disorders are highly prevalent, may be extremely distressful to patients and their partners, and influence the course and prognosis of therapy. This paper focuses on this important aspect of human sexuality. Some clinical features of hypoactive sexual desire are described, and some hypotheses about etiology and prognosis are presented.
Studied female sexuality in 3 generations. A standard interview schedule was used, consisting of 300 precoded questions about sexuality, social conditions, and health. At the time of interview the women in each generational group were 70, 40, and 22 yrs old. Of these women, 72%, 67%, and 95%, respectively, had experienced spontaneous sexual desire, and 88%, 96%, and 91% had experienced orgasm. Also, 38%, 47%, and 81%, respectively, had masturbated at least once, and fantasies during masturbation were used by 50%, 48%, and 68%. Seven percent of the women born in 1910 and 44% of women born in 1958 had sexual fantasies in general, and 14% and 39% had fantasies during intercourse. (0 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This is a sexological study of a random sample of 225 40-yr-old women representative of the Danish female population at the age of 40. These women were questioned by a female physician utilizing a structured interview; 94% of the women invited to participate in this study agreed to do so. The purpose of this research was to elucidate sexual behaviour, experience, knowledge and attitudes.Some of the findings were the following. Menstruation still seems to be a taboo subject; 36% of this population knew little about this topic. 96% of these women had experienced orgasm at least once in their lives and 67.6% had experienced spontaneous libido. Genuine homosexuality appears to be a rare phenomenon. A monogamous heterosexual life style is the norm, as reflected by low number of partners and low frequency of infidelity. Yet, 35% of these woman had sexual problems.There is a need for advice and treatment of sexual difficulties in this population, but these are at present, in Denmark, not generally available.
A group of 11 women entering sex therapy for treatment of low arousal, and a comparison group of 11 women experiencing no arousal deficit, viewed an erotic film, listened to an erotic audiotape, and engaged in sexual fantasy during two experimental sessions. Session I occurred pre-treatment for the low arousal group. Session II occurred post-treatment. The adequate arousal group was tested at comparable points in time. Sexual arousal was measured subjectively by self-rating and physiologically by a vaginal photoplethysmograph. Contrary to expectation, the two groups showed equivalent significant increases in physiological response during the erotic stimuli in both sessions. However, the adequate arousal group rated subjective arousal significantly higher than the low arousal group in Session I, while no difference was found between the groups in Session II. Significant correlations were present between physiological response and ratings of several affective reactions to the audiotape, though few significant correlations were found between physiological and subjective sexual arousal measures. These data indicate a discrepancy between genital responses and ratings of sexual arousal for which several interpretations are offered.