ANRV307-CP03-10 ARI 2 March 2007 13:46 Sexual Dysfunctions in Women Cindy M. Meston and Andrea Bradford Department of Psychology, University of Texas at Austin, Austin, Texas 78712; email: [email protected] Annu. Rev. Clin. Psychol. 2007. 3:233–56 Key Words First published online as a Review in women’s sexuality, orgasm, desire, arousal, sexual pain Advance on October 12, 2006 Access provided by University of Texas - Austin on 06/08/16. For personal use only. The Annual Review of Clinical Psychology is Abstract Annu. Rev. Clin. Psychol. 2007.3:233-256. Downloaded from www.annualreviews.org online at http://clinpsy.annualreviews.org In this article, we summarize the definition, etiology, assessment, and This article’s doi: treatment of sexual dysfunctions in women. Although the Diagnostic 10.1146/annurev.clinpsy.3.022806.091507 and Statistical Manual of Mental Disorders, fourth edition (DSM-IV- Copyright c 2007 by Annual Reviews. TR) is our guiding framework for classifying and defining women’s All rights reserved sexual dysfunctions, we draw special attention to recent discussion 1548-5943/07/0427-0233$20.00 in the literature criticizing the DSM-IV-TR diagnostic criteria and their underlying assumptions. Our review of clinical research on sexual dysfunction summarizes psychosocial and biomedical man- agement approaches, with a critical examination of the empirical support for commonly prescribed therapies and limitations of re- cent clinical trials. 233 ANRV307-CP03-10 ARI 2 March 2007 13:46 women with sexual problems that are not Contents clinically diagnosable, on the opposite end of the spectrum is the percentage of women in INTRODUCTION................. 234 that figure who would meet clinical diagno- FEMALE SEXUAL DESIRE AND sis for sexual dysfunction. For those women, AROUSAL DISORDERS ........ 235 the NHSLS proved beneficial in spreading Definitions and Epidemiology..... 235 the word about women’s sexual concerns. The Etiologic Factors ................. 237 increased discourse and awareness of the ex- Assessment ....................... 239 tent of women’s sexual dysfunctions has un- Treatment ....................... 241 doubtedly helped many women with sexual FEMALE ORGASMIC concerns feel more comfortable talking about DISORDER ..................... 243 their sexual concerns and, perhaps, justified Definitions and Epidemiology..... 243 and/or motivated them to seek help. Clini- Etiologic Factors ................. 244 cians in the field of sexuality are now, more Assessment ....................... 245 than ever, faced with the challenge of ef- Treatment ....................... 245 fectively diagnosing the many women who SEXUAL PAIN DISORDERS....... 247 present with sexual dysfunctions and offering Definitions and Epidemiology..... 247 them the best available treatment options. Etiology ......................... 248 The Assessment ....................... 249 Diagnostic and Statistical Manual of fourth edition (DSM-IV- Treatment ....................... 249 Mental Disorders, TR; Am. Psychol. Assoc. 2000), classifies sex- CONCLUSION .................... 251 ual dysfunctions into disorders of desire (e.g., affecting thoughts about sex or motivation to engage in sexual activity), arousal (affecting psychological and physiological excitement in INTRODUCTION response to sexual stimulation), orgasm (de- In the past decade, a number of pivotal events layed, diminished, or absent “peak” intensity NHSLS: National in the field of women’s sexuality have in- of sexual pleasure or sensation), and pain (i.e., Health and Social creased our knowledge of psychological con- genital or pelvic pain occurring before, dur- Life Survey (see tributors to female sexual dysfunction. One ing, or after sexual activity). In the past decade, Laumann et al. 1994) of these events was the publication of The three International Consensus Conferences Social Organization of Sexuality by Laumann gathered experts in the field of women’s sexu- et al. (1994), which presented the results of ality for discussion of the definition and clas- the National Health and Social Life Survey sification of female sexual dysfunctions. The (NHSLS) of 1410 men and 1749 women aged most recent of these consisted of four meet- Access provided by University of Texas - Austin on 06/08/16. For personal use only. 18 to 59 years who were given comprehensive ings during 2002 and 2003, and was composed Annu. Rev. Clin. Psychol. 2007.3:233-256. Downloaded from www.annualreviews.org interviews about their sexuality. Based on the of an international, multidisciplinary group of survey, it was reported that a shocking 43% 13 experts from five countries. The result of of women in America experience sexual con- these consensus conferences was the glaring cerns. This report evoked criticisms for label- realization that the DSM-IV-TR and the In- ing what was defined as sexual “problems” in ternational Statistical Classification of Disease and the survey interviews as sexual “dysfunctions” Related Health Problems (ICD10) definitions in the results, with the concern being that the of female sexual dysfunction are unsatisfac- high-prevalence statistic would contribute to tory. As noted in the conference publication the medicalization of women’s sexuality and (Basson et al. 2003), this stems in part from lead to overprescribing drugs to treat psy- the problematic conceptualization of women’s chological issues (e.g., Bancroft 2002a, Tiefer sexual response cycle. That is, the DSM- 1996). Although this is a valid concern for IV-TR and ICD10 definitions of women’s 234 Meston · Bradford ANRV307-CP03-10 ARI 2 March 2007 13:46 sexual dysfunction are based on a model more genital engorgement with vasodilator drugs. characteristic of men than of women (Masters This finding, which contrasts the high cor- & Johnson 1966, Kaplan 1979), with the as- respondence between self-report and physi- FSAD: female sumed sequential stages of desire, arousal, ological sexual arousal with vasodilator drug sexual arousal and orgasm. The panel challenged several as- use in men, highlights the limitations of apply- disorder sumptions underlying the DSM-IV-TR and ing a male template to study women’s sexual HSDD: hypoactive ICD10 definitions of women’s sexual dysfunc- concerns. sexual desire disorder tions and provided a revised classification sys- In this article, we review current conceptu- tem (Basson et al. 2003), which is discussed alizations and treatments of the major sexual below in this article. Hopefully, the revised dysfunctions in women, with a focus on recent definitions will aid future research on women’s empirical and theoretical advances. In partic- sexual dysfunctions by better delineating the ular, we refer to the results of recent epidemi- clinical realities of women’s sexuality and by ological and clinical studies and to the rec- helping clinicians to minimize inappropriate ommendations of the consensus panel on the classification and pathologizing of women. classification of women’s sexual dysfunctions Undeniably, the introduction of sildenafil (Basson et al. 2003). (Viagra) in 1998 for male erectile disorder, and the subsequent investigation of vasodila- tor drugs for women’s sexual dysfunction, has FEMALE SEXUAL DESIRE AND had an enormous impact on psychological AROUSAL DISORDERS research on women’s sexuality. Two findings Definitions and Epidemiology that emerged from the many clinical trials of sildenafil and similar drugs in women war- Hypoactive sexual desire disorder (HSDD) rant mention here. First is the finding of is defined in the DSM-IV-TR as persistent a substantial placebo effect of up to about or recurrent deficient (or absent) sexual fan- 40% in women with sexual problems (e.g., tasies and desire for sexual activity that causes Basson et al. 2002), and second is the finding marked distress or interpersonal difficulty. that these drugs often increased physiologi- The clinical judgment is made taking into cal sexual arousal in women without showing consideration factors that affect sexual func- a comparable increase in psychological sex- tioning, such as age and the context of the per- ual arousal (Basson et al. 2002, Laan et al. son’s life. The disorder is subtyped into life- 2002). The former of these findings points long versus acquired and generalized versus to the powerful influence that factors such situational. as expectancies for improvement, enrolling in A primary criticism of the DSM-IV-TR a study about sexuality, talking to a profes- definition of HSDD made by the consensus Access provided by University of Texas - Austin on 06/08/16. For personal use only. sional about sexual concerns, and/or monitor- panel is the characterization of sexual fan- Annu. Rev. Clin. Psychol. 2007.3:233-256. Downloaded from www.annualreviews.org ing sexual responses can have on women’s sex- tasies as being a primary trigger for sexual ual response. Future research is now needed behavior. Although engaging in sexual fan- to parse the potential contribution of each tasy may be characteristic of women in new of these nonspecific factors to improved sex- relationships, research suggests that sponta- ual functioning and explore how these ben- neous sexual thoughts or fantasies occur far eficial elements might be applied in thera- less frequently among sexually healthy women peutic settings. The second finding, which in longer-term relationships (e.g., Cawood we note in the pharmacological treatment of & Bancroft 1996). Moreover, women report female sexual arousal disorder (FSAD) sec- a wide range of triggers or cues leading to tion in this article,