"The question is, how much of that is because the mental health profession says they have a problem?" asks Slowinski. "Do women have a problem because their partner says they have a problem...or is it because they themselves say they have a problem? And is it causing them personal distress?"
Although psychologists have been studying sex and treating sexual problems for decades, a hot debate is brewing over how to define sexual dysfunction--and whether the pharmaceutical industry's interest in developing drugs to treat sexual problems will help women or medicalize their difficulties. While some believe that developing better definitions of women's sexual problems will lead to better treatment, others worry that such classifications won't reflect the diversity of women's sexual experiences.
"Many physicians are approaching this as a largely biological phenomenon," says psychologist Dennis Sugrue, PhD, a past-president of the American Association of Sex Educators, Counselors and Therapists. "They're doing a disservice to the fact that a woman's sexual experience is an incredibly complex phenomenon that is shaped by cultural scripting, family-of-origin experience, relationship dynamics as well as biological factors."
However, other psychologists say that the development of drugs for female sexual dysfunction (FSD) has great potential. "There's a tendency to throw the baby out with the bath water because the pharmaceutical industry is involved," explains Raymond C. Rosen, PhD, of the University of Medicine and Dentistry of New Jersey (UMDNJ).
What is FSD?
In the quest to better define FSD, sex experts met in 1998 at the International Consensus Development Conference of Female Sexual Dysfunction to develop a new classification system for women's sexual problems. Following the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and World Health Organization International Classifications of Diseases (ICD-10), they divided FSD into four disorders that cause personal distress, briefly defined as:
Desire disorder, a persistent absence of desire for sexual activity.
Arousal disorder, a persistent inability to attain or maintain sufficient sexual excitement.
Orgasm disorder, a persistent difficulty, delay or absence of orgasm after sufficient stimulation.
Pain disorder, persistent genital pain associated with sexual intercourse or stimulation.
The report from the conference was first published in the Journal of Urology (Vol. 163, No. 3) and reprinted in the Journal of Sex & Marital Therapy (Vol. 27, No. 2) with psychologists' and others' commentaries. While many agreed that the new system is an improvement over the DSM-IV and ICD-10, some say the conference could have been more inclusive and question the fact that several pharmaceutical companies underwrote its development. Others express concern about the classification system's reliance on what they consider an outdated model of sexual response. Sugrue, for one, says the system's definition of how sex happens--a triphasic model of desire followed by arousal followed by orgasm--fits men well, but is not reflective of many women's experiences.
"Orgasm is not the pinnacle for many women," he explains. "But the triphasic model suggests this linear model, and if the orgasm doesn't occur, then somehow the sexual experience got derailed....I don't think that does us service in terms of our understanding of women and their sexuality."
Rather, he says, any definition of sexual function or dysfunction should acknowledge that women's "sex scripts" are variable. For example, they may be aroused by their partner before feeling desire or value the intimacy of the experience more than having an orgasm.
Indeed, many worry that by solidifying what is normal and what is dysfunctional, many women who are comfortable with their sexuality will be told they have a problem when they do not. For example, the media have widely reported on a 1999 Journal of the American Medical Association (JAMA) (Vol. 281, No. 6) study that found that 43 percent of the 1,749 women interviewed by researchers reported experiencing such events as a lack of interest in sex, inability to achieve orgasm and trouble lubricating in the past year, compared with 31 percent of men.
"The unfortunate thing is that the number has grabbed the attention of the press and has really reinforced an unfortunate stereotype in our culture that women, much more so than men, are somehow sexually flawed," says Sugrue.
Moreover, some disagree with the study's definition of women's sexual problems. "If half of the women in the country have a problem, it's not a problem by definition," says Leonore Tiefer, PhD, of the New York University School of Medicine. "It just doesn't make sense from a public health point of view."
The 1998 classification system requires that a problem cause personal distress to be defined as a disorder, but Tiefer and others note that the JAMA study only asked about women's experiences, not whether women were distressed. They point to a forthcoming study in the Archives of Sexual Behavior by John Bancroft, MD, that finds that only 24 percent of women said their problems distressed them.
However, others say many disorders should be considered problems, even if people don't see them that way. "There are some people who are not worried by their obesity," says Rosen, a co-author of the JAMA study. "Does it mean they don't have obesity? No, it just means they don't want to deal with it."
Indeed, Sugrue takes issue with the 1998 consensus system's requirement that a symptom must be distressful. In his practice, he says he has seen women who, as a defense mechanism, say they aren't distressed about their sexual problems.
The future of FSD
Psychologist Sandra Leiblum, PhD, and Rosemary Basson, both involved in the 1998 consensus conference, are now co-chairing a group that is revising the system to address the concerns of Sugrue and others.
They plan to include six factors that should be considered when describing women's sexual problems, ranging from partner considerations to medications. "We are carefully avoiding pathologizing women's sexual problems," says Leiblum, who directs the Center for Sexual and Mental Health at UMDNJ. Other ideas on the table include emphasizing that women are different from each other within and across cultures, giving more attention to accurate diagnosis of sexual pain and stating that reduced sexual interest is normal with age, length of relationship and other factors.
However, Tiefer and others are pushing for a more drastic rethinking of women's sexual problems. With the Campaign for a New View of Women's Sexual Problems, she and others have created an alternative classification system outlined in "A New View of Women's Sexual Problems" (Haworth Press, 2001). Women's sexual problems are seldom medically based, they propose. Rather, they more often are attributable to:
Sociocultural, political or economic factors, such as inadequate sex education or fatigue from family and work obligations.
Partner and relationship problems, including discrepancies in desire for sexual activity and loss of interest due to conflicts over commonplace issues.
Psychological factors, such as past abuse, depression or fear of pregnancy.
Tiefer says she worries drug companies' development of FSD drugs--and the subsequent marketing of them--will leave some women thinking a pill or cream can fix sexual problems that are actually rooted in, for example, a fear of intimacy or a stressful relationship.
"On the other hand," counters Rosen, "the pharmaceutical industry brings a lot more funding," which has greatly increased the pace of research into both women's and men's sexual problems.
To date, the Food and Drug Administration has approved one mechanical device but no drug for FSD, although unregulated supplements, which sex experts regard with skepticism, have made their way to the public. If a drug should be approved, psychologists are split on whether they'd recommend it.
"If women who generally need help can be helped, it's the job of the therapist to offer them what's available," says Slowinski. However, Sugrue says that, in his experience, even when there is a physical problem behind FSD, medical interventions often have a limited impact unless psychological factors are addressed.
Goldstein, I. (Ed.). (2002). [Special Issue.] Journal of Sex & Martial Therapy, 28(Suppl. 1).
Goldstein, I., & Rosen, R.C. (Eds.). (2002). Female Sexuality and Sexual Dysfunction. [Special Issue.] Archives of Sexual Behavior, 31(5).
Kaschak, E. (Ed.) (2001). A New View of Women's Sexual Problems. [Special Issue.] Women & Therapy, 24(1-2).
Moynihan, R. (2003). The making of a disease: Female sexual dysfunction. BMJ, 326, 45-47.
Segraves, R.T. (Ed.). (2001). [Special Issue.] Journal of Sex & Martial Therapy, 27(2).
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