A closer look at female sexual dysfunction (FSD)

Female sexual dysfunction (FSD) wears a lot of cloaks and costumes, and can appear for a variety of reasons.

We have sex for lots of reasons, with making babies actually the least of those reasons. Humans have sex to connect, to have fun, to share affection and intimacy, and because we love a bit of romance in our lives. And from time to time, we have sex to make a baby.

While it is becoming clearer and clearer with every study released that women are very sexual creatures, socially women are taught to hide their sexuality, while men are taught to celebrate it. This is changing. Rapidly.

NOTE: This article is long and reasonably comprehensive so buckle up! Skip further down to the section you want, for example, physical causes for low sexual drive and arousal disorders, or keep reading to get a good understanding of your body, how it’s meant to work, and why sometimes it doesn’t.

How does this fit in with our sexual response?

It is still true that despite women being sexually aroused by a variety of stimuli and loving sex for sex’s sake, women tend to report their other motivations as being for emotional intimacy, to increase their sense of wellbeing, to be seen as desirable, and to please their partner.^​1​

Women tend to suffer from lack of sexual desire more frequently than men, particularly in long-term relationships.

• Responsive desire – once sexual stimulation happens in the mind and/or body, sexual desire can be accessed.
• Subjective arousal – excitement and pleasure depending on the circumstances
• Physical genital arousal – genitals engorge with blood, and this physical response can lead to orgasm

Read about the normal female sexual response and a study into how clinicians assess FSD.

Factors affecting a woman’s ability to be sexually aroused^​2​

• Mental health (a healthy mind makes for better sex)
• Emotional wellbeing (being miserable is not an aphrodisiac)
• Physical health (any state outside of good health will impact libido)
• Hormonal profile (low levels of sex hormones mean lower libido)
• Age (desire typically diminishes with age, but increases with a new partner at any age)
• Quality of relationship with a sexual partner (no matter who it is – long-term, short-term, one night, holiday fling)

The female sexual response includes several key factors:

• The motivation to have sex, which includes simply wanting to have sex (thoughts, words, sights, smells, touch)
• Subjective arousal – being excited by something in the circumstances or act
• Physical genital arousal (which is grotesquely named genital congestion in scientific textbooks)
• Orgasm (climax)
• Resolution (the body returns to normal)

The role of hormones in sexual function

The role of oestrogen and testosterone is incompletely understood, but it is believed that oestrogen has a positive effect on vaginal and clitoral tissues and that lowered levels of oestrogen actually have a detrimental effect on the blood supply to the vagina and clitoris.

Testosterone may act via androgen and oestrogen receptors.^​3​ Once a woman nears and enters postmenopause, oestrogen declines, but the production of androgens in the ovaries can vary, though generally declines.

These relationships are poorly understood, however, and no definitive answers can be given – women can enjoy a healthy sexual response at any age, but it can get a bit harder and take a bit longer after menopause.^​4​

Some research suggests that postmenopause the brain increases production of some sex hormones (neurosteroids), but it isn’t known precisely how this works or why. It may increase sexual desire.^​5​

What’s involved in our brain during sexual arousal?

The brain – our biggest sexual organ – orchestrates our sexual response. The brain areas that are active during arousal include cognition, emotion, motivation, and the physical genital response.^​6​

The neurotransmitters our body produces act on certain receptors in the brain, with the most helpful (prosexual) neurotransmitters for sex being dopamine, norepinephrine, and melanocortin.

Sexually inhibitory neurotransmitters include serotonin (usually), prolactin (produced in large quantities during lactation), and GABA (an excitatory neurotransmitter).

Physical genital arousal (genital congestion)

The physical genital response to sexual stimulus results in engorgement of the tissues with blood and lubrication from the Bartholin’s glands. This can happen quickly and is related to the brain’s assessment of whether something is biologically sexual, not that it is necessarily subjectively arousing, or even erotic. This is a triggered response.

All manner of things sexually trigger people. The smooth muscle that surrounds the vulva, clitoris and vagina dilates (opens up), allowing more blood to flow through. This blood engorges the tissue, and forces moisture through to the vagina – wetness.

Funnily enough, we may not even be aware of this increase in blood supply to the vaginal area, and may not register as being turned on at all. In fact, we can be showing biological signs of being sexually aroused while the mind is very much on other things, or even feels disgust, anger, or other negative feelings that are not often associated with sex (and in fact are not in these instances).

The connection doesn’t appear to be there between the physical signs of arousal and a woman’s psychological state).

The resting level of blood flow (basal genital blood flow) decreases as a woman ages, but her physical genital sexual response does not necessarily diminish.

The female orgasm

An orgasm is the peak of a woman’s excitement and manifests with pelvic muscle contractions (every 0.8 seconds apparently), and the release of blood from the genitals.^​7​

Oxytocin, prolactin and antidiuretic hormone (ADH) are released at orgasm and can contribute to positive feelings after sex, though these positive feelings can occur after sex without having an orgasm.

Women can have multiple orgasms and can be restimulated immediately after orgasm (if she wants). Read more about the female orgasm. ^​8​

Fun science fact: Orgasm is possible even when the spinal cord has been severed, with the cervix being stimulated with a vibrator (or other stimulation).

Female sexual dysfunction

When the female sexual response stops working properly, it generally means a woman is experiencing a decrease or increase in her sexual responsiveness.^​9​

The categories of female sexual dysfunction include:

• Persistent genital arousal disorder – the genitals are overly aroused despite the rest of the body and brain not being on board
• Sexual interest disorder (also sexual desire disorder) – absence or decrease in sexual interest, thoughts, fantasies, or sexual response
• Sexual arousal disorder – lack of subjective arousal or physical genital arousal, or both
• Orgasmic disorder – absent, diminished or delayed orgasm despite high subjective arousal
• Vaginismus – a reflexive tightening of the vaginal muscles at attempted penetration, despite a desire expressed by the woman for penetration
• Dyspareunia – pain on penetration, usually diagnosed as vulvar vestibulitis, vulvodynia, or provoked vestibulodynia

Diagnosis of female sexual dysfunction

Usually, these issues only come to light after a woman visits a doctor to ask about them because they cause an issue.^​10​ One of the important things to note here is that it is almost expected that women won’t want to have sex, suffer chronically low libido, or otherwise, are not sexual. This is not true for most people.

Lack of sexual desire means many things to us and changes all the time, and may not cause distress at all, however it must be acknowledged as part of a normal and healthy human since a lack of libido can really point to many other underlying conditions.

These underlying conditions can include our mental and emotional state, poor-quality relationships, and health conditions that impact hormones, energy, and overall vitality.^​11​

In saying that, a perfectly healthy human can have very little interest in sex, orgasm or being aroused – just make sure it isn’t because of something else if this is the case for you or your partner.

A sexual disorder is generally not diagnosed unless it is causing the person a problem. On top of this, one condition can lead to another, so for example, chronic vaginal or vulvar pain might lead to an end to sexual desire since sex is no longer enjoyable. This removes a huge layer of sexual motivation.

Clinical labels for sexual dysfunction

To properly put your disorder into a neat little category, we have established the following:

• Lifelong
• Acquired
• Situation-specific
• Generalised
• Mild
• Moderate
• Severe

There is no evidence to suggest that sexual preference has any bearing on the incidence of female sexual dysfunction.

Why it’s not (necessarily) all in your head and how that matters

Doctors and researchers used to like to separate our psychological and physical entities. This is a fallacy, since any change in our mental and emotional wellbeing has direct – and fast – impacts on our hormones, nervous system, and has a secondary impact on every single structure in our body.

Physical affects psychologically, and vice versa – they are not exactly the same thing, but they are so closely related that they are heavily influenced by one another.^​12​

The cause may not be clear, but finding a solution is the important bit. Understanding the problem may never happen, and that’s ok. That’s when we start to branch into the psychological causes of female sexual dysfunction.

Psychological factors in female sexual dysfunction

1. Those suffering from mood disorders are famously not up for it. Low desire and arousal are commonplace in those suffering depression, with antidepressants working on this issue successfully in many women, but sometimes causing orgasm disorders.
2. Anxious women are more likely to suffer desire, arousal and orgasm disorders, and also to have vulvodynia.
3. Fear is a huge problem, stemming from feelings of vulnerability, rejection or a loss of control, with low self-esteem part of the package.
4. Previous experiences can really hinder your development (psychosexual development), with these including negative sexual experiences that have led to shame and guilt; emotional, physical or sexual abuse during childhood or adolescence, resulting in hiding feelings; and trauma and loss.
5. Worry about unwanted pregnancy/infertility, sexually transmitted diseases, being unable to climax, and the idea of having sexual dysfunction can cause sexual dysfunction.
6. Negative self-image can really put a damper on a woman’s sexual response. There are many issues facing women today in terms of their body image, and this extends way past thinking she’s fat or unattractive – it may be a physical or mental impairment, the removal of one or both breasts or reproductive organs (uterus, ovaries), or ageing and menopause.
7. Relationships matter. Trust, respect and good communication between partners usually results in healthy outcomes for relationships and sex, but relationships are a minefield – you may lose sexual attraction for your partner for one of many reasons, you may be having a rough patch with a partner, or actually want to end the relationship.
8. The atmosphere also matters. You need to feel comfortable where you are having sex – this means feeling safe, private, and having what you need at minimum for your surrounds (lingerie, sheets, lighting, or whatever you like). You can’t underestimate the impact of your erotic atmosphere on the sexual response.
9. Cultural or religious beliefs can really impede your sexual response, with religion being a particularly bad bedmate. Guilt, remorse, regret, shame and self-loathing are all staples of several religions when it comes to sex. Some religious beliefs also prohibit some sexual activities.
10. Being too busy cannot be understated as a contributing factor to low sexual arousal. Being distracted from the task at hand for whatever reason won’t get you wet.

Physical factors in the female sexual response

Disease

• Infections (herpes, HIV)
• Local vaginal irritation (vaginitis, lichen sclerosus)
• Atrophic vaginitis (dry vagina, thinning of the skin)
• Cancers

Hormone changes or disruptions

• Ovary removal in premenopausal women (oophorectomy)
• Debility, illness, fatigue
• Hyperprolactinemia
• Thyroid, adrenal or pituitary disorders and diseases
• Nerve damage (from disease, surgery, injury)

Physical hindrances

• Congenital malformations and anatomical abnormalities
• Post-surgery narrowing of the vaginal entrance (introitus)
• Fibrosis or stenosis from radiation therapy
• Recurrent vaginal/posterior fourchette fissures
• Vulvar dermatoses (dystrophy)
• Wounds or damage
• Genital mutilation

Drugs and medication

• Alcohol and drug dependence
• Gonadotropin-releasing hormone (GnRH) agonists (used to prevent ovulation)
• Anticonvulsants
• Beta-blockers
• Some antidepressants, specifically SSRIs

Testosterone levels in women with and without desire appear to be about the same, offering some evidence that testosterone doesn’t play as big of a role in female sexual desire as previously thought.

Diagnosing female sexual dysfunction

It is recommended that physicians interview both partners in the relationship separately and together to get their views. A pelvic examination will be performed to identify any physical causes. 

A full history will be taken to determine any causative factors. Check out the assessment sheet to see what the practitioner will want to know.

Treating female sexual dysfunction^​13​

Treatment will depend entirely on the cause.

1. Understanding the female sexual response may be the simplest answer (many people don’t understand the mechanics of sex or how the female body is supposed to respond to stimulus).
2. Correcting any contributing factors, including psychological or physical. Not everything can be resolved simply, however, so it’s important to manage expectations in this area. Keep in mind that many diseases can be treated or managed quite well, and every attempt should be made to make sexual intimacy possible and pleasurable.
3. Changing drug choices can also work wonders. SSRIs are frequently guilty of causing female sexual dysfunction. Your doctor may additionally add bupropion to your SSRI prescription (or exchange), with other substitution possibilities being moclobemide, mirtazapine or duloxetine. The other listed drugs can also have replacements made where applicable – talk to your doctor.
4. Counselling and therapy is often suggested rebe required for deeper, darker issues. Don’t be scared to face your demons – good sex may be on the other side!
5. Cognitive behavioural therapy can also be really helpful, as can EFT/NLP, no matter what the trigger – if a disorder or disease has caused emotional repercussions, deal with both.
6. Mindfulness – yes, getting in touch with your spiritual self helps absolutely everything in your life, because it has far-reaching implications for your body and mind. It doesn’t matter what you want to call this, but it’s safe to say you will benefit from regular practice – five minutes a day is fine – of mindfulness, meditation, getting back to base. It may not cure your problem, but it will make it easier to deal with, get your creative brain set up to find solutions where before you could see none, and help you feel at ease in life. A good start is Head Space – a free app that helps teach you how to meditate in 10 days, five minutes per day.

Dealing with incurable vaginal disease

If you have a disease that severely interferes with your vagina in an ongoing, incurable (or long treatment period) fashion, you need to sort out your emotional self.

Chronic disease is extraordinarily difficult to come to terms with, especially when it means the end of your life as you know it, and the end of vaginal sexual intimacy with a partner. Sometimes thing are not able to be fixed or treated, and must simply be managed.

Grieving for your vagina and your former private life must be done, so don’t just try to be brave and grin and bear it. Get upset and mourn. Then, when that’s done, get on with your life. Get help with this, and don’t try to just manage it on your own.

Find fellow sufferers and survivors on forums, get a counsellor, talk about it. Cry about it. Get angry. You do not have a disease because you are being punished, because you did something wrong, or because you needed character-building.

You just got a disease, and usually, you will never know why. What’s more, it usually doesn’t matter either. We are organisms that are susceptible to getting sick, just like every other organism on this planet. We are not infallible.

References

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