Psychosexual problems for women

Female Sexual Arousal Disorder

Related pages:

• Overview of sexual problems

• Low sex drive in men and women

• Tips for improving your sex drive

• What to do when your partner goes off sex

• Rapid orgasm - the effect on men

Female Sexual Arousal Disorder (FSAD for short) is a fairly new concept, one that perhaps reflects Western society's uncertainty about women's sexuality and orgasms. Generally speaking, up until the 1950s a woman's sexual pleasure and orgasm were not regarded as very important - plenty of women would never have an orgasm. Worse, the fact that a woman was not getting aroused during sex was rarely seen to be a problem. There was a widespread sense of a woman having sex as a marital duty. But things have changed: since the sexual revolution of the 1960s (and 70s and 80s) men and women alike now expect women to have orgasms. A woman may feel disappointed, tricked or somehow lacking if she does not have them. And so, of course, whether women become aroused or not during sex has now become an issue for both the medical profession and the sexual therapist.

What is FSAD?

Let's start by being clear what FSAD is.

The human sexual response cycle has four phases: the initial excitement, a plateau phase of arousal, an orgasm and a so-called "resolution" phase.

To experience any initial sexual excitement one needs to have at least some interest in sex. This depends on a person's sex drive or libido. If there are problems with a person's libido we talk about them having a low sex drive. We need our libido to remind us that sex is something we might be interested in. As you might expect, over the years there's been rather a lot of research in this area - not least thousands of years of experimentation with things that might act as an aphrodisiac (that's a substance which enhances libido and therefore increases sexual enjoyment). The third phase, orgasm, is easy to identify. Orgasm refers to the main release of physical, emotional and sexual tension at the peak of sexual activity. If women struggle with having an orgasm even though they are very aroused we speak about anorgasmia, or an inability to orgasm. For men, a similar inability to orgasm happens in a condition called delayed ejaculation.

Female sexual arousal disorder specifically refers to problems during the plateau and arousal phase of the sexual response cycle. If a woman does not get aroused during sexual contact, it means that she feels no increase in emotional or sexual tension as sexual activity proceeds. She won't develop the physical signs of sexual arousal such as lubrication of the vagina and the erectile tissues in her clitoris and around her vagina won't fill with blood. Women have just as much erectile tissue in their genitals as men do, per kilo body weight, and FSAD looks very similar to erectile dysfunction in men.  A woman may also not experience any feelings of sexual excitement. Women who are sexually aroused often report throbbing sensations in their genitals, a sense of fullness and swelling as well as lubrication. Women with arousal problems often say they don't experience any physiological signs of arousal or find it hard to maintain their arousal.

Prevalence and Causes or FSAD

FSAD has not really received a lot of attention from sex therapists and sexologists, because most professionals have focused their work on the female orgasm (or lack of it). However, FSAD is probably a fairly common state of affairs. In a study in 1994 19% of women aged between 18 and 59 years of age reported problems with lubrication and the figure rose to 44% for post menopausal women.

We know very little about the causes of FSAD, but it is certainly a problem which cannot be linked to one single thing. As we saw above, FSAD becomes more of an issue with increasing age just like erectile dysfunction does for men. Emotional factors which probably contribute to FSAD include feelings of shame about sex, difficult childhood experiences around sexuality and excitement, a lack of parental "permission" to be sexual (for example when parents disapprove of any expression of sexuality), and difficulties with sustaining and expressing strong feelings in general.

We need to draw a distinction between FSAD and problems with low sexual desire. If a woman generally lacks sexual desire, but can get aroused when she does engage in sexual activity, the problem is clearly around lack of libido, a low sex drive. On the other hand, if a woman struggles to get aroused in the first place, she may either have a problem in the arousal phase or she may also have an underlying lack of libido. In reality, it is often difficult to pinpoint exactly where the problem lies. This shows how complex the female sexual response - both in mind and body - actually is!

Medical issues which can contribute to FSAD include some medications, especially anti-depressants, anti-convulsants and anti-psychotics: these also cause problems with erections in men. FSAD could also be a symptom of a condition such as diabetes, underactive thyroid gland, anxiety, phobias or multiple sclerosis. It's also possible that FSAD could be an after-effect of a sexually transmitted disease, especially if it's caused a woman a lot of discomfort or anxiety.

Another parallel to men's sexuality is that recent research suggests that sexual arousal is inhibited by high cholesterol and other fats in the blood (hyperlipidemia) (Geddes 2009). As already mentioned above, women also have a lot of erectile tissue which swells up during sex. If there are problems with blood flow caused by hyperlipidemia this might inhibit arousal. In men high cholesterol can often result in problems with erections and even impotence so it is not surprising that the same condition may also affect women's sexual functioning. To summarize, hyperlipidemia or high cholesterol caused by poor diet and a high BMI seems to impact female sexual arousal negatively and may contribute to FSAD.

The connection between FSAD and age suggests that it may be something to do with hormonal changes - perhaps a lack of estrogen after the menopause, or even a lack of testosterone, which is just as important for a woman's libido as it is for a man's, although women have much lower levels.

And of course a woman's lack of arousal may have a lot to do with her relationship. Perhaps her lover doesn't give her the right kind of stimulation or she's not very keen on having sex with him (or her). Any ongoing problems such as repressed anger or lack of emotional connection and warmth in the relationship may impact a woman's ability to get aroused during sex, and high stress and anxiety in life doesn't help one's libido either.

Assessment and General Treatment of FSAD

Although FSAD may seem difficult to change, it's certainly worth trying to o something about it, either by yourself or with the help of a sex therapist. If you have access to medical care, please get a full gynecological check up with a specialist physician or gynecologist to screen out any STDs or medical problems. Then, if you go to a sex therapist, you'll talk about things like your current sexual functioning, your levels of arousal when you do have sex, how often you have sex, whether or not you masturbate and whether or not you ever reach orgasm or experience sexual fantasies. Additionally, a sex therapist will check on your mental health in general, that's things like your levels of anxiety and depression, and whether you've ever used any legal or illegal drugs. And naturally, you'll look at your past and present relationship issues, your family history and your sexual history.

There is no single way of treating FSAD. One reason for this is that the condition is complicated. For example, who has a problem with a woman's lack of arousal? The woman herself may be quite distressed or frustrated about her lack or arousal, or her partner may find it frustrating and challenging while she is completely OK with it. Therefore, each case needs to be looked at individually. And one of the best ways to do this is for a woman who has this problem to think carefully about what might be causing it in her case, and whether it matters to her or not. She may decide that she is quite OK with her sexual response (or lack of it): each person's sexuality, and, for that matter, how much they actually want to be sexual, is different. This means that all of this might only be a problem because it is a problem for a woman's partner

Pharmaceutical treatment options

Like we said above, a medical and gynecological check up will screen out any medical causes. Additionally, a doctor can investigate any hormonal imbalances which might be part of peri-menopausal or post-menopausal symptoms. Unfortunately, hormone levels in women are notoriously difficult to interpret because of the normal fluctuations of the menstrual cycle. Some women benefit from estrogen replacement therapy if their test shows a lack of estrogens, but this does not always increase a woman's arousal response. Indeed, for some women, estrogen replacement therapy will actually reduce their sexual arousal, possibility due to a reduction in free testosterone in their blood.

Women with FSAD could also receive low dose testosterone replacement therapy. Testosterone replacement needs to be considered very carefully as it can cause a whole range of unwanted side effects such as thinning of one's hair. An alternative to oral testosterone could be topical testosterone creams which are applied directly to the vulva.

There has also been some use of the hormone progesterone, which is prevalent in the last trimester of pregnancy, and drugs such as Sildenafil or Viagra, which is now the standard treatment for erectile difficulties in men. However, neither progesterone nor Viagra have proven to be reliable treatments for FSAD. More research is needed in this area - happily, it's going on right now, which is not surprising considering the amount of money drugs like Viagra can generate for the drug companies.

Finally, some anti-depressant drugs can sometimes help to increase sexual arousal. This might be due to a lessening of the anxiety or depression which caused the FSAD in the first place.

To sum up, there are no wonder drugs to cure FSAD, nor are there any on the horizon. Women's sexual response is much more complicated than men's, and an easy pharmaceutical cure may never be available for women who have problems with sexual arousal.

Psychological treatment options

Couples therapy is often the preferred treatment for FSAD. This may involve both partners and the therapist, or there may be additional individual sessions with the therapist and either partner. During couples therapy the focus will be on how the couple as a team functions sexually - perhaps even how they "maintain" the woman's sexual difficulty. Therapy may also include behavioral assignments such as sensate focus exercises, sexual skills training for both partners, and exercises to improve communication between them. Couples therapy would be ideal if you have a sense that FSAD is partly due to difficulties in your relationship.

Individual therapy may be the best option if you feel that your problems around sexual arousal are due to long standing personal issues or you simply want to explore your feelings without having your partner present. Individual psychotherapy could be with any psychotherapist who is qualified and undergoes their own supervision and who has an interest in working with sexual issues. You could explore your childhood in general, and more specifically how your experiences as a child may have affected your sexual expression as an adult. Therapy might also help increase your self-confidence, and improve your experience and expression of all emotions, not just sexual arousal; it can also help you to manage your anxiety. And, even better, individual therapy can also support you as you build up more intimacy with your partner and become more assertive in asking for what you want.

Psychosexual therapy would be specifically targeting your sexual symptoms. Many psychosexual therapists give out homework assignments such as sensate focus exercises, sexual fantasy training, guided masturbation exercises, and experimentation with a vibrator. A psychosexual therapist will be used to hearing the minute details of people's sex life on a regular basis so you don't need to feel awkward about sharing them!

Tips for your personal journey

The following pointers may be useful in developing your sexual response:

• Read our page on tips for low sex drive. Is there anything there that you may want to implement?

• Learn more about female sexual anatomy and have a look for yourself.

• Explore your sexual fantasies through erotic material with which you can be comfortable with, such as selected films or books.

• Always use plenty of lubricants when masturbating or during sexual activity. Feel free to experiment with different products to find one that really suits you.

• Deal with any emotional issues you have with your partner.

• Learn to communicate; during sex, show your partner how you want to be touched.

• Experiment with vibrators and masturbation by yourself without feeling any pressure to become aroused.

• Increase your awareness about those thoughts, feelings and behaviors which make you feel stressed, anxious, shamed or otherwise unsexual.

• Have a look at these excellent books:
  Heiman, J.R., LoPiccolo, J. (1988) Becoming orgasmic: A sexual and personal growth program for women (rev. and expanded ed.). New York: Simon and Schuster
  Sundahl, D. (2003) Female ejaculation and the G-spot. Hunter House Publishers

References:

Bartlik, B., Goldberg, J. (2000) Female Sexual Arousal Disorder. In Leiblum, S. and Rosen, R. (Eds.) (2000) Principles and Practice of Sex Therapy. Third Edition, The Guilford Press

Geddes, L. (2009) Not tonight honey, I haven't taken my statins. New Scientist 12 September 2009, 12

Written by Anna January 12 2008, last edited 13.9.09

All material copyright, ©2009 Sex And Relationships
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