What was originally called Female Hypoactive Sexual Desire Disorder by the DSM-IV is now called Female Sexual Interest/Arousal Disorder in the DSM-V (Segraves R. 2006). According to a study of Korean women, average age 28, with factors controlled for depression and sexual abuse, a majority of the women describe their sexual dysfunction as a lack of desire and an arousal problem, the other lesser problems are biological issues such as lubrication, orgasm, and pain (Sang, S., Hyewon, J., Soo, K., Jae, P., Hwanchelo, J., 2008). This is not an easily diagnosed or treated disorder because of the dual nature of psychological/biological presentation. I believe most women, or at least most of the clients I have observed, wish for biological treatment. Even after a referral from their gynecologist, most want to emphasize how their problems only presented after changing birth control or after having their first child. Surely, it’s a hormonal issue! The pattern, clear to me, often seems too blurry for them. They understand what was once enjoyable is now difficult and they are carrying the baggage of depleting self-worth, frustration, disappointment, and sadness over the change from what was to what is.
Many women of childbearing age are suffering in silence. They are not like the postmenopausal crowd that understands they are experiencing a radical shift in hormones and has a wider acceptance socially as well as visually through media outlets offering relief. This group is shifting in life roles as well as undergoing radical hormone changes due to childbearing or fertility practices. They are not educated, nor socially accepted for the changes that start to encroach rapidly as these women start to experience a shift in sexual desire as well as arousal. Most think, something is wrong and it’s my fault. I just need to try harder. As long as my partner is pleased I am happy. WRONG. Creating sexual desire is not something that can just be “tried harder to achieve”. In examining what external factors are influencing internal response women can take an honest look at the multi-systemic factors influencing their problems. Most importantly if these women are able to regain their desire and arousal, once menopause actually occurs they can have a greater understanding of themselves, their bodies, and what the psychological/biological balance actually is.
Female Sexual Arousal/Interest Disorder is defined by the DSM V as:
Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:
Absent/reduced interest in sexual activity. Absent/reduced sexual/erotic thoughts or fantasies.
No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual). Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts).
When diagnosing this disorder a desire discrepancy must be ascertained and identified in order to be ruled out as significant to the diagnosis of the disorder. A client can not have FSD if she simply wants less sex than her partner. She must display at least three of the indicators listed above for a minimum duration of at least six months (American Psychological Association, 2013). This disorder can be co-morbid but can not exclusively be attributed to a specific medical condition or a physiological side effect of another medication (Nappi, R., Martini, E., Terreno, E., Albani, F., Santamaria, F., Toani, S., Choivato, L., Pollati, F., 2010). The DSM-V states that the prevalence in the U.S. population is unknown, but according to the Prevalence of Female Sexual Problems Associated with Distress and Determinants of Treatment Seeking and the Women’s International Study of Health and Sexuality one in ten women in the U.S. and Europe exhibit symptoms of FSD (Nappi, R., et. al., 2010). Causes vary greatly since most are bio/psychological in nature. Biologically, according to the study by Nappi, R., et. al, “When an imbalance between the dopaminergic system (which increases sexual desire and excitement) and norepinephrine system (which affects arousal and orgasm) occurs, women may feel unable to begin the sexual response cycle.” Psychologically “bother and distress” factors play a direct roll in the levels of quality of life measurement. Quality of life refers to the physical and emotional satisfaction levels with partners( Goldstein, E., Noel, K., Clayton, K., DeRogatis, L., Giraldi, A., Parrish, S., Pfaus, A., Simon, J.,Kingsburg, S., Meston, C., Stahl, S., Wallen, K., Worsely, R., 2017) . Dissatisfaction with sex life, partners, or marriage and negative emotional states, including frustration, hopelessness, anger, poor self-esteem, and loss of femininity all are potential issues that a counselor could discuss with the client as contributing factors of FDS (Goldstein, E., et al. 2017). Current treatments focusing on the individual are Cognitive Behavioral Therapies. Since there are a plethora of factors contributing to multiple negative patterns of thinking, challenging what is specifically causing the greatest negative thoughts can be tailored to the individual to influence behavioral adjustments. CBT was found to be the most effective in women with low arousal, but not as helpful in women showing lower sexual interest overall (Goldstein, E. et al., 2017). Couple focused, Sensate Focused Therapy, reintroduces touching without intercourse to reduce anxiety over sexual activity with a focus on reconnection of the physical sensations related to intimacy (Goldstein, E., et al., 2017).
Young women need to know about their mental health and how it affects all aspects of self. Sexual arousal and desire are pivotal for successful intercourse. To deny the self and deny that intervention is necessary does a great disservice to women’s ever-changing and developing sexuality. As we question just how many more commercials we can stomach that make men's erectile issues as common as a headache, we need to normalize the fluctuation in women’s sexual arousal as well. If women start to acknowledge that feeling disconnected, hopeless, or dissatisfied with the quality of their intimate relationships plays a direct role in their ability to be aroused and interested sexually, then they might be more inclined to examine these issues in more detail. Biological excuses provide easy solutions, but hormone replacement and SSRI’s do not make a spouse more approachable. The answers are two-fold. This applies to Westernized society only. This emphasizes that women have a choice in their sexuality. None of this would be applicable in a society where a woman's sexuality is considered a duty and not something she is allowed to derive any pleasure from or choice in. Ethically, it is important to examine each woman’s comfort level with their own sexuality. FSD manifests for many different reasons for many different women. To understand the woman means uphold beneficence, helping her find solutions to her sexual issues that she is comfortable with. Non-maleficence means not pushing a client to practice intervention strategies that take them too far out of their comfort zone thus creating a more negative self-image of sexuality.
Any issue that pertains to sexuality is delicate. Especially for women. Society is changing but how many commercials do we see that emphasize estrogen-based creams that enhance female lubrication vs. a little blue pill that makes Grandpa as fertile as a 17-year-old boy? Not as many! But any change is a good change. Anything that increases female sexual empowerment decreases vulnerability and shame.