Female Sexual Functioning and Dysfunction
Stanley Ducharme, Ph.D.
The Incidence of Female Sexual Dysfunction
Female sexual dysfunction is a multicausal medical issue that is still very much misunderstood among both the able and disabled population. It has both biological as well as psychological characteristics. In addition, relational issues are considered much more highly correlated to sexual dysfunction in women than they are in men. For women, sexual difficulties are age related, progressive and highly prevalent among the general population.
Current epidemiological studies now suggest that sexual dysfunction now affects 30 to 50% of American women. The National Health and Social Life Survey of 1749 women estimates this number to be at 43%. Among women with spinal cord injury, clinical as well as empirical data suggest that virtually all women have some degree of sexual dysfunction following the onset of an in injury. The same neurogenic etiologies that cause erectile dysfunction in men can also cause sexual dysfunction in women. These include spinal cord injury, diabetes, diseases of the central or peripheral nervous system and complete upper motor neuron injuries that affect sacral spinal segments.
Interestingly enough, ongoing studies in various aspects of women's sexual health have also demonstrated that life style factors that affect men's sexual abilities also play a significant role on women's sexual functioning as well. These include the aging process, cigarette smoking, cardiovascular health, alcohol consumption, high cholesterol and body mass index.
In addition, Goldstein (1998) has postulated that oral contraceptive forms of birth control can complicate women's sexual health by reducing sexual drive, making orgasm difficult and lowering essential female hormones such as testosterone levels. Unfortunately, the negative effects of oral birth control can be long lasting and do not necessarily subside after the birth control pill has been discontinued.
Although the main factor behind sexual dysfunction in women with spinal cord injury is a neurological phenomenon, the presence of these life style factors always either intensify or diminish the degree of sexual dysfunction. Unfortunately, these systemic issues, as well as the psychological contributions are always minimized in women with SCI because of the obvious neurogenic underpinnings.
The Classification of Female Sexual Disorders
There have been several hypotheses as to why studies in female sexual functioning have lagged so far behind parallel studies in male sexual health. These have included the relative lack of female researchers in this area, the more passive nature of the female sexual response and the lower incidence of women with SCI (17%) as compared to men with SCI ( 83%). These may all be relevant, however the primary barrier to the development of research in this field has been the absence of a well-defined classification system of female sexual difficulties. Recently, The American Foundation of Urologic Disease (AFUD) addressed this dilemma at a national consensus conference on the topic. They updated the definitions and classifications based on current research and clinical practice. The current classifications include: hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder, sexual pain disorder and orgasmic disorder. Although women with spinal cord injury can certainly be prone to low sexual interest, pain during intercourse or an aversion to sex secondary to early trauma or abuse, the most frequently noted difficulties are sexual arousal disorder or poor lubrication and orgasmic disorders.
The Female Sexual Response Cycle
Since the 1960's there have been several attempts to define the various stages of the female response cycle. Even the controversies regarding the stages of sexual excitement, which would seem to be relatively straight forward, demonstrate the difficulties in accurately understanding the female body during sexual activity.
Early sexual pioneers Masters and Johnson began the classification process by describing four distinct stages: excitement, plateau, orgasm and the resolution phase. They postulated that various anatomical genital structures became engorged with blood as sexual stimulation progressed. Helen Singer Kaplan in 1979 challenged this early model by postulating that sexual desire was the critical and missing aspect of the cycle. She believed that sexual desire was the factor that incited and initiated the overall sexual response cycle.
In October 1998, AFUD again revised the female sexual response cycle by introducing the concept of sexual satisfaction. They conceptualized the cycle as a "feedback loop" in which libido, arousal, orgasm and satisfaction either had a negative or positive impact on the subsequent phase. The response cycle could be "short circuited" at any time during sexual activity should any phase be missing or absent. Ultimately, psychiatrists embraced this sexual model and it became the foundation of the psychiatric definitions of female sexual disorders. Ultimately, it seems only a matter of time before another model of female sexual responses will become accepted in the scientific and professional literature.
The Impact of Hormones
Both estrogen and testosterone play a significant role in regulating female sexual functioning. The significance of these hormones is evident for both women with spinal cord injury and without injury, Again, hormonal levels are but one more factor along with the neurological issues that determine the extent of the sexual dysfunction.
Estradiol levels affect cells throughout both the peripheral and central nervous system. A decline in these levels results in a thinning of the vaginal mucosa and ultimately a thinning of the vaginal walls. These changes affect the acidity of the vagina and can also lead to vaginal infections and urinary tract infections. With the onset of menopause, most women experience some changes in the hormonal balance and all the typical dysfunctions such as poor desire and diminished lubrication become more evident and more pronounced.
Today, there is tremendous attention being focused on the role of testosterone for women. In fact, many women are being prescribed testosterone gels and creams off label, (without FDA approval). Therapeutic success for improving sexual desire is being reported on a regular basis in the sexual medicine and urologic journals. Women with a history of breast cancer are should not be prescribed testosterone since it can be converted to estrogen and can place women at high risk.
The Psychogenic Issues
For women with and without spinal cord injury, the neurogenic aspects of their sexual responses are further complicated by the emotional and relationship factors. Thus far, it has never been documented as to how significant these factors are for men with or without disabilities. How a woman will respond sexually is to a large part determined by self-esteem, body image, comfort with a partner, safety and the quality of the relationship.
Her past history including sexual abuse, molestation and early sexual education will also affect her ability to respond sexually. For women with past sexual trauma, the ability to respond sexually or to have an orgasm is greatly reduced.
In my own clinical work, I have noted that early sexual fondling by a male babysitter; brother or other man will often lead to a serious aversion to the penis during the adult years. These are the painful, long repressed memories of a post traumatic stress disorder. Couples in such therapy often report that the woman will go to great lengths to avoid touching the male genitalia. This anxiety and apprehension subsequently leads to poor lubrication and pain during sexual intercourse. Naturally, marital discourse is a secondary complication of no less significance.
As is well documented in the literature, depression and other mood disorders are also associated with female sexual dysfunction. The most frequently used medications for treating uncomplicated depression are the serotonin re-uptake inhibitors (SSRIs). Unfortunately, these are the most notorious drugs available in terms of their negative impact on a woman's sexual health. Sadly enough, they are often used, instead of therapy, in treating the woman's emotional reactions to a spinal cord injury.
Women receiving these medications often complain of decreased desire, decreased arousal, decreased genital sensation and difficulty achieving orgasms. Sjoberg and his colleagues have recently published some pilot data that suggest that Viagra may be somewhat helpful for women who require anti-depressants for their psychological well-being.
Currently, slow, steady progress is being made in understanding a woman's sexual health. The post-viagra frenzy and unrealistic hopes for the woman's miracle drug never did materialize however. Women's sexual functioning ultimately proved to be more complex than researchers originally believed.
On the positive side, for women with spinal cord injury there is more attention to their sexual response than ever before. Pharmaceutical companies have continued their quest for better clinical treatments. Medical and scientific understanding has improved.
Women with incomplete injuries retain their capacity for psychogenic arousal and vaginal lubrication. Sexual desire can often be addressed with the careful monitoring of hormone supplements. With regard to orgasm, women with SCI have more difficulty achieving orgasm but the ongoing work by Sipski and the Berman sisters have been encouraging in demonstrating that orgasm is often possible for women at all levels of injury.
Most importantly, women with spinal cord injuries are becoming more educated as to their bodies and their own unique sexual responses. They are seeking information from their doctors and from their other health care providers. We have come a long way from those early days, not so long ago, when women believed that they had lost their sexual capacity after these injuries. There is reason for encouragement!