Sexual Dissatisfaction: Common Causes of Sexual Dysfunction

A solution to sexual challenges may lie within you and your partner, not at your local pharmacy:

""The findings from our study show how a woman's expectations to improve sexually can have a substantial positive effect on her sexual well-being without any actual drug treatment," Meston says. "Expecting to get better and trying to find a solution to a sexual problem by participating in a study seems to make couples feel closer, communicate more and even act differently towards each other during sexual encounters."

"Many women reported they received more stimulation during sexual activity while they participated in the trial, even though their partners were not given any special instructions."

Original Medical Article SummaryRelated: Placebo Affect

Webmaster's Note: While the information presented below is based on a book published more than 10 years ago, I'm not aware that our understanding of normal female sexual function has increased significantly since then, and progress on treatment of female sexual dissatisfaction/dysfunction has progressed even less. No magical wonder drug has been discovered, despite everyone's expectations. Female sexuality has proven to be much more complex than originally envisioned. When new information is added to the website, often in the form of Medical Quotes and News Article Quotes, they are listed on the Updates Page. Those additions may be placed within other articles, rather than here. The article "Low or Absent Female Sexual Desire" has relevant information.

Illustration by Patsy

The following information is from the book For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. I highly recommend this book to any woman who is not satisfied with all aspects of her sexuality. All women should consider owning it as it will give them a better understanding of their sexuality, and the things and events that may have a negative impact on it at some point in their life. Even if you feel your sex life is perfect now, you will want to ensure that it stays that way. If you value your sexual pleasure, you will want to own this book. Guys, buy this book for your partner! Illustrations contained within the book For Women Only can be seen in the anatomy section.

The clinical or correct term used to specify "sexual dissatisfaction" is actually "sexual dysfunction." The Bermans prefer to use the term "sexual dissatisfaction" when speaking with their patients. The correct "label" is unlikely to be one a woman wants to apply to herself. In addition, if a woman is not happy with all aspects of her sexuality she is not automatically "dysfunctional." A woman is more likely to feel comfortable saying she is dissatisfied than she is to say she is dysfunctional. It is for this reason that I have chosen to use the term "sexual dissatisfaction" as well.

This book contains the latest information on the diagnosis and treatment of female sexual dissatisfaction. A recent study found 43% of women are experiencing the effects of sexual dissatisfaction. Only recently has the medical profession put any significant effort into trying to discover the causes. Since the true causes have often been unknown, there has been a lack of effective and reliable treatments. Women who are searching for a solution to the sexual difficulties they are experiencing may very well find themselves needing to read this book cover to cover prior to taking it with them when they visit their doctor, therapist, psychologist, or psychiatrist. There is an extremely good chance your doctor may not be aware of the information it contains, as much of it has been developed or discovered within in the past three years. Do not expect medical professionals to know all the information it contains. Most medical professionals receive little or no training in female sexuality.

In 1998 a panel of nineteen medical specialists from around the world met to redefine the definitions used to describe female sexual dissatisfaction. Prior to then, sexual dissatisfaction was thought to be solely psychological in origin, now it is accepted that in may have a medical origin. The original definitions may have dealt solely with psychological causes as the American Psychiatric Association created them, twenty years ago. The panel agreed upon four classification of female sexual dissatisfaction, they are given below.

The information presented in the next four paragraphs is Copyrighted 2001 by Jennifer Berman, M.D., and Laura Berman, PH.D..

The following definitions became outdated in May 2013 with the publication of a new Diagnostic and Statistical Manual. The changes are explained offsite in the article Changes to the Sexual Dysfunction Disorders in DSM-5.

1. Hypoactive Sexual Desire Disorder: A lack of sexual desire that causes a woman personal distress. This includes a persistent or recurring deficiency or absence of sexual fantasies or thoughts, or a lack of interest in sexual activity. As a subcategory, it includes sexual aversion disorder. Hypoactive sexual desire disorder may be the result of medical factors (such as medications), emotional factors (such as depression), or menopause (either natural or surgical). Sexual aversion disorder is the complete avoidance of sexual intercourse or relations. It is also classified as a phobic disorder that can result from physical or sexual abuse or childhood trauma. [Hypo- means lack or deficiency.]

2. Sexual Arousal Disorder: An inability to attain or maintain adequate genital lubrication, swelling, or other somatic [somatic relating to the body, not the mind] responses, such as nipple sensitivity. Disorders of arousal include a lack of vaginal lubrication; decreased clitoral or labial sensation; decreased clitoral and labial engorgement; or lack of vaginal lengthening, dilation, and arousal. Although these conditions can be caused by psychological factors, such as depression, they can also have a medical basis, such as diminished vaginal or clitoral blood flow. Some women with physically based sexual function problems understandably develop psychological problems, which must also be addresses.

There are four subtypes of Sexual Arousal Disorder:

a) Subjective Sexual Arousal Disorder is "characterized by diminished or absent feelings of sexual excitement and pleasure but intact vaginal lubrication." This occurs when exposure to mental and/or physical sexual stimulation results in physical sexual arousal but a woman is not aware of her physical arousal. For some reason her brain does not make her aware of the fact that her body is sexually aroused. During partnered sex she may not "feel" sexually aroused but increased vaginal lubrication indicates to her partner that she is. This subject is addressed in a Question & Answer.

b) Genital Sexual Arousal Disorder is "characterized by diminished or absent genital arousal, i.e. lubrication and sensation." This occurs when sexual stimulation does not result in physical sexual arousal. Her mind may be telling a woman she is sexually aroused but there is no increased vaginal lubrication or blood engorgement of her genitals. This is more likely to be indicative of a physical or medical problem, but current research indicates this is a much less common experience than subjective sexual arousal disorder.

c) Combined Genital and Subjective Arousal Disorder is "characterized by diminished or absent sexual excitement and genital arousal." This is a combination of the above two definitions. This occurs when there is neither physical or mental sexual arousal. This may be caused by medical or environmental factors. Women with insufficient levels of testosterone may experience decreased or absence of sexual desire, arousal, and sensation. Natural and surgical menopause and medically prescribed hormonal treatments like birth control pills and hormone replacement therapy (HRT or ERT) can reduce testosterone production.

d) Persistent Genital Arousal Disorder is "characterized by spontaneous and persistent genital arousal which is unwanted." This a new diagnosis that appears to be relatively rare, yet causes significant emotional distress for those who experience it. It is possible that women who stop taking an antidepressant medication after using it for an extended period of time are more susceptible to this condition than others. After having their sexual responses impaired by the medication it is possible their body is unable to limit their sexual responses as it should. This is not to be confused with an intense yet normal level of sexual desire and arousal. 53% of women in a survey on this website say they believe their level of sexual desire is greater than that of their peers and in another survey 45% say they believe their level of sexual arousal is greater than that of their peers. This indicates women in general believe they have stronger or more intense sexual feelings than their peers, or what is socially acceptable. This subject in addressed in a Question & Answer.

3. Orgasmic Disorder: A difficulty or inability to reach orgasm after sufficient sexual stimulation and arousal. Orgasmic disorder also includes any difficulty or delay in reaching orgasm that causes the woman personal distress. The quality of the orgasm may also be diminished. Some women with orgasmic disorder describe their orgasms as "muffled," particularly if they have had strong orgasms in the past. Orgasmic disorder is most often categorized as primary, meaning that a woman has never achieved orgasm, or secondary, meaning that she can no longer achieve orgasm because of surgery, hormone deficiencies, or trauma. Primary orgasmic disorder can be caused by emotional trauma or sexual abuse, but many medical factors, such as medications or damage to the pelvic nerves during surgery, may also contribute to the problem. Clitoridectomy, or the removal of the clitoris, as practiced in some cultures in Africa, the Middle East, and Asia, would seem to be a natural cause of this category of dysfunction.

4. Sexual Pain Disorders: These include dyspareunia, which is a recurrent or persistent genital pain associated with sexual intercourse. Dyspareunia can develop as a result of medical problems, such as vaginal infections or thinning of the vaginal lining during menopause, or following some vaginal or vulvar surgical procedures. It can also be psychological based or reflect a relationship problem or other emotional conflict. More often than not, as with most disorders, it is a combination of physiological and psychological factors. Another sexual pain disorder is vaginismus, or involuntary muscles spasms of the lower third of the vagina, which interferes with or precludes vaginal penetration. Vaginismus usually develops as a conditioned response to painful penetration, but it can also be due to emotional or relationship problems. The panel identified a third subcategory as other sexual pain disorders, or genital pain induced by noncoital sexual stimulation. This is pain that occurs with any type of sexual stimulation other than intercourse. Although sexual stimulation triggers the pain, the primary cause of the pain can include vaginal infections, prior genital mutilation (a rite of female passage in some African countries which we discuss in chapter 6), or vestibulitis, a recurring inflammation and burning sensation around the opening of the vagina.

Sexual Pain Resources:

Medical Abstract:

Originally Published: July 2009

A Prospective Study of Pelvic Floor Physical Therapy: Pain and Psychosexual Outcomes in Provoked Vestibulodynia

Introduction. Research suggests that increased tension in the pelvic floor muscles of women with provoked vestibulodynia (PVD, the most common form of chronic vulvar pain) may play an important role in maintaining and exacerbating their pain. However, no prospective studies of pelvic floor physical therapy (PFPT) for PVD have been carried out.

Aim. This study prospectively examined the effectiveness of a PFPT intervention in treating the pain and sexual and psychological components of PVD, and determined predictors of greater treatment success.

Methods. Thirteen women with PVD completed eight sessions of PFPT. Participants were assessed at pre- and post-treatment via gynecological examinations, vestibular pain threshold testing, structured interviews, and standardized questionnaires. A 3-month follow-up interview assessed any further changes.

Main Outcome Measures. Outcome measures included: vestibular pain thresholds, gynecological examination and intercourse pain ratings, sexual function and intercourse frequency, mental health, negative pain cognitions, and success rates.

Results. Following treatment, participants had significantly higher vestibular pain thresholds and significantly lower pain ratings during the gynecological examination. Participants reported significant reductions in pain intensity during intercourse and were able to engage in significantly more pain-free activities. Although overall sexual function significantly improved, various components of sexual function and frequency of intercourse did not. Participants' mental health did not significantly improve; however, pain catastrophizing and pain-related anxiety significantly decreased. The treatment was considered to be successful for 10 of the 13 participants, and predictors of greater treatment success included greater reductions in helplessness and a longer period of time in treatment.

Conclusions. Results provide preliminary support for the effectiveness of PFPT in treating the pain of PVD, as well as some of the sexual and cognitive correlates of PVD. The results also indicate the need for large-scale, randomized studies of the effectiveness of PFPT in comparison and in conjunction with other treatment options. [Source]

It Has a Name, Now What?

Okay, now you have a fancy medical term to apply to your particular type of sexual dissatisfaction, now what do you do? The next thing you will want to know is what are the possible causes. If you do not know the cause, you are less likely to find a solution. Below are abbreviated descriptions of known medical and psychological conditions that can impact sexual satisfaction. While I want to point out the vast number of factors that can impact a woman's sexuality, I cannot go into the same detail as the book does. This is just meant to be a general overview.

Pelvic Surgery or Trauma: Doctors simply have a very limited understanding of the location and routing of the nerves and blood vessels that pass through the female pelvis on their way to the vagina and vulva. They simply do not know what areas to avoid when performing surgery in this area. As a result, a woman's sexual responses and feelings can be impacted by such surgeries as hysterectomy, uterine embolization, and episiotomy. In addition, injuries to the vagina during childbirth can cause damage to the vagina, and nerve and vascular damage to the vagina and clitoris. Damage to the blood vessels can affect a woman's clitoral, labial, and vaginal sensitivity and her ability to experience sexual arousal and lubrication, and as a result orgasm. Removal of the uterus and cervix can change a woman's orgasms, particularly if she experiences "pelvic orgasms." Pelvic fractures and other straddles injuries may also affect the pelvic and genital organs and their blood and nerve supplies. Many doctors simply do not know pelvic surgery can have negative consequences for a woman's sexuality. They may tell women just the opposite, and adamantly stand by their convictions. More can be learned at Institute for Sexual Medicine: Sexual Dysfunction after Hysterectomy

Vasculogenic or Blood Flow Problems: The flow of blood through the pelvic and genital organs is a major component of female sexual response. It directly affects a woman's ability to experience arousal, lubrication, and engorgement, and as a result orgasm. If you restrict or sever this blood flow a woman's sexual responses will likely be impaired. Here are the diseases and activities that can affect pelvic blood flow.

  • Coronary heart disease: We are frequently informed by the media about the risks of coronary heart disease. One aspect of this disease they do not mention is that the same plaque that builds up in the arteries of the heart also builds up in the arteries of the pelvis. This can restrict the flow of blood to the pelvic and genital organs. It may also lead to thickening and scaring within of the muscles of the vagina and the smooth muscles tissues of the clitoris. This can lead to a lack of lubrication and pain during foreplay and intercourse.

  • High blood pressure: The affects of high blood pressure on female sexuality are not fully understood at this time. What is know is, high blood pressure can damage the blood vessels resulting in an increased risk for coronary heart disease, described above. The medications used to treat it may directly affect female sexual response as well. These medications are discussed on the Health page.

  • Smoking: While we have all been made aware of the damage cigarette smoking can do to our bodies, few would expect it to affect our sexuality. Smoking causes the blood vessels to constrict. This can affect the blood flow to the pelvic organs. Toxins in cigarettes can also damage the walls of the arteries leading to coronary heart disease.

  • Bicycle riding: The use of standard narrow bicycle seats can result in damage to the blood vessels and nerves that lead to the clitoris. This can result in clitoral numbness, at first it is just temporary but may become permanent. Women, and men, should only use wide bicycle seats. You can learn more about this at: Institute for Sexual Medicine: Bike Riding and Your Sex Life. An interesting medical article abstract can be read here. Medical Quote, "Handlebars positioned lower than the saddle were significantly associated with increased perineum saddle pressures and decreased genital sensation in female cyclists." Read More

Hormonal Problems: The level of estrogen and testosterone in a woman's body can have a significant affect on her sexuality. Some of the common hormonal conditions that contribute to female sexual dissatisfaction are given below.

  • Menopause: The decreased production of estrogen that occurs during menopause can result in hot flashes, vaginal dryness or irritation, incontinence, a thinning or loss of elasticity of the skin, mood swings, and depression. A corresponding decrease in androgen hormones like testosterone can result in reduced muscle strength, appetite, energy, memory, sexual desire, and responsiveness. Testosterone appears to be the main controller of sexual desire. A medical article abstract says the sexual functioning of the brain changes after menopause, possibly the result of hormonal changes. There was a medical study done to see if the changes that occur in the female genitals during menopause could be observed by Magnetic Resonance Imaging (MRI) and they were successful, which provided some information on how they change. Read that article.

  • Endocrine disorders: The endocrine glands are spread throughout the body and are responsible for controlling the body's internal functions by producing numerous hormones. Diseases and illnesses that affect such glands as the pituitary, hypothalamus, thyroid, and adrenals can have a significant affect on a woman's sexuality. Hormones control the production of other hormones so a chain reaction of events may lead to sexual dissatisfaction.

  • Postpartum hormone deficiencies: While a short-term loss of libido flowing pregnancy and childbirth is normal, it should not last for years. When a woman is breast-feeding her body produces oxytocin and prolactin that suppress the production of testosterone. As a result, breast-feeding women may experience a decreased desire for sex for as long as they nurse. (The benefits of breast-feeding still greatly outweigh the negatives.) Women who do not breast feed, and after others stop doing so, may also experience a chronic decrease in sexual desire and this may be the result of a decrease in or total absence of testosterone. The reason why testosterone production ceases is not known.

  • Diabetes: A diabetes related disorder called diabetic neuropathy can affect the nervous system and blood vessels. More than fifty percent of diabetics develop neuropathy. This condition often results in a loss of feeling in the feet, hands, and legs. The small arteries in the pelvis may also be affected by the resulting vasculogenic problems.

Neurogenic Problems: Any medical condition that affects the nervous system can have a major impact on a person's sexual function.

  • Spinal cord injury: Paralysis often results in a significant sexual impairment but not a decease in sexual desire. Women may experience a loss of genital sensitivity and may not be able to experience orgasm following a spinal injury. New research though has shown some women with paralysis are able to experience orgasm by using non-conventional means. Some experience orgasm while stimulating the cervix or vagina. Others experience orgasm by using a standard vibrator. Still others find other areas of their body become erogenous zones, like the nipples, neck, and ears. Disabilities are often only as debilitating as a person allows them to be.

Other Physical Problems:

  • Endometriosis and fibroids: Women with endometriosis and fibroids may suffer sexual dissatisfaction as a direct result of medical treatments they receive; like D&C (dilation and curettage), hysterectomy, or uterine embolization. The effects these procedures may have on a woman's sexual satisfaction have been addressed above.

  • Vaginal and urinary tract infections: The symptoms associated with vaginal and vulvar infections like vulvitis, vulvadynia, urinary tract infections, and cystitis can result in a woman's vulva and vagina being too sensitive or irritated to permit any form of sexual contact. Some of these infections result in unpleasant smells as well. While most of these infections are easily treated and have a limited impact on a woman's sexuality, others are chronic and debilitating. Unfortunately, all of these diseases are not fully understood and as a result there is no known treatment for some of them.

  • Interstitial cystitis: This is a chronic inflammation of the bladder. It is indicated by a frequent urge to urinate, lower abdominal, vaginal, and rectal pain. This disease can be hard to detect and often requires the visual examination of the bladder using a cystoscope, to look for hemorrhages. This condition often becomes debilitating and leads to sexual dissatisfaction. It can result in labial, vaginal, and pelvic pain and difficulties with arousal and orgasm. Researchers are still searching for a cause and developing new medications to treat it.

  • Pelvic floor disorders: These disorders result in the relaxation and loosening of the muscles and connective tissues that support the pelvic organs; like the uterus and bladder. Women who experience this may also experience vaginal pain, loss of sensitivity within the vagina, and arousal and orgasmic impairment. New and better surgeries are being developed to help protect a woman's sexual functioning, to protect her vital nerve and blood supplies when surgical treatments are undertaken.

Medications that Affect Sexual Function: Medications that can have a detrimental affect on female sexuality are discussed on the Health page.

Psychological causes of female sexual dissatisfaction:

  • Depression and dysthymia: Depression affects twice as many women as men. It has many causes, chemical imbalances within the brain, severe stress, grief, family history, emotional conflict, or any combination of factors. Dysthymia is a less severe form of depression that usually goes undetected. A woman with dysthymia may feel sad and unattractive. Both forms of depression can lead to sexual dissatisfaction and avoidance of sex.

  • Stress: Many women have two careers, they perform the tasks required of a mother and a businesswoman at the same time. Today's working mother often times does not have the support of multiple nuclear family members to the degree they once did. The responsibilities associated with both careers results in women who are under much more stress than the average man. Stress can lead to emotional and medical problems and as a result sexual difficulties. Women who find they are feeling stressed need to ask for, if not demand, assistance from others. If you cannot relax in the arms of your partner you are very unlikely to be able to experience sexual arousal and orgasm, if you are able to attempt intimacy at all.

  • Sexual or emotional abuse: The potential ways in which sexual and emotional abuse can affect a woman's sexuality are enormous. Women who have been exposed to this may experience one or more of the four types of sexual dissatisfaction listed above. It can cause women to avoid sex or be unable find it pleasurable. A woman may find herself unable to develop a committed and lasting emotional relationship with someone; she may seek pleasure through frequent sex, perhaps with multiple partners that have no emotional attachment to her. For a woman to heal from abuse it often takes a sizeable investment of time and a very supportive partner. I want to point out that just because a woman has a strong interest in sex or has no interest in sex at all, that does not automatically mean she was abused as a child. In addition, a woman who was abused may still have a healthy sex life as an adult. Women should be careful not to become the victims of suggestion.

  • Drug and alcohol use: Women may abuse drugs and alcohol as a result of a preexisting emotional conditions. While the drugs and alcohol may allow them to hide from their problems, it only adds to them by creating new ones. Women who are always intoxicated or under the influence of drugs when they engage in sex may be unable to relate to their partner on an emotional level when they are sober. Once a woman is no longer addicted she often finds herself unable to have a fulfilling sexual relationship with her partner, in part because the emotional problems come to the forefront once again. Some women use sex as a form of distraction, as a means of avoiding their problems. Sex becomes the drug; hormones produced during sex may result in a natural high or peaceful state-of-mind. Women who have been treated for alcohol or dug abuse often need extensive counseling and a supportive partner if they are to find sexual happiness.

  • Sexual addiction: This is a controversial subject. Women in the past were labeled nymphomaniacs if they expressed any outward interest in sex. Now if they express "too much" interest they may be called a sex addict. Is it possible that only the label applied to a sexual woman has changed with time, rather than our opinion of her? Who exactly is defining what is too much? What is sexual addiction and what is a strong yet normal sex drive? If your desire for sex precludes all else, specifically work and family, then it is unhealthy emotionally. If the only thing you and your partner(s) do while together is have sex, then you may be using sex as a means of avoiding emotional and intimacy issues. Sex is just one spoke in the wheel of life, if all the other spokes are broken or weak, the wheel will collapse when jostled.

  • Body image and self-esteem problems: Women often compare their body to an unrealistic and unhealthy ideal created and propagated by the mass media. Women often expect they should naturally look like the underweight or surgically modified models frequently shown on the covers of magazines, television, and in movies. Women who are considered very attractive by those around them often find significant fault with their body; especially those very women who adorn the covers of magazines. As a result, many women are uncomfortable showing their body to their partner. They never allow their partner to see them undressed, with the lights on. They may not allow their partner to look at or touch certain areas of their body, specifically their vulva. If a woman cannot undress fully in front of her partner with the lights on and allow them to examine her entire body with their eyes and hands, she is not going to be able to fully enjoy her sexual interactions with them. How a woman values herself in her work and relationship also affects her sexuality. If a woman feels she has no skills or qualities others value, she will likely find she unable to express herself sexually. If a woman believes her partner will not listen to or respect what she has to say she will never make her sexual needs known. If she does not feel comfortable with herself and her partner she is less likely to be able to relax and have an orgasm. Having an orgasm may cause a woman to feel very vulnerable, if she does not have confidence in herself or the relationship she may not allow herself to have an orgasm, consciously or unconsciously. See Body Image section of website for more information on this subject.

  • Relationship problems: The state of a couple's sexual relationship is often a direct indicator as to the state their entire relationship. If a couple is having sexual difficulties, those difficulties usually have a negative impact on their entire relationship, and vise versa. If the relationship is in turmoil then no form of treatment that involves only the woman will solve their sexual difficulties. If the woman's sexual dissatisfaction is the result of her partner's sexual difficulties or lack of sexual skills, treating her alone will most surely result in failure. If a couple does not trust one another and have good communication skills, achievement of sexual satisfaction is unlikely. Some couples have trouble accepting the natural changes their relationship undergoes with the passing of time. Many relationships start out as the result of mutual infatuation that is intense and often accompanied by sexual passion. Once the newness of the relationship has worn off the relationship becomes mellower and less exciting. If the couple has good communication skills and there is mutual trust and respect the relationship will survive the transition, the couple discovers love. If a person expects to maintain that initial emotional and physical intensity throughout the relationship they often find themselves bouncing from one relationship to the next. Many couples have false expectations as to what their sex life should be like, ignoring all the other things that have changed within the relationship. Having children for example will usually require a couple's sexual relationship to change. A healthy relationship is essential to enjoyable sex. Love is not an essential quality of a healthy sexual relationship, but mutual respect and trust, and the ability to communicate effectively are. Unfortunately, society is to blame for much of the mutual distrust that exists between the sexes.

Physiological and psychological assessment: As can be seen, there are many possible causes for sexual dissatisfaction. To determine which are responsible for an individual woman's dissatisfaction requires a thorough diagnosis process. Since the cause is seldom purely physiological or psychological in nature, both areas need to be assessed jointly. If a woman goes to either her gynecologist or therapist but not the other she is less likely to know the true cause and extent of her sexual dissatisfaction. If a woman sees one or the other, the diagnosis is more likely to be wrong or incomplete and as a result the prescribed treatment is less likely to succeed.

Jennifer and Laura Berman's clinic is perhaps a bit unusual in that they are able to look at both the psychological and physiological aspects jointly and team up to form a diagnosis and an appropriate treatment. Many of the women who read this may have trouble locating a doctor and therapist who already work together and who have the knowledge base necessary to do the same. A woman may have to seek out a doctor and therapist separately, and request that they work together as a team. When she does, she may need to provide the information necessary for her diagnosis and treatment. By this I do not mean a woman should self diagnose herself, she should only insure that all possible options are explored. She needs to make sure the medical doctors know of the possible medical causes and do the appropriate tests, and the therapist should be made aware of known medical conditions. The woman may also need to make sure the therapist does not assume there are no medical conditions that are the basis for her emotional problems. She needs to ask a lot of question and at the same time answer just as many. A woman should be careful not to force her doctors to a desired diagnosis, consciously or unconsciously. If she does not agree with their diagnosis then she may want to seek out a second opinion.

I realize many of the women who read this are likely going to feel they cannot perform the task of searching out the appropriate doctor and therapist. If a woman is having sexual difficulties she may not have the self-confidence required to make the necessary phone calls, understandably. Given the "sexual" nature of her difficulties she probably will not be overly eager to talk about it with multiple strangers, who may not be understanding of her problems and concerns. Anyone she does speak to needs to know how to address sexual issues in sensitive and professional manner. Luckily there are organizations that can help women complete this task. One of them is, The American Association of Sex Educators, Counselors, and Therapists (AASECT). They have put together a list of thousands of sex therapists from all over the United States. There are several ways to contact them for a list of qualified therapists in your area. That information is presented below.

The American Association of Sex Educators, Counselors, and Therapists (AASECT)
PO Box 1960
Ashland, VA 23005-1960
804-752-0056 (fax)
Website: AASECT

The psychological assessment process is beyond the scope of this article and given the complexities of the human mind, it would be inappropriate to try and describe it here. The Berman's recommend women seek out a therapist who is trained and proficient in both general and sexual therapy; so they have the necessary skills required to address all emotional aspects of the sexual dissatisfaction. The therapist needs to assess the entire relationship. The medical assessment process used by Dr. Jennifer Berman includes some medical procedures that have just recently come into existence. Your local doctors may not be aware of their existence. In addition, the assessment tools may not exist in the average doctor's office. You may have to seek out a doctor who has them and is qualified to use them.

The medical tests used by Dr. Berman are described below.

  • Full gynecological and urological exam: This involves the thorough examination of the internal and external structures; including an examination of the clitoris, which is not normally done during pelvic examinations. A woman's medical history is also taken. The doctor needs to know about past surgeries, illnesses, family history, and treatment of emotional problems.

  • Determination of the vaginal pH level: A small flexible probe is inserted into the vagina to measure its acidic level. A reading of 4.5 to 5.1 is considered normal for premenopausal women. Post-menopausal women who are not on estrogen replacement therapy experience an increase in acidity. A measurement of 0-7 is considered acidic, 7-14 is considered alkaline. A measurement of 7 is neutral.

  • Measurement of clitoral and labial sensitivity: This is done using a biothesiometer; a device that measures the sensitivity of the skin to high and low frequency vibration. It is used to determine the sensitivity of the clitoris and labia to stimulation, and the condition of the nerves.

  • Determination of vaginal compliance: This test is done to measure the ability of the vagina to relax and lengthen. A small balloon like device is inserted into the vagina and slowly inflated. A woman is asked to indicate when she first feels a sensation of pressure within the vagina and then when the dilation begins to become uncomfortable.

  • Examination using ultrasound: Using a small matchstick sized ultrasound probe, the anatomy and blood flow of the clitoris and labia is examined. The doctor is able to observe the anatomy and blood flow on a television screen. A tampon sized ultrasound probe is then inserted into the vagina to do a similar examination of the vagina and uterus.

  • Assessment of arousal: This is perhaps the type of procedure women would least expect to occur in a doctor's office. In order to measure a woman's ability to become sexually aroused she needs to be aroused sexually. Dr. Berman gives the women a pair of 3-D surround sound video glasses and a vibrator. The glasses fill the woman's full range of vision and allow her to watch an erotic video, designed for and produced by women. (One would hope they also have videos for use by their lesbian clients.) The woman is then asked to engage in self-stimulation (masturbation) for fifteen minutes using the vibrator to achieve a high degree of arousal. The doctor is not present while the woman is engaged in this activity. When the doctor returns she repeats the three prior steps to determine the level of lubrication, blood flow, sensitivity, and the elasticity of the vagina when the woman is aroused. If the expected changes do not occur, it could be a sign that there are physical factors involves in the woman's sexual dissatisfaction. If a woman is not able to become aroused because of the situation she currently is in, she needs communicate this to her doctor.

  • Assessment of arousal when Viagra is used: On a subsequent visit a woman may be give a dose of sildenafil (Viagra) and the above step is repeated. This is done to see if this prescription medication will have the desired beneficial affects on the woman's sexual response. An increase in blood flow and sensitivity are the desired results. If emotional issues are at play, even if a woman is highly aroused physically, orgasm may still be unachievable. The Berman's have found that if careful screening is done before hand, prescribing Viagra can be very beneficial for women. This is not true for all women. Viagra is not an effective treatment option for all or most forms of sexual dissatisfaction. It usually works best for women who once had a fulfilling sex life but due to physiological changes is no longer able to experience the necessary level of sexual arousal required to achieve orgasm.

Some medical offices and research facilities now have special equipment like the GSA Genitosensory Analyzer that is used to test the nerves of the vulva and clitoris to see if there is appropriate sensitivity to temperature and vibration. You can see a list of some of the facilities in North America that have this device here. Some of these facilities may not work with the general public, since they are research facilities.

Preliminary medical research has confirmed there is a significant potential for women experiencing arousal and/or orgasmic dissatisfaction, in the absence of other sexual and medical symptoms, to have decreased clitoral and/or vaginal sensitivity. This mean's the tissues and nerves of their clitoris and/or vagina are less sensitive to stimulation than is considered typical. This would indicate the symptoms weren't purely psychological in nature, that they had a physical and measurable manifestation. The presence of this impaired sensation would influence a woman's ability to become sexual aroused and experience orgasm, as a result of physical vulvar and vaginal stimulation alone. Psychological (mental) and androgenic (hormonal) induced arousal and desire may not be adversely affected, but given the occurrence of purely mentally induced orgasms is extremely infrequent, orgasm could be greatly impaired even if arousal isn't. Unfortunately, identifying the cause of this impaired sensation wasn't part of this medical study. Access to doctors with the necessary testing equipment and knowledge is likely very limited as well; see prior paragraph. Estrogens and Androgens influence genital tissues and their sensitivity to sexual stimulation; other possible causes are described above.

Here is the medical abstract describing that research:

Genito-Sensory Analysis in Women with Arousal and Orgasmic Dysfunction

Introduction. Diagnosis and treatment of female sexual dysfunction (FSD) are currently based on subjective female reports and physical examination. The GenitoSensory Analyzer (GSA) is a quantitative sensory testing tool designed to quantify vibratory and thermal sensation in the vagina and clitoris in a reproducible manner, and may therefore contribute to the diagnosis and management of FSD.

Aim. To address the question of whether women with arousal and/or orgasmic sexual disorders have genital sensory abnormalities as measured by the GSA.

Main Outcome Measures. Thresholds for warm, cold, and vibratory sensation at predetermined points in the vaginal wall and clitoris.

Methods. Female subjects complaining of arousal and/or orgasmic sexual disorders for more than 6 months were evaluated using a questionnaire based on the female sexual function index (FSFI). Women with a desire disorder, pain disorder, vulvar vestibulitis syndrome, or acute vaginal or/and introital infection were excluded. The GSA device measured thresholds for warm, cold, and vibratory sensation at predetermined points in the vaginal wall and clitoris. Eight measurements were obtained, and deviations from previously published normative values were identified.

Results. Twenty-eight women (age 40.4 ± 13 years) complaining of arousal and/or orgasmic FSD comprised the study cohort. Twenty-five of them (89%) had at least one pathologic genitor-sensory threshold on GSA testing and 19 (68%) had >3 pathologic thresholds. Pathologic GSA results were associated with lower arousal scores on the FSFI questionnaire, older age, and menopausal status.

Conclusions. Most of the study women had at least one genitor-sensory pathology on GSA testing, indicating a possible organic component in their disorder. Our findings support the incorporation of the GSA as a quantitative tool in the assessment and diagnosis of patients with FSD.


Can Your Doctor Improve Your Sex Life?

From Glamour Magazine, July 2004

Webmaster's Note 2011: I don't believe there has been any changes to the information presented below, there is still the lack of agreement, and no single or common solution to female sexual dissatisfaction exists.

Got an intimate question about your body and its pleasure zones? Glamour gathered seven of the country's top female experts for a closed-door Q & A every woman should read.

By Noelle Howey and Gayle Forman

For lots of women, having great sex is a complicated matter: You know it ("Why don't I feel like it tonight? Why haven't I felt like it for the last month? Am I going to have an orgasm, or what?"). Men know it ("Why doesn't she feel like it tonight? Why hasn't she felt like it for the past month? Is she going to have an orgasm, or what?"). Even the pharmaceutical behemoth Pfizer knows it--the company just abandoned an eight-year-long quest to perfect its blockbuster drug Viagra for women (you can just imagine a bunch of white coats standing around test subjects, rubbing their chins and muttering, "Why doesn't she feel like it tonight? Why hasn't she felt like it for a month? Is she going to have an orgasm, or what?").

So who do you turn to for answers to these questions you ask in the dark? Who's got a handle on how all the parts function and what makes sex reliably good? For most women it's their ob-gyn. That's right, your plain old, Pap-performing, Pill-prescribing ob-gyn. You've probably never said boo to her about your sex life, but you should, because she's in a position to know you and your sexual history, as well as the facts and the drugs out there that can help. That said, not all doctors think alike on the topic of women's sexuality. So to give you the range of expert advice out there, Glamour assembled a dream team of groundbreaking female physicians, therapists and researchers who know about sex. Read their opinions-then keep the conversation going with you ob-gyn.

What's the most common complaint you hear from women?

JENNIFER BERMAN, M.D.: Across the board, having a low libido is the number-one problem.

HILDA HUTCHERSON, M.D.: Women often say they used to have desire, and now it's gone.

EILEEN PALACE, PH.D.: And that's understandable-because every part of a woman's life can affect her sex drive: fatigue, stress, anger or lack of trust in her relationship, power issues, and emotional intimacy. A woman's not ready for sex at night because she's doing the grocery list. Thinking about work. Angry with her partner for not paying attention to her all day.

LAURA BERMAN, PH.D.: But sometimes there really may be a physiological cause. For example, is she on antidepressants or birth control pills, both of which can kill sex drive? That's a huge problem with younger women. So is anxiety. Through my practice, I've found that women who are under chronic stress can have lower levels of testosterone, which can cause a drop in their libido.

DR. HUTCHERSON: I don't know-I think it's very rare for a woman under 40 to have a hormonal imbalance. Certainly physical problems can come up-sometimes I think patients hope there is something wrong physically, because then maybe there's a pill they can take for it! Reaching for a pill or a cream is often easier than figuring out how to deal with difficult emotional issues in your relationship or you life.

So how do you get your desire back if it sputters out?

LEONORE TIEFER, PH.D.: I say to couples, focus on just having pleasure with the other person. Let's say I'm working with a couple and the first assignment I give them is to trade massages. Often they have a better time giving each other back rubs than when they had intercourse. Why? There was no pressure, and because they didn't know what they were doing or what felt good to their partner, they had to communicate with each other.

DR. HUTCHERSON: Women have heard this all before, but it's good advice: Learn how to tune out the world for a while. Take the phone off the hook. Take that bubble bath together.

DR. JENNIFER BERMAN: And get some rest. Stress can cause women to have more interest in sleep than in sex and can inhibit their ability to become aroused and have an orgasm. And for a woman to feel sexual, she needs to nurture and pamper herself.

PALACE: Experimentation is also important. I tell women to touch themselves to get to know their whole body, so they can communicate their needs more effectively to their partners. They can use an ice cube, a feather, a pillowcase, even a toothbrush, just to elicit different senses.

BEVERLY WHIPPLE, PH.D.: I give participants in my workshops a list of 36 body parts and 16 types of touch, such as rubbing or stroking. Alone or with a partner, they mix and match the parts and the types of actions and rank their feelings on different combinations, say from one to ten. I help guide them by bringing in my own experience. For example, if my husband blows in my ear I want to barf. If he sucks on my big toe, it's like a plus 12. A lot of women don't really understand what arouses then, so this exercise helps them get to know themselves.

What's up with all the new drugs? Can any of them help women have better sex?

DR. HUTCERSON: First, women have to know that there isn't one pill that cures every thing. Patients will say, "you have to give me a drug that will make it all better". Doctors will still prescribe Viagra-the men's version-to women, but I can give you a huge dose, and if you hate your partner or your body, it won't do a thing. Yet in some cases, drugs like testosterone and Viagra can help.

LAURA BERMAN: If a woman feels good about herself and the person she's with but has had a medical problem, maybe from a hysterectomy or pelvic surgery, I've found that Viagra can work well.

PALACE: Here's the bottom line on Viagra prescribed for women. It may increase women's orgasmic frequency, lubrication and their excitement-that is, arousal. But it doesn't work well with desire. Arousal is the physiological change that takes place: lubrication, breast sensation. But desire comes before arousal; it's the wanting, dreaming, initiation, being receptive, how much you think about sex.

LAURA BERMAN: If a woman has low desire and low testosterone levels, sometimes I recommend testosterone replacement, maybe cream or a patch. Women can get it from ob-gyn. It's not yet approved but the FDA for use in women, but many doctors prescribe it off-label.

DR. HUTCHERSON: Yes, it's a miracle. I've had women cry in my office after I've given them testosterone cream and it's brought their orgasms back.

PALACE: I'm not at all impressed with testosterone. Researchers thought for years that testosterone was going to increase male sexual desire, but it has not been proven to be an effective treatment. Now doctors are prescribing creams, films and patches for women, and overall it's not having a dramatic effect.

TIEFER: I think it's premature to use testosterone, based on the available research. If women are benefiting from it, it could just be that they're more comfortable using a cream as a lubricant-the active ingredient isn't all that important. I think if a person is comfortable touching herself and using lubrication, that's a lot more empowering than having her feel like she's defective and needs medicine to be sexual.

LAURA BERMAN: We know this is not just about lubrication because women may use a patch, cream or other form of testosterone replacement, and they don't necessarily take it before sex or apply the cream only to their genitals.

TIEFER: I believe that with testosterone and Viagra, the only effect is the placebo effect.

PALACE: But the placebo effect is powerful, I once studied women who'd complained of a lack of desire and arousal problems. After monitoring them while they were watching an erotic film, I told them that they'd had an increase of blood flow to their vaginas. They hadn't. But after I told them about their "results," their blood flow matched women who had no problems with sexual desire or arousal, and they had better sexual response in follow-up tests.

Should we be this focused on more and better sex? Could all the talk about drugs, creams and the number of orgasms be putting too much pressure on women?

DR. HUTCHERSON: In many ways, there is too much pressure. Women today are much freer than previous generations to discuss their sexuality with their partners and their doctors. But we also have to be aware of what I call the "Samantha syndrome," because patients tell me all the time, "I thought I was having an orgasm, it's not like Samantha's on Sex and the City. I'm not having multiple orgasms, I'm not screaming, I'm not breaking down the bed. I must be missing something." Women in their twenties are the ones telling me this, and they really take it to heart. They come in raw to my office because they had been rubbed so much, trying to have the right kind of experience.

LAURA BERMAN: It's great that there are all these role models, like Samantha, who are asking for what they want. On the flip side she's having this fabulous sex every time; she doesn't have any sexual problems. I've seen women who think that's what their sex life is supposed to be like.

WHIPPLE: Most women are still pleasure-oriented-they are as fulfilled holding hands or cuddling as having sex. But some women have become more goal-oriented about sex, the way many men have always been. I see this especially among women in the business world. A woman sets an appointment for when she's supposed to have sex on her Palm Pilot. Her mind-set is: I've got to check sex off the list. But where's the pleasure in that?

JEANNE ALEXANDER, M.D.: There is tremendous pressure on women to be like men in bed, but we're not. For the most part, the average woman wants to feel close to the person she's with. Sometimes you're going to have the physical and emotional connection, like rockets are shooting off. And sometimes it's going to be quite peaceful but still enjoyable.

WHIPPLE: Because women are hearing so much more about sex these days, we're much more about sex these days, we're more informed about sexual pleasure and satisfaction. But that can have a downside. For example, more than two decades ago my research showed that the G-spot could be a center for orgasm for many women. But somehow some women started thinking they had to have a G-sport orgasm instead of one through clitoral stimulation. Absolutely not! I was just trying to validate women's range of experiences. My concern for the 30-year-olds of today is that they're going to think that they're missing something when they're not.

DR. HUTCHERSON: Women are experiencing a lot of confusion, pressure and performance anxiety, which can affect their orgasms. When I tell my patients that more than 70 percent of women don't have an orgasm through intercourse alone, they give me this sigh of relief. The thing is, you need to decide whether you really want to have sex more often-or whether you feel like you're supposed to want to have it more often. Twice a day is normal for some couples, and once a moth is just as normal for others. Your degree of frequency is only a problem if you think it is. And if it is, you should initiate sex more. Don't expect the man to do all the work.

So why don't some women have orgasms? And are women still faking it?

DR. JENNIFER BERMAN: Here's what an orgasm is: Your nerves get stimulated, which leads to increased blood flow and engorgement of your genitals. Your heart rate and blood pressure rise, and continued stimulation leads to an orgasmic release. Unless a woman has a hormonal imbalance or physical issue, we still don't know why some women can't have that response.

PALACE: All women have a capacity for an orgasmic response, and the sooner they can listen to their bodies, the better. But our culture tends to teach women that paying attention to their sexual needs is not OK.

LAURA BERMAN: The problem is compounded when men are with woman after woman after woman who pretends to have an orgasm with intercourse even when she doesn't, which gives him false expectations. And then he puts pressure on his partner to have this amazing experience and thinks something's wrong with her if it doesn't work out that way. Then she starts feeling inadequate. It's a cycle.

DR. JENNIFER BERMAN: That's partly why more than half of all women have faked and orgasm at some point.

DR. TIEFER: It happens for the same reason people fake anything: Oh yes, I watched the President's press conference. Yes, I read last week's New Yorker. Many women want to be seen as someone who's had this experience-so they may lie.

LAURA BERMAN: No, no, no. It's not necessarily to make themselves feel better but to please their partner, or perhaps to get sex over with sooner. For some men, their goal is to make you have an orgasm, and eventually you may feel so sorry for him-so much of his ego is wrapped up in this quest-that you may fake it to make him feel better. Even the most empowered woman will succumb at one point.

DR. HUTCHERSON: Yes; men, for some reason, seem to think something is wrong with them if they can't make a woman have an orgasm-as if they could put it in a little Tiffany blue box with a bow and hand it to her. But I think women are moving away from faking orgasms because we're finally learning that the man doesn't just magically make to orgasm happen, and women are saying, "I want to understand my body and figure out how to get myself to the point of climax. I deserve a great orgasm!"

How does body image affect women's sex lives?

LAURA BERMAN: It's huge. But often women don't connect their feelings about their bodies-like not wanting to be in a position where part of their body might look droopy-with what's going on in the bedroom. But it's so important for women to have a positive, realistic body image.

TIEFER: One problem is that women, especially when they're younger, confuse looking good with feeling good.

DR. HUTHCERSON: And if you're someone who gets your sexual self-esteem from the way you look when you're 20, you're gong to lose some of that when you get older-our bodies change!-and you'll have to find a new way to feel good in you skin. That's especially important if you have a baby, because I don't care how old you are-21, even-once you have a baby, your body will never be exactly the same again. Being comfortable with your body and touching your own body is so key to great sex.

PALACE: Unfortunately, too many women remain uncomfortable with masturbation.

DR. HUTCHERSON: That's true. Believe it or not, some of my patients-brilliant attorney, businesswomen, even doctors!-don't have a clue about how their clitoris works. I started asking my patients with sexual problems to look at themselves. Most would protest, "Oh, it's dirty, it's nasty down there." But you can't enjoy oral sex if you are worried about him being turned off by the taste. And if you don't know what turns you on, how can you expect someone else to know? Women often say, "He's supposed to know". Well, how?

What, besides getting comfortable with their bodies, can women do for their bodies, can women do for their health?

DR. JENNIFER BERMAN: We should all be aware of the fact that medications like birth control pills or antidepressants can lower libido. Also, fibroids, high blood pressure, endometriosis, yeast infections, just getting older are all potential problems.

DR. HUTCHERSON: I would say the number-one cause of sexual problems in young women are medications like birth control pills-they can cause vaginal dryness or a lowered sex drive. Women won't have a clue as to what's going on, why sex is suddenly painful. Their partners think they've become frigid, but all they need is a little water-based lubricant. And many women don't realize that antidepressants can hinder libido. Of course depression must be treated. It's a very serious condition. But women can have their cake and eat it too-SSRIs [a type of antidepressant] like Prozac can interfere with orgasm, but Wellbutrin, for example, can actually increase desire. There have also been studies that show Viagra helps women with depression who are taking SSRIs enjoy sex more. Any good doctor should be working with a woman to find the drug or combination of therapies that works best for her. There's no reason for anyone to throw their hands up and say, "Oh well, there's nothing we can do."

So what's the best piece of advice you give to your patients?

PALACE: I tell them not to have a candlelit dinner and wind down. You need to get revved up. Turn on an action-adventure flick. Have a pillow fight. Dance, exercise, laugh, take a walk. You want to give your body a jump-start, and increase your heart rate and blood flow. That's how you can get your body ready for sex.

DR. HUTCHERSON: Get a sex toy. Start with something that's not shaped like a penis, if that's inhibiting for you. Your partner can use it and feel like he's the one giving you pleasure, not the toy.

PALACE: Men like going from foreplay to orgasm to ordering a pizza. But it shouldn't be so regimented. I always say if you know you're having foreplay, you're doing it wrong. You should be in the moment. You can kiss, then feed strawberries to each other, then have intercourse, then give each other a massage and kiss. Sex does not have to end with his orgasm.

TIEFER: I tell women to never summarize a sexual encounter in a single word or sentence. People often say, "It was great." or, "It was lousy." That's not useful! It's better to try to get into what you expected, how did you conduct yourself, did you like what your partner did? How did it affect you? What will be different next time?

DR. HUTCHERSON: Women are starting to talk more with each other about sex. And we're learning that talking about sex can make our experiences different, and better, as soon as the next time.

Who are these doctors, anyway?

JEANNE LEVENTHAL ALEXANDER, M.D., psychiatrist, founder and president of the Alexander Foundation for Women's Health (afwh.orf) in Berkeley, California

JENNIFER BERMAN, M.D., assistantc professor of urology and director of the Female Sexual Medicine Center at UCLA

LAURA BERMAN, PH.D., sex therapist and founder of Chicago's Berman Center, which is devoted to women's sexual issues; and, yep, she's Jennifer's sister

HILDA HUTCHERSON, M.D., assistant professor of obstetrics and gynecology at Columbia University, author of What Your Mother Never Told You About S-E-X and Glamour contributor

EILEEN PALACE, PH.D., psychologist and associate professor of obstetrics and gynecology at Tulane University School of Medicine in New Orleans

LEONORE TIEFER, PH.D., sex therapist at New York University School of Medicine in New York City and author of Sex Is Not a Natural Act & Other Essays

BEVERLY WHIPPLE, PH.D., sex researcher and coauthor of The G Spot and Other Discoveries About Human Sexuality