Introduction

One of the side-effects of the introduction of sildenafil (Viagra®) has been increased interest in the possibility that medication might be discovered to address sexual dysfunction in women. The pharmaceutical industry has not been backward in exploring this opportunity. Although "Female Sexual Arousal Disorder" and "Female Orgasmic Disorders" are included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), there is considerable controversy over the definition of the more common term "sexual dysfunction" and, indeed, its frequency in women.

In 1999 a study was reported that concluded that FSD affected 43% of American women.¹ This extraordinarily high rate has been widely quoted, but more recently the concept of "dysfunction" has come under scrutiny in a study conducted by staff at the Kinsey Institute, Indiana. It raises the question whether absence or reduction of sexual interest or response is necessarily dysfunctional. The investigators deliberately use the term "sexual distress" instead of dysfunction in their work, to allow for assessment of how bothersome the problem is to women. Here's a summary of their report.

Method

A telephone survey of women in a heterosexual relationship for over 6 months was carried out. Random digital dialing was used to survey women between 20 and 65 about their sexual experiences in the previous month. Computer-assisted interviewing was done, to reduce embarrassment, interviewer influence, or bias, and to enhance participation. A fee of $25 was paid for completion of the interview. If someone refused, but subsequently agreed to be interviewed, she was paid $50.

Sexual distress was assessed by two questions: "During the past 4 weeks, how much distress or worry has your sexual relationship caused you?" and "During the past 4 weeks, how much distress or worry has your own sexuality caused you?" Participants could answer 'none', 'slight', 'moderate', or 'great distress'; relatively few people responded with 'moderate' or 'great', so the results for these response categories were combined to form a 'marked distress' category.

In addition to the questions on sexual experience, the survey included items that covered basic demographics and aspects of physical and mental health.

Results

The sample consisted of replies from 987 women, which represented a responder rate of 53.1%. Missing data on one or more questions led to a useable data base of 853 cases. Weighting was done to make the sample results more representative of the general US population.

A total of 24.4% of the women had 'marked distress' about their sexual relationship, their own sexuality, or both. Analyses were done to determine the likely predictors of distress. Increasing age had only a modest effect on both types of distress.

For distress about the sexual relationship, mental health scores were highly significant; the higher the level of mental health, the less likely the occurrence of distress. Physical health had a lesser effect, but in the same direction. A greater level of sexual distress was reported in women who had not been sexually active in the previous month. Premature ejaculation by the man was also associated with more distress in the woman.

Distress about their own sexuality was very similar to that for sexual relationships. However, high mental and high physical health scores were about equal as predictors of lower distress levels.

The physical characteristics of sexual response in women - arousal, vaginal lubrication, and orgasm - were poor predictors of their reported distress. They were more commonly impaired in the older women, but there was no clear correlation with 'distress' levels.

Comment

The investigators observe that their findings regarding the prediction of sexual distress don't fit well with the criteria used for FSD in the DSM-IV. The overall findings suggest that lack of emotional well-being and negative emotions during sexual relations are the most important determinants of sexual distress in women.

How do these findings compare with the 1999 report of 43% of US women having FSD? In fact, this study found 44.3% of women with an absent or impaired sexual response, but only 24.4% who reported marked distress. After reviewing five other publications in the field, the authors of this study conclude that conflicting frequencies depend largely on the definition of "a problem". Many cases of sexual dysfunction may not constitute a problem to the woman concerned.

They illustrate this with their findings on age. Low sexual interest was significantly more common in older women, but when the association between low interest and marked distress was considered, the age factor 'largely disappeared'.

One can reconcile the 43% frequency of sexual dysfunction and the 24.4% frequency of sexual distress by accepting that about 20% of women can be sexually dysfunctional, but it doesn't distress them. And this may be more common as women get older. The conclusion may sound facile, but it could help clarify some of the apparent uncertainty in readers' minds!