The epidemiology and definition of female sexual disorders

World J Urol (2002) 20: 74–78 DOI 10.1007/s00345-002-0272-5 T O P I C P A PE R Aristotelis G. Anastasiadis Æ Anne R. Davis Mohamed A. Ghafar Æ Martin Burchardt Ridwan Shabsigh The epidemiology and definition of female sexual disorders Published online: 3 May 2002 Ó Springer-Verlag 2002 Abstract Female sexual dysfunction (FSD) is a multifactorial condition that has anatomical, physiological, medical, psychological, and social components. Similar to erectile dysfunction in men, FSD is highly prevalent and often undertreated. Due to the development of successful treatment for male erectile dysfunction, FSD is receiving increased attention. Only a few studies dealing with epidemiology of female sexual dysfunction are available in the literature. However, research efforts in the field are increasing. This overview presents currently used classification systems, recently updated definitions, as well as prevalence data on the different entities of female sexual disorders. U.S. women, indicate that a third of women experience loss of sexual interest and nearly a fourth do not experience orgasm [12]. Sexual dysfunctions may impact significantly on mood, self-esteem, quality of life, cause emotional distress, and lead to relationship problems [11]. In contrast to basic and clinical research in the field of male sexual dysfunction, the sexual problems of women have received relatively little attention. However, after the introduction of effective and safe oral medication for male erectile dysfunction, FSD has attracted significant attention in the last few years, raising important questions concerning its epidemiology and classification. Keywords Female sexual dysfunction Æ Epidemiology Æ Definitions Classification systems Female sexual dysfunction (FSD) is a complex set of conditions, associated with multiple biological, medical, and psychological risk factors. FSD can be age related and appears to be highly prevalent, affecting 20%–50% of women [3]. Data from the National Health and Social Life Survey (NHSLS), a large representative sample of A.G. Anastasiadis Æ A.R. Davis Æ M.A. Ghafar R. Shabsigh (&) Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA E-mail: [email protected] Tel.: +1-212-3050123 Fax: +1-212-3050126 M. Burchardt Department of Urology, Heinrich-Heine-Universität, Düsseldorf 40225, Germany R. Shabsigh New York Center of Human Sexuality, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, Dana Atchley Pavilion, 11th Floor, New York, NY 10032, USA Most FSD classification systems are based upon the models of the sexual response cycle of Masters and Johnson, and Kaplan [10, 13]. Masters and Johnson first characterized the female sexual response as consisting of four successive phases: excitement, plateau, orgasmic, and resolution [13]. In the 1970s, Kaplan proposed the aspect of ‘‘desire’’ and a three-phase model, consisting of desire, arousal, and orgasm [10]. The phase of sexual desire consists of the motivational or appetitive aspects of sexual response, and includes sexual urges, fantasies, and wishes. The phase of sexual excitement refers to a subjective feeling of arousal or sexual pleasure and accompanying physiologic changes, includes vaginal lubrication and genital swelling. The orgasm is defined as the peak of sexual pleasure, with the rhythmic contractions of the genital musculature. In the final phase, resolution, a general sense of relaxation and well-being is experienced [15]. This four-phase model forms the basis for the classification of FSD in the fourth edition of the Diagnostic and Statistical Manual of Mental disorders (DSM-IV) [1]. In the DSM-IV, sexual dysfunctions are defined as ‘‘disturbances in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal 75 difficulty.’’ FSD includes hypoactive sexual desire disorder (HSDD, 302.71), sexual aversion disorder (302.79), female sexual arousal disorder (FSAD, 302.72), female orgasmic disorder (302.73), and sexual pain disorders, including dyspareunia (302.76) and vaginismus (306.51). According to the World Health Organization International Classifications of Diseases-10 (ICD-10), the definition of sexual dysfunction includes ‘‘the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish’’ [24]. Specific categories in the nomenclature include a lack or loss of sexual desire (F52.0), sexual aversion disorder (F52.1), failure of genital response (F52.2), orgasmic dysfunction (F52.3), nonorganic vaginismus (F52.5), nonorganic dyspareunia (F52.6), and excessive sexual drive (F52.7). Both classification systems are based on the sexual response cycle, and both include subjective distress as a criterion in their definitions. However, neither classification system for female sexual dysfunction distinguishes between psychogenic and organically based disorders. In 1998, an international multidisciplinary consensus development conference on female sexual dysfunction was convened to begin to address the shortcomings and problems associated with the abovementioned previous classifications [3]. The 19 selected panelists from five countries represented a wide range of disciplinary backgrounds, including endocrinology, family medicine, gynecology, nursing, pharmacology, physiology, psychiatry, psychology, rehabilitation medicine, and urology. The objective of the panel was to evaluate and revise existing definitions and classifications of female sexual dysfunction, results presented in Table 1. The four major categories of dysfunction described in the DSM-IV and ICD-10 were preserved in order to maintain continuity in research and clinical practice. However, the definitions of several disorders have been altered to reflect current clinical and research practice, and a new category of sexual pain disorder, including noncoital sexual pain, has been added [3]. Sexual desire disorders Hypoactive sexual desire disorder Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent deficiency (or absence) of sexual Table 1. Classification of female sexual dysfunction, according to the 1999 consensus classification system [3] I. Sexual desire disorders A. Hypoactive sexual desire disorder B. Sexual aversion disorder II. Sexual arousal disorder III. Orgasmic disorder IV. Sexual pain disorders A. Dyspareunia B. Vaginismus C. Other sexual pain disorders fantasies/thoughts, and/or desire for or receptivity to sexual activity, which causes personal distress [3]. According to the DSM-IV, hypoactive sexual desire is the persistent lack (or absence) of sexual fantasies or desire for any form of sexual activity [1]. The new definition expands the concept of receptivity. Thus, the large group of women with only responsive desire are not pathologized [2]. Basson clarifies the following subgroups of apparent HSDD: 1. Women with retained ability but low motivation to capitalize on responsive desire who continue to have sexual thoughts, dreams, or fantasies. 2. Women with retained ability but low motivation to capitalize on responsive desire but with minimal sexual thoughts, dreams, or fantasies. 3. Women unable to respond to sexual cues, which would be expected to trigger responsive desire, but who retain ongoing sexual thoughts, dreams, or fantasies [2]. HSDD may be secondary to other sexual dysfunctions, such as anorgasmia. It may also result from a variety of medical and psychiatric conditions, as well as partner conflicts and loss of attraction. Low desire is a highly prevalent sexual problem in both men and women [15]. In the population based NHSLS, 33.4% of women between the ages of 18 and 59 experienced low sexual desire for at least a few months of the last year. Low desire was more common in women with the lowest education levels (42%) and in AfricanAmerican women (44%) [12]. HSDD may be related to age and increasingly prevalent above the age of 60 in both sexes [17]. Low desire is more common in those with comorbid medical and psychiatric disorders, particularly chronic illnesses and depression. Loss of libido is a frequent complaint of patients taking antihypertensive or antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs) [5, 16]. However, whether these medications cause low libido has yet to be determined in prospective studies. Women are more commonly affected by HSDD than men; the female to male ratio is about 2:1 or 3:1, and in some reports, even higher [15]. Female patients with arousal or orgasmic disorder may also have a secondary diagnosis of HSDD. Relationship conflict is often cited as an important causal factor for HSDD in women, specifically lack of trust and intimacy, conflicts over power and control, and loss of physical attraction to the partner [17]. In one study, women with HSDD reported increased frequency in premarital sex, poorer marital adjustment, and diminished feelings of emotional closeness with their partners [22]. Sexual aversion disorder Sexual aversion disorder is the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress [3]. The 76 prevalence of sexual aversion disorder is currently unknown, since it is considered a subcategory of HSDD and, therefore, separate prevalence data for this disorder are not available. A history of sexual trauma or abuse is associated frequently with this disorder in the clinical literature [15, 17]. Sexual arousal disorder Female sexual arousal disorder (FSAD) is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses [3]. The consensus definition accepts the interplay of psychological and biological factors and allows the woman who may be lubricated but who lacks mental excitement to be diagnosed with FSAD [2]. Disorders of arousal can include decreased labial and clitoral sensation and engorgement, and the lack of vaginal smooth muscle relaxation. FSAD may be associated with psychological factors or underlying medical conditions, which lead to diminished vaginal or clitoral blood flow. Prior pelvic surgery, trauma, or medications can be etiologically responsible [4]. Women with FSAD may experience pain with intercourse due to inadequate lubrication and vaginal irritation. Although sexual arousal problems are common in both sexes, FSAD is less well characterized than its male counterpart, erectile dysfunction. According to the NHSLS, approximately 20% of women ages 18–59 reported difficulty in becoming lubricated during sexual stimulation [12]. Similar results were reported in a large British study, where ‘‘Problems with arousal’’ and ‘‘Vaginal dryness’’ were reported as a current problem by 17% and 28% of all female respondents, respectively [6]. 49% of the women with vaginal dryness reported this as a lifelong problem. In another study of 329 women attending an outpatient gynecology clinic, 13.6% of women experienced a lack of lubrication during most or all sexual activity and 23.3% reported having this problem on occasion [18]. Among the postmenopausal women in this study, the incidence of lubrication problems increased to 44.2%. It should be noted that, depending upon the definition of the disorder and the type of sample studied, the prevalence of FSAD can vary greatly. Orgasmic disorder Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress [3]. With the consensus definition, there is a recognition that if the woman does not have a definite release during her experience of arousal, and if this lack of release is not distressing to her, she does not have a dysfunction [2]. ‘‘Interpersonal difficulty,’’ mentioned in the DSM-IV definition, possibly resulting from the partner’s attitude toward the situation, does not alone pathologize the woman [1, 2]. Orgasmic disorder may be primary or secondary: primary orgasmic dysfunction or anorgasmia describes a condition, in which the individual has never achieved orgasm through any means of stimulation. In contrast, individuals who are orgasmic with masturbation but not with a partner, are referred to secondary or situational orgasmic dysfunction [13]. Female orgasmic dysfunction is a highly prevalent female sexual problem: The rate of anorgasmia in women among sex therapy clinic samples has been reported to range from 24% to 37% [15]. These rates are comparable to population-based survey studies [6, 18]. According to the NHSLS, the prevalence of anorgasmia is significantly higher in single women, compared with married women [12]. The NHSLS found no relationship between anorgasmia and race, socioeconomic status, and educational or religious background [8, 12]. In the previously mentioned study of 329 women attending an outpatient gynecology clinic, 15.4% of the premenopausal women and 34.7% of postmenopausal women reported having difficulty in achieving orgasm during sexual stimulation [18]. Orgasmic dysfunction has been associated with relationship and psychologic distress factors, decreased satisfaction with marital relationships, concurrent psychiatric disorders, and other relationship conflicts in several studies [6, 8, 14]. A delay or absence of orgasm is a common complaint in women receiving antidepressant medications, particularly SSRIs [16]. This side effect has been reported to occur in up to 50% of some samples, depending on both the type of drug and dosage. The mechanism is unknown. Possible mediators include: drug accumulation, elevated prolactin levels, anticholinergic effects, and inhibition of nitric oxide synthetase [16]. Sexual pain disorders Dyspareunia Dyspareunia is the recurrent or persistent genital pain associated with sexual intercourse [3]. The differential diagnoses include vaginismus, inadequate lubrication, atrophy, and vulvodynia (vulvar vestibulitis). Less common etiologies are endometriosis, pelvic congestion, hymenal scarring, adhesions or infections, and adnexal pathology. Urethral disorders, cystitis, and interstitial cystitis may also cause painful intercourse [7]. Dyspareunia is a common sexual problem. According to the NHSLS, 14.4% of women have experienced pain during sexual activity throughout the past year. In this study, dyspareunia was found to be inversely related to age and minority status [12]. According to the prevously mentioned British survey, 18% of the women reported 77 dyspareunia as a current sexual problem and 45% of these as a lifelong sexual problem [6]. The age groups of the participants, as well as their cultural background, are factors, which might lead to a selection of the sample, thus, resulting in a great variability of prevalence data. In a study from North Carolina, the prevalence of dyspareunia and pelvic pain was assessed using a questionnaire in a clinical population of 701 consecutive women ages 18–45 years in obstetrics and gynecology and family medicine practices. Dyspareunia and pelvic pain were reported by 46% and 39%, respectively. Low income was found to be a risk factor for dyspareunia, and African-American race was found to be a risk factor for pelvic pain. Dyspareunia and pelvic pain were not associated with age, parity, marital status, income, or education [9]. In contrast, a study of 300 healthy women, ages 16–53, who sought services at family planning centers in Tehran, Iran, demonstrated a prevalence of dyspareunia in only 10%. All participants were married and 38% of the women had at least one sexual dysfunction, including inhibited desire (15%), inhibited orgasm (26%), lack of lubrication (15%), and vaginismus (8%) [19]. There are two European studies that address the prevalence of dyspareunia in postmenopausal women. One cross-sectional, nationwide survey studied 2,157 non-institutionalized Dutch women, ages 50–75. The survey sample was representative of the female population aged 50–75 with respect to age, marital status, level of education, and menopausal age. The response rate was 81.6% (n=1,761). The prevalence of vaginal dryness, soreness, and dyspareunia was 27%. [23]. Another study from Sweden showed a prevalence rate of 41% in 630 women in the age group of 61 years [21]. Thus far, dyspareunia is the only female sexual dysfunction in which organic factors have been shown to play a major role, and there is a need to integrate medical and psychologic formulations [15]. Other sexual pain disorders Noncoital sexual pain disorder is recurrent or persistent genital pain induced by noncoital sexual stimulation [3]. This disorder includes anatomic and inflammatory conditions, including infections, vestibulitis, prior genital mutilation or trauma, and endometriosis [4]. The previous classifications can be further subtyped as lifelong vs acquired, generalized vs situational, and organic vs psychogenic or mixed. The etiology of any of the disorders can be multifactorial, and frequently, an overlap of the disorders can be observed. The various FSDs are not mutually exclusive, neither clinically nor epidemiologically. An individual may experience one or more dysfunctions simultaneously or sequentially. Conclusions Female sexual dysfunction is a common, important health concern, which is influenced by medical and psychosocial factors. It is often untreated, and can cause significant personal distress and impact on quality of life. Due to its complex, multifactorial nature, a multidisciplinary approach is often mandatory. Recent advances in the treatment of male sexual dysfunction have initiated a cascade of epidemiological, clinical, and basic research studies in FSD. An important development has been to establish improved definitions of female sexual disorders, which, if adopted widely, will make epidemiologic comparisons more meaningful. However, further research is needed in order to determine the incidence of female sexual dysfunction, establish risk factors, determine its impact on mental and physical health, and develop safe and effective treatment. 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