In the previous chapter, the definition and clinical treatment of female sexual arousal disorder (FSAD) were described. When thinking about FSAD, one should ask what women really mean when they talk about arousal. In the DSM-IV-TR and ICD-10, the diagnostic criteria for FSAD focus on the physical responses of the genitals, as increased blood flow results in tumescence of the genitals and vaginal lubrication, which is highly influenced by age, vascular response, and neurologic and endocrine state [1–4]. So, is it only the physical genital response that women describe when they refer to sexual arousal? Some women may describe the physical genital response, whereas others may talk about being “turned on” and “feeling excited” and describe a more subjective picture not necessarily focused on the genitals. Interestingly, the DSM-III-R described arousal as either an impaired genital response or lack of a subjective sense of sexual excitement , with the latter portion of the definition excluded in the DSM-IV. Consequently, most recent epidemiological studies have focused on the physical genital response in assessing the prevalence of arousal problems, showing a steep increase with age and menopause attributable to hormonal and vascular changes .
Janssen and colleagues state that arousal can be described by two components in which the mind’s processing of sexual stimuli is of importance: (1) conscious and unconscious processing leading to an automatic genital response and (2) a cognitive process appraising the sexual content of the stimulus [7, 8]. Based on these observations, FSAD can be described as both a diminished genital response and/or a lack of appraisal of the response in the genitalia and absence of a reaction to sexual stimuli.
In 2003, Basson et al. suggested a new classification of FSAD including (1) genital sexual arousal disorder, with a focus on the genital response; (2) subjective arousal disorder, with a focus on the woman having absent or diminished feelings of sexual arousal (excitement or pleasure), even though the genital response is intact; and (3) combined sexual arousal disorder including difficulties in both genital and subjective arousal . These definitions encompass a broad group of women. Genital FSAD would embrace women with a clear genital impairment such as postmenopausal women and women with adverse effects stemming from antihormonal treatment after breast cancer or after radiation therapy or surgery involving the pelvic floor. The subjective FSAD would include women that might have problems with recognizing, processing, or appraising their genital response, consequently with a lack of subjective excitement, and the combined definition would encompass women with problems in both domains. However, the suggested classifications were not incorporated into any broadly applied diagnostic systems. Instead, in the recent changes in the DSM-5, a new disorder was created, female sexual interest/arousal disorder (FSAID) [1, 4], which has led to significant debate [10–12]. One of the major drawbacks of the FSAID definition is that women with a predominantly genital arousal disorder, such as that resulting from antihormonal treatment or pelvic radiation therapy, but with intact desire (spontaneous or receptive) would not be diagnosed with FSAID despite their problem stemming from a lack of arousal.
There is evidence that, especially for women, genital sexual arousal responses do not always coincide with the subjective experience of being aroused and “turned on” and that the women’s experience may be based more on the interpretation of the situation than on the genital response [13, 14]. Thus, for some women, the objective and subjective aspects of arousal do not coincide. As such, are arousal problems in women without any evident impairment of genital response due to an inability to identify sexual cues from their genitals as suggested by Barlow et al. and not a lack of genital response ? There is likely more than one answer—some women may have a genital impairment, whereas others may have normal genital response but do not recognize it as they are more focused on the lack of subjective arousal. Alternatively, some women may not receive sufficient sexual stimuli or do not fully perceive the stimuli they receive.
In the post-phosphodiesterase 5 inhibitor (PDE5i) era, several studies have investigated the possible beneficial effect of PDE5i’s for women with FSAD alone or combined with desire or orgasmic disorders . The majority of these studies showed that while PDE5i’s increase both vaginal and clitoral blood flow along with vaginal lubrication, they do not, in a majority of the studies, improve female sexual function significantly when compared with placebo. This may reflect the fact that most studies evaluated premenopausal women, in whom the genital response is unlikely to be impaired, and the complaints were better accounted for by a “subjective FSAD” or the fact that even though the women had an increased genital arousal, whether or not they perceived it, it did not alter their phenomenological or subjective sense of arousal. For them, unlike many men using the same drugs, increased vasocongestion did not correlate with an increased sense of erotic arousal.
So what are the clinical and research implications? First, we need to specify what we mean when we talk about FSAD, both as researchers and clinicians. Is it objective or subjective arousal or a combination? Different disciplines may focus on different aspects of FSAD, which will have implications for how we approach the problem and which questions we apply to research, diagnosis, and defining individualized treatments. An ongoing debate about the definition of FSAD is necessary, not only to clarify the diagnostic criteria, which will help identify affected women, but ultimately to benefit all the women who are candidates for treatment and who are currently overlooked. With our female patients, we need to explore how women define arousal and how they individually interpret it.
A better understanding of FSAD will also have implications for treatment choice. Some studies have shown beneficial effects of PDE5i’s in women where it is more likely that there is a biologically determined genital component of dysfunction, such as women with spinal cord injury (for a review, see ) or the many postmenopausal women in whom estrogen treatment relieves the symptoms of genital FSAD [16–18]. On the other hand, women with subjective FSAD may benefit from approaches that help focus the woman’s attention on an increased genital response. The studies from Brotto have shown that mindfulness training that focuses on recognizing what is happening in the body found a positive effect on self-assessed genital wetness despite little or no change in actual physiological arousal and a marginally significant improvement in subjective and self-reported physical arousal during an erotic stimulus . Other studies have shown that distraction is associated with lower levels of genital arousal . An interesting new pharmacological concept is to develop pharmacological treatment that enhances both the genital response using a PDE5i and the sensitivity to recognize the sexual cue from the genitals using testosterone, as described by Poels et al. . Both the pharmacological as well as the psychotherapeutic treatments need to be further investigated to better define efficacy and the group of patients who may benefit from these approaches.
In conclusion, arousal is not just arousal and may be perceived differently by individual women, clinicians, and researchers. Furthermore, the definitions of arousal disorders have changed with every new version of the DSM, with the focus shifting between genital and subjective aspects. Our continued clinical and research experiences continuously drive the development of a better understanding of pathologic mechanisms and subsequent treatment modalities, integrating medical and psychotherapeutic approaches.
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