What’s So Distressing About Female Sexual Dysfunction?

Many of my middle-aged patients experience female sexual dysfunction (FSD) of one sort or another, but not all of them seem particularly perturbed by it and others seem distraught about it. Why are some women more distressed by FSD than others?

Female sexual dysfunction (FSD) is the term used to describe various sexual problems, including low desire, diminished arousal, orgasm difficulties, and dyspareunia. FSD is common, with a widely quoted prevalence of ~43%, a percentage derived from large population-based surveys in the United States and Europe.1 Considered more clinically relevant, however, is the fact that the American Psychiatric Association, the American Urological Association, and the US Food and Drug Association (FDA) include in the definition of FSD that it produces personal distress.

In 2006, the Women’s International Study of Health and Sexuality (WISHeS) study² evaluated 952 pre- and postmenopausal women regarding their experience with sexual desire. Prevalence of HSDD ranged from 9% in naturally postmenopausal women to 26% in younger surgically postmenopausal women. HSDD prevalence was significantly greater among surgically postmenopausal women aged 20-49 years than premenopausal women of similar age, whereas there was no significant difference in the prevalence of HSDD between surgically postmenopausal women aged 50-70 years and naturally postmenopausal women. The women classified as having HSDD (via validated questionnaires) were significantly more likely than those with normal sexual desire, to agree with statements expressing negative emotional states, including feelings of frustration, hopelessness, anger, loss of femininity, and decreased self-esteem.

Prevalence Associated with Distress and Determinants of Treatment Seeking Behavior (PRESIDE) study,³ published in 2008, was a large cross-sectional, population-based survey of 31,581 US women. Among this group, 43.1% reported having at least one sexual problem, and approximately 12% reported experiencing a distressing sexual problem (defined as reporting both a sexual problem and sexually-related personal distress). The most prevalent sexual problem associated with distress was low desire, which affected approximately 1 in 10 women. Correlates of sexually-distressing problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence. Among women with distressing desire problems, most were <55 years of age, with a current partner. Most also experienced co-existing sexual problems (eg, problems with arousal or orgasm). Several health problems, particularly depression, were positively correlated with distressing lack of desire. Decreased sexual desire was also associated with poor self-image, mood instability, and strained relationships with partners. 

In 2009, Biddle et al⁴ published a study conducted on 1189 postmenopausal women. Using quality-of-life surveys, the researchers asked women about their levels of sexual desire and feelings of emotional and physical wellbeing or distress. Results confirmed that women with low sexual desire with distress were likely to be depressed and to express dissatisfaction with their home life and with their sexual partners. Women with HSDD also scored lower on measurements of vitality and social functioning than did women without HSDD. 

Also in 2009, the National Women’s Health Resource Center and the Association of Reproductive Health Professionals designed a survey to explore women’s attitudes regarding their sexual health.⁵ In this national survey of 1200 women, 70% confirmed that they had experienced a sexual health problem and 22% felt very or extremely concerned about the problem. The most common problem was lack of sexual desire. Of the respondents who experienced a sexual health problem, 66% noted that it caused them to experience stress and anxiety, 44% reported adverse effects on their romantic relationship(s), 43% reported adverse effects on their self-esteem, 28% reported an effect on their sleep patterns, and 28% reported an effect on their weight. The results also showed that most women ranked having a healthy sexual life higher than career satisfaction, home ownership, travel, and social life.

Most recently, preliminary results of the Desire and its Effects on Female Sexuality Including Relationships (DESIRE) study were reported at the International Society for the Study of Women’s Sexual Function in February 2010.⁶ Data suggested that low sexual desire with distress was a common problem, experienced by 11.6% of the more than 65,000 women surveyed. The respondents represented several countries in Europe, including France, Germany, Italy, Spain, and the United Kingdom. Of the 5098 women who completed in-depth surveys about the experience of having low sexual desire, 28.7% were unhappy about their sexual relationship, 36% felt guilty about their sexual difficulties, 28.5% were frustrated by their sexual problems, 21.6% reported feeling stressed about sex, 24.7% had regrets about sexuality, 32.8% were distressed about their sex life, 23% were angry about their sex life, 36.3% felt dissatisfied with their sex life, and 18.1% felt inferior because of their sexual problems. Women with HSDD were more likely to be perimenopausal and married, and to be more often in a long-term relationship (>24 months) than in a newer  relationship (<24 months) . More studies are needed to elucidate the exact relationship between negative emotional states and HSDD, particularly in terms of whether negative emotions predate or are the result of HSDD in women. What is clear is that women with low sexual desire do experience adverse effects and are often saddened  by their sexual problems. They may feel confused and upset because they “want to want to have sex.”

There are presently no FDA-approved pharmacologic treatments for low sexual desire. However, given the large number of women who experience sexual health problems, nurse practitioners need to provide women with accurate, unbiased information about female sexuality. Fortunately, many sexual health concerns, including lack of sexual desire, can be successfully addressed through direction to educational resources, suggestions for lifestyle changes, and referrals for individual and/or couples counseling. Women should be routinely evaluated for sexual health concerns and encouraged to continue their dialogue with their NP andwith their partner.