In this section we discuss the most frequent sexual problems of women.

Arousal Problems

Also referred to as hypoactive sexual desire, lack of interest in sex is the most frequent sexual problem reported by women in the United States. Colson et al. (2006) also noted that diminution of sexual desire was the primary sexual complaint of 519 French women. Lack of interest and difficulty becoming aroused (Quirk et al., 2005) may be caused by one or more factors, including restrictive upbringing, nonacceptance of one’s sexual orientation, learning a passive sexual role, and physical factors such as stress, illness, drug use, and fatigue. Dennerstein (2006) also noted that menopause may be related. More often, lack of interest in sex and difficulty in becoming aroused can be explained by the woman’s emotional relationship with her partner. In addition to a negative emotional context, there may be lower testosterone levels in women reporting low sexual desire.

          The treatment for lack of interest in sex depends on the underlying cause or causes of the problem. The following are some of the ways in which lack of sexual desire can be treated.

         1. Improve relationship satisfaction. Treating the relationship before treating the sexual problem is standard therapy in treating any sexual dysfunction, including lack of interest in sex. A prerequisite for being interested in sex with a partner, particularly from the viewpoint of a woman, is to be in love and feel comfortable and secure with the partner. Sammons (2003) emphasized the role of subjective mental factors in a woman’s sexual arousal. Couple therapy focusing on a loving egalitarian relationship becomes the focus of therapy. Lau et al. (2006) also emphasized the importance of trust in one’s partner as a prerequisite for positive sexual functioning.

         2. Practice sensate focus. Sensate focus is a series of exercises developed by Masters and Johnson used to treat various sexual dysfunctions. Sensate focus may also be used by couples who are not experiencing sexual dysfunction but who want to enhance their sexual relationship. In carrying out the sensate focus exercise, the couple take turns pleasuring each other in nongenital ways, with each taking turns giving and receiving pleasure (while getting feedback from the partner about what is and is not pleasurable). On subsequent occasions, genital touching is allowed, but orgasm is not the goal. Indeed, the goal of sensate focus is to help the partners learn to give and receive pleasure by promoting trust and communication and by reducing anxiety related to sexual performance.

         3. Be open to re-education. Re-education involves being open to examining and reevaluating the thoughts, feelings, and attitudes learned in childhood. The goal is to redefine sexual activity so that it is viewed as a positive, desirable, healthy, and pleasurable experience. A national study of Finnish w inomen shows dramatic changes in their reported increases in sexual satisfaction. Women from unreserved and nonreligious homes who had high education and who were sexually assertive reported the greatest pleasure in sexual intercourse (Haavio-Mannila and Kontula, 1997). The authors suggested that increased emancipation of women would be associated with increases in sexual pleasure experienced by women.

         4. Consider other treatments. Other treatments for lack of sexual desire include rest and relaxation. This is particularly indicated where the culprit is chronic fatigue syndrome (CFS), the symptoms of which are overwhelming fatigue, low-grade fever, and sore throat. Still other treatments for lack of sexual desire include hormone treatment and changing medications (if possible) in cases where medication interferes with sexual desire. In addition, sex therapists often recommend that people who are troubled by a low level of sexual desire engage in sexual fantasies and masturbation as a means of developing positive sexual images and feelings.

         In 2004 Proctor and Gamble applied to the Food and Drug Administration (FDA) to market Intrinsa, a drug to treat women who experienced low libido and who wanted to feel more sexual desire. The patch would be worn by the woman to provide a continuous dose of testosterone. However, the 14-member FDA advisory committee, plus voting consultants, for Reproductive Health Drugs unanimously rejected the request.  The panel cited insufficient research to document the safety of the drug for premenopausal women who may be taking estrogen as well as estrogen with progesterone.  There was a fear that if the drug were made available to surgically menopausal women that physicians would prescribe the drug for other populations (referred to as “off label” use).  Intrinsa is available in the United Kingdom, France, and Germany. Controlled studied are yet to be published on its effectiveness.

         Discrepant interests in sexual behavior can be a catastrophic problem in marriage. How couples manage this dilemma varies. While some compromise their frequency of sex, others agree that the partner with the higher interest may have other sexual partners. A unique solution of one couple where the husband wanted sex once a day and the wife wanted it once every two weeks was for the husband to nightly look at pornography on the Internet and masturbate. Said the wife… “He’s still in the house, gets his nightly orgasm/ejaculation, and we don’t have to get tangled up the problems of an extramarital affair.”

Unpleasurable Sex

Sex that is not pleasurable may be both painful and aversive. Pain during intercourse, or dyspareunia, occurs in about 10 percent of gynecological patients in the United States. Colson et al. (2006) noted that 15.5 percent of 519 French women identified dyspareunia as the primary sexual complaint. Dyspareunia may be caused by vaginal infection, lack of lubrication, a rigid hymen, or an improperly positioned uterus or ovary. Because the causes of dyspareunia are often medical, a physician should be consulted. Sometimes surgery is recommended to remove the hymen.

         Dyspareunia may also be psychologically caused. Guilt, anxiety, or unresolved feelings about a previous trauma, such as rape or childhood molestation, may be operative. Therapy may be indicated.

         Some women report that they find sex aversive. Sexual aversion, also known as sexual phobia and sexual panic disorder, is characterized by the individual’s wanting nothing to do with genital contact with another person. The immediate cause of sexual aversion is an irrational fear of sex. Such fear may result from negative sexual attitudes acquired in childhood or sexual trauma such as rape or incest. Some cases of sexual aversion may be caused by fear of intimacy or hostility toward the other sex.

         Treatment for sexual aversion involves providing insight into the possible ways in which the negative attitudes toward sexual activity developed, increasing the communication skills of the partners, and practicing sensate focus. Understanding the origins of the sexual aversion may enable the individual to view change as possible. Through communication with the partner and through sensate focus exercises, the individual may learn to associate more positive feelings with sexual behavior.

Inability to Achieve Orgasm

Orgasmic difficulty, also referred to as inhibited female orgasm, or orgasmic dysfunction, occurs when a woman is unable to achieve orgasm after a period of continuous stimulation. Colson et al. (2006) noted that 15.5 percent of 519 French women identified orgasm difficulty as the primary sexual complaint. Difficulty achieving orgasm can be primary, secondary, situational, or total. Situational orgasmic difficulties, in which the woman is able to experience orgasm under some circumstances but not others, are the most common. Many women are able to experience orgasm during manual or oral clitoral stimulation but are unable to experience orgasm during intercourse (i.e., in the absence of manual or oral stimulation).

         Biological factors associated with orgasmic dysfunction can be related to fatigue, stress, alcohol, and some medications, such as antidepressants and antihypertensives. Diseases or tumors that affect the neurological system, diabetes, and radical pelvic surgery (e.g., for cancer) may also impair a woman’s ability to experience orgasm.

         Psychosocial and cultural factors associated with orgasmic dysfunction are similar to those related to lack of sexual desire. Causes of orgasm difficulties in women include restrictive childrearing and learning a passive female sexual role. Guilt, fear of intimacy, fear of losing control, ambivalence about commitment, and spectatoring may also interfere with the ability to experience orgasm. Other women may not achieve orgasm because of their belief in the myth that women are not supposed to enjoy sex.

         Relationship factors, such as anger and lack of trust, can also produce orgasmic dysfunction. For some women, lack of information can result in orgasmic difficulties (e.g., some women do not know that clitoral stimulation is important for orgasm to occur). Some women might not achieve orgasm with their partners because they do not tell their partners what they want in terms of sexual stimulation out of shame and insecurity. Or, even in those cases where the woman is open about her sexual preferences, the partner may be unwilling to provide the necessary stimulation. Hence, a cooperative partner rather than a nonorgasmic woman should be the focus for resolution.

         Kelly et al. (2006) found that inorgasmic women were more likely to be in marriages where there was poorer communication. Specifically, marriages where the wife had difficulty achieving an orgasm were characterized by greater blame and conflict.

         Since the causes for primary and secondary orgasm difficulties vary, the treatment must be tailored to the particular woman. Treatment can include enhancing positive communication, rest and relaxation, testosterone injections, or limiting alcohol consumption prior to sexual activity. Sensate focus exercises might help a woman explore her sexual feelings and increase her comfort with her partner. Treatment can also involve improving relationship satisfaction and teaching the woman how to communicate her sexual needs. Teaching the woman how to masturbate is also a frequent therapeutic option. The rationale behind masturbation as a therapeutic technique for a nonorgasmic woman is that masturbation is the behavior that is most likely to produce orgasm and can enable her to show her partner what she needs. Masturbation gives the individual complete control of the stimulation, provides direct feedback to the woman of the type of stimulation she enjoys, and eliminates the distraction of a partner.