Drug Treatments for Women's Sexual Disorders

Journal of Sex Research, August, 2000 by Walter Everaerd, Ellen Laan

Drug treatment for women's sexual disorders is a relatively new field. We will review possible prosexual treatments and will attempt to explain responsible psychophysiological and behavioral mechanisms, to eventually arrive at relevant insight into the workings of the drugs. We begin with a description of what is known about women's sexual disorders and the psychophysiology of women's sexual response. We will briefly consider subjective experience and relevant physiological changes in the domains of behavior, cognition, and emotion, with specific attention to sexuality. This will function as a background for a sketch of drug effects on hypoactive sexual desire, arousal disorders, and inhibited orgasm.

The picture we will be sketching is a rather bleak one. There is not much consensus and standardization in any of the separate domains of female sexual dysfunction. Despite steady progress over the past decades, knowledge of female sexual function still seriously lags behind that of male sexual function. With the advent of the new vasoactive drugs, interest in female sexual dysfunction is now rapidly increasing. This upsurge in attention has once again uncovered the lack of consensus and knowledge in the field of female sexuality.

WOMEN'S SEXUAL PROBLEMS

Several studies investigated the prevalence of sexual dysfunctions in women (e.g., Garde & Lunde, 1980; Laumann, Paik, & Rosen, 1999; Rosen, Taylor, Leiblum, & Bachmann, 1993; Spector & Carey, 1990). The National Health and Social Life Survey of Laumann et al. is both the most recent and the largest study. One third of the women report lack of sexual interest, and almost one fourth of the women don't experience orgasm. A little bit less than 20% have lubrication difficulties, and more than 20% find sex not pleasurable. An addition of these numbers shows the widespread prevalence of sexual complaints. Also, these data suggest substantial comorbidity of sexual problems (Laumann et al., 1999). Data were collected by presenting subjects with seven dichotomous response items, measuring presence of symptoms during the past months. The items covered the DSM-IV classification of sexual dysfunctions (American Psychiatric Association [APA], 1994). However, the implication that these data allow an assessment of the prevalence of sexual dysfunction remains uncertain. From the simple yes/no answers it seems impossible to estimate whether the subjects meant to indicate sexual problems (dysfunctions) or problems with sex (difficulties). The classification of all these answers as dysfunctions may easily result in an overestimation of their prevalence. Frank, Anderson, and Rubinstein (1978) reported that in their sample 50 percent of the men and 77 percent of the women reported difficulty that was not dysfunctional in nature. It further appears that the number of difficulties reported was more strongly and consistently related to overall sexual dissatisfaction than the number of dysfunctions.

In the current DSM-IV classification system female sexual disorders are described as disturbances in desire, arousal, and orgasm; there is a separate sexual aversion disorder and there are two sexual pain disorders, dyspareunia and vaginismus (APA, 1994). Although it is widely accepted, this classification system lacks objective, empirically grounded criteria.

Derogatis and Conklin-Powers (1998) recently formulated a hypothesis on how the disorders are related to the widely accepted Human Sexual Response Model by Kaplan (1974) and Masters and Johnson (1966). They suggested that the majority of DSM-IV categories reflect disruptions in sexual arousal. An example may be vulvar vestibulitis. According to Meana, Binik, Khalife, and Cohen (1997a, 1997b), vulvar vestibulitis is the most frequent cause of dyspareunia in premenopausal women. Vulvar vestibulitis is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to a cotton-swab palpation of the vestibular area, and local red spots that are not necessarily related to the intensity of the pain. Several authors have suggested that an arousal disorder may underlie this (e.g., de Jong, Ramakers, & van Lunsen, 1998). Having sex without sufficient sexual arousal may lead to pain. Repeated intercourse without arousal may result in vulvar infections and chronic irritation, and may even lead to secondary vaginismus, fear of sex, or the avoidance of sexual activity altogether.

To further complicate matters, we suggest it is very unlikely that hypoactive sexual desire and female orgasmic disorder are unrelated to arousal. Orgasm without arousal is impossible, and lack of arousal can lead to lack of desire. Why would someone have desire for something that does not excite her or him? In fact, Segraves and Segraves (1991) reported that in their sample of 906 people comorbidity of hypoactive sexual desire and sexual arousal disorders was high.

The concept of sexual desire is problematic for yet another reason. The Human Sexual Response Model is a sequential model; it places desire before arousal (Kaplan, 1995). But how are we to conceive of sexual desire if there is not already sexual activation of some kind? In our model of sexual response, desire is part of arousal, triggered by a stimulus that has sexual meaning, regulated, that is, facilitated or inhibited, by situational and sexual partner variables (Everaerd, Laan, Both, & van der Velde, 2000; Everaerd, Laan, & Spiering, 2000).