However, there is little doubt that these problems exist.
In the late 90's a landmark, large-scale survey of sexual dysfunction in women was reported in the Journal of the American Medical Association. This survey of more than 1,700 American women reported that:
- 33 % of respondents complained of low libido
- 20 % experienced problems with arousal
- 25 % failed to achieve orgasm regularly
- 15 to 20 % reported discomfort during intercourse
‘This last figure varied according to the age of the women, with younger women being more susceptible,’ said Dr. Stephen Holzapfel, director of the Sexual Medicine Counselling Unit at Women's College Hospital and associate professor in the departments of family and community medicine, obstetrics and gynecology at the University of Toronto.
'A surprising number of these women push themselves to have intercourse through persistent pain.’
Holzapfel cautions against taking the survey’s results as a final statement about female sexuality, noting that definitions of sexual health vary with place and time.
‘In Victorian times, for instance, women who lusted for sex and experienced orgasm were seen as sick and deviant. Today, these women are seen as healthy and their sexually quieter sisters are labelled dysfunctional, when they just might be at the low end of the normal spectrum.’
Still, many sexually active women feel there’s something missing in their sex lives. They may respond, to some degree, to their partner’s advances, but only rarely make the first move. They sense that sex could be a more compelling experience, but don’t quite know how to make it happen.
A declining sexual response can reflect emotional issues in the woman’s life and her relationships. Particularly for women approaching menopause, it may also be associated with hormonal changes
Emotional issues
‘Arousal is simpler for men and more complex for women,’ said Holzapfel. In the beginning of a relationship the discrepancy is masked by novelty and excitement. But he says that when the relationship settles, ‘men continue to get aroused by simple visual clues like seeing their partner undress, while arousal for women becomes more context-dependent.’
In other words, women in long-term relationships need a context of intimacy to jump-start their sexual desire, whereas men typically use sex as a conduit to intimacy. Which is why, when one of his female patients complains of a lacklustre libido, Holzapfel always begins by assessing the ‘state of the union’ between the woman and her partner.
After the birth of a child or with the passage of time, many couples stop displaying the loving behaviours that stoke a woman’s sexual response, he says. His prescription for these couples is to express appreciation to your partner, even if it feels awkward at first. Also, schedule ‘wicked weekends’ sans kids at least four times a year.
‘Such measures may sound trite, but in my practice I’ve found that they really do work,’ said Holzapfel.
Karen Kaffko, a psychologist and sex therapist in private practice in Toronto, challenges couples to revise their 'mental picture' of sex.
‘Many couples give up the necking and petting that got them all revved up when they were dating, and come to equate sex with intercourse, which of course is very boring,’ she said.
In therapy, Kaffko helps couples redefine sex as an encounter that results in arousal, rather than in penetration or orgasm. ‘This forces them to be more creative and intimate, and also less anxious, since there are no orgasm Olympics to compete in.’
Kaffko also treats women whose sexual response suffers from what she calls 'negative self-talk' about sex. These women may have come from a family that looked on sex with suspicion, or may have a history of sexual abuse.
Through cognitive-behavioural therapy, Kaffko helps them challenge their internalized assumptions about sex. ‘It doesn’t happen overnight, but progress is certainly possible.’
Depression, which affects at least twice as many women as men, also wreaks havoc on sexual response.
‘Part of what gets depressed is the sex drive,’ said Holzapfel. Ironically, many antidepressants that boost serotonin further lull desire and genital sensitivity in about two-thirds of long-term users.
Some people find that waiting until after they’ve had sex before taking their daily dose of medication, or interrupting their drug regimen when they expect to have sex, is enough to normalize their sexual response. But such 'drug holidays' can be dangerous unless closely supervised by a doctor.
Hormonal changes
Many women also experience a decline in sexual interest in the years leading up to and following menopause. This should come as no surprise, said Holzapfel, since menopause wipes out about half of a woman’s testosterone (the hormone that drives desire in both men and women) and 80 % of her estrogen.
The vaginal dryness that accompanies diminishing estrogen can easily cause women to lose interest in sex.
‘Vaginas aren’t stupid,’ said Holzapfel. ‘If they’re in pain, they’ll make sure that desire shuts down so they won’t have to go through the experience again.’ Hormone replacement therapy, genital lubricants or simple peanut oil can sometimes remedy the problem.
Some doctors may offer women with vaginal dryness the medication Viagra, which in men enhances blood flow to the pelvic region. In women, physicians hope that the little blue pills will restore plumpness and sensitivity to the vaginal tissues.
‘Though it’s not officially approved for use in women, doctors do prescribe it,’ said Holzapfel. However, studies of Viagra in women have produced disappointing results so far.
Doctors who suspect that a woman has low testosterone can order a blood test and, if the levels are indeed low, initiate testosterone replacement therapy (TRT).
Although TRT is also not currently approved for use in women, doctors will prescribe it, said Dr. Nancy Durand, a gynecologist at Women's College Hospital. Available by injection, as pills, or as a topical cream, testosterone can cause unwanted hair growth and liver impairment, so patients on TRT need to be closely monitored by their physician.
Durand cautions that women shouldn’t expect testosterone to solve all their sexual problems.
‘Some women with low testosterone have great libidos, and others with normal blood levels have low desire,’ she said. Consequently, TRT does not always influence low libido. Still, about 30 to 50 % of patients on TRT report a significant improvement.
Regardless of a patient’s age and specific sexual complaint, Durand prefers to refer her (and her partner) to a therapist to explore her complaints as well as doing lab tests and taking supplements, if indicated.
Women may manifest their conflicted feelings about a relationship as sexual dysfunction, she says. As such, ‘the best prevention is a healthy relationship.’
