Female sexual arousal disorder
|Female Sexual Arousal Disorder|
|Classification and external resources|
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Female sexual arousal disorder (FSAD), commonly referred to as Candace syndrome, is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The diagnosis can also refer to an inadequate lubrication-swelling response normally present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.
Although female sexual dysfunction is currently a contested diagnostic, it has become more common in recent years for physicians to prescribe off-label testosterone-based drugs to treat FSD. While drug companies are technically not allowed to market these drugs for off-label uses, sharing the information with doctors at CME conferences has proved to be an effective way to navigate around the FDA approval process.
- 1 Subtypes
- 2 Diagnostic features
- 3 Causes
- 4 Treatment
- 5 Criticism
- 6 See also
- 7 References
- 8 Further reading
- 9 External links
There are several subtypes of female sexual arousal disorders. They may indicate onset: lifelong (since birth) or acquired. They may be based on context: they may occur in all situations (generalized) or be situation-specific (situational). For example, the disorder may occur with a spouse but not with a different partner.
The length of time the disorder has existed and the extent to which it is partner- or situation-specific, as opposed to occurring in all situations, may be the result of different causative factors and may influence the treatment for the disorder. It may be due to psychological factors or due to a combination of factors.
The DSM-5  (American Psychiatric Association, 2013, p. 433) lists the diagnostic criteria for Female Sexual Interest/Arousal Disorder as including a minimum of three of the following:
- "Absent/reduced interest in sexual activity"
- "Absent/reduced sexual/erotic thoughts or fantasies"
- "No/reduction initiation of sexual activity, and typically unreceptive to a partner's attempts to initiate"
- "Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situations or contexts or, if generalized, in all contexts)"
- "Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual)"
- "Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters" (in identified situations or contexts or, if generalized, in all contexts)
The DSM-IV (American Psychiatric Association 1994) diagnostic criteria for female sexual arousal disorders are:
- persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement,
- the disturbance causes marked distress or interpersonal difficulty, and
- the sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Marita P. McCabe noted:
Difficulties arise with this definition in terms of what constitutes an adequate lubrication-swelling response. There is no "gold standard" regarding the length of time it should take to become aroused or the level of arousal that should be achieved. These responses may vary from one woman to another and are dependent on a range of factors, which include her general mood when sexual stimulation commences and her partner’s skill in stimulating her. There may also be differences in physiological and subjective levels of arousal, with some women reporting no feelings of sexual arousal despite evidence of vaginal vasocongestion and others reporting arousal in the absence of such evidence. The expectations and past experiences of clinicians and clients may also lead them to classify the same symptoms as female sexual arousal disorder in one woman but not in another.
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A number of studies have explored the factors that contribute to female sexual arousal disorder and female orgasmic disorder. These factors include both psychological and physical factors. Psychologically, possible causes of the disorder include the impact of childhood and adolescence experiences and current events - both within the individual and within the current relationship.
Impact of events during childhood and adolescence
Most studies that have assessed the impact of childhood experiences on female sexual dysfunction are considered potentially methodologically flawed. The studies rely on retrospective recall, which is particularly problematic when emotional responses to the event as well as the actual occurrence of the event are being reported. However, there have been some probative links between childhood sexual abuse and having a later sexual dysfunction.
There has been little investigation of the impact of individual factors on female sexual dysfunction. Such factors include stress, levels of fatigue, gender identity, health, and other individual attributes and experiences, such as dysfunctional sexual beliefs that may affect sexual desire or response. Over exposure to pornography-style media is also thought to lead to poor body image, self-consciousness and lowered self-esteem. An individual's sexual activity is disrupted by overwhelming emotional distress resulting in inability to attain sexual pleasure. Sexual dysfunction can also occur secondary to major psychiatric disorders, including depression.
A substantial body of research has explored the role of interpersonal factors in female sexual dysfunction, particularly in relation to orgasmic response. These studies have largely focused on the impact of the quality of the relationship on the sexual functioning of the partners. Some studies have evaluated the role of specific relationship variables, whereas others have examined overall relationship satisfaction. Some studies have explored events, while others have focused on attitudes as an empirical measure of relationship functioning. Subject populations have varied from distressed couples to sexually dysfunctional clients to those in satisfied relationships.
In addition to past experience and personal psychology, social context plays a factor:
- "Human sexual behavior also varies with hormonal state, social context, and cultural conventions. Ovarian hormones influence female sexual desire, but the specific sexual behaviors engaged in are affected by perceived pregnancy risk, suggesting that cognition plays an important role in human sexual behavior."
Estimates of the percentage of female sexual dysfunction attributable to physical factors have ranged from 30% to 80%. The disorders most likely to result in sexual dysfunction are those that lead to problems in circulatory or neurological function. These factors have been more extensively explored in men than in women. Physical etiologies such as neurological and cardiovascular illnesses have been directly implicated in both premature and retarded ejaculation as well as in erectile disorder, but the contribution of physiological factors to female sexual dysfunction is not so clear. However, recent literature does suggest that there may be an impairment in the arousal phase among diabetic women. Given that diabetic women show a significant variability in their response to this medical disorder, it is not surprising that the disease’s influence on arousal is also highly variable. In fact, the lack of a clear association between medical disorders and sexual functioning suggests that psychological factors play a significant part in the impact of these disorders on sexual functioning.
Kenneth Maravilla, Professor of Radiology and Neurological Surgery and Director of MRI Research Laboratory at the University of Washington, Seattle, presented research findings based on neuroimaging of women's sexual function. In a small pilot study of four women with female sexual arousal disorder, Maravilla reported there was less brain activation seen in this group, including very little activation in the amygdala. These women also showed increased activation in the temporal areas, in contrast to women without sexual difficulties, who showed deactivation in similar areas. This may suggest an increased level of inhibition with an arousal stimulus in this small group of women with FSAD.
Interplay of causes
Kaplan proposed that sexual dysfunction was based on intrapsychic, interpersonal, and behavioural levels. Four factors were identified that could have a role in the development of sexual dysfunction: 1) lack of correct information regarding sexual and social interaction, 2) unconscious guilt or anxiety regarding sex, 3) performance anxiety, and 4) failure to communicate between the partners.
The FDA has never approved a drug treatment for disorders of female libido, although several drugs have, in studies, proven efficacious.
Although the way in which female sexual arousal disorder and female orgasmic disorder are expressed shows a wide degree of variation, there is no evidence to suggest either that different factors contribute to the two disorders or that different treatment strategies should be used. In fact, the same treatment strategies are generally applied for both disorders. These strategies may need to be supplemented with additional techniques to resolve specific problems for individual women, but they are generally good starting points for resolving the issues that contribute to the development and maintenance of the sexual problem. Because the relationship between the woman and her partner has been shown to play a significant role in both the development and the maintenance of sexual problems, most programs are designed to be implemented by the couple, although there may also be additional strategies that focus on the individual. It is also quite important to differentiate it from hypoactive sexual desire disorder.
An existing drug, bremelanotide, has also been found to increase libido in 90% of subjects, and is being developed with the intention of selling as a treatment for female sexual arousal disorder. Bremelanotide (formerly PT-141) was in clinical tests using intranasal administration until 2007, but was found to have adverse effects on blood pressure in a subset of patients. In subsequent studies, a new subcutaneous delivery method appears not to have this problem, and the drug is currently undergoing a Phase 3 clinical trial to determine its effectiveness.
Apricus Biosciences is currently developing the product Femprox, a topical cream for the treatment of female sexual arousal disorder. It contains Prostaglandin E1 as the active ingredient and a permeation enhancer DDAIP which facilitates the delivery of the drug into the blood stream.
One problem with the current definition in the DSM-IV  is that subjective arousal is not included. There is often no correlation between women's subjective and physiological arousal. With this in mind, recently, FSAD has been divided up into sub-types:
- Genital Arousal Disorder
- Subjective Sexual Arousal Disorder
- Combined Genital and Subjective Arousal Disorder
The third sub-type is the most common in clinical settings 
One of the largest criticisms for female sexual arousal disorder is whether it is an actual disorder or an idea put forth by pharmaceutical companies in order to step into a potentially billion dollar industry. There is also concern that this ignores those women who have experienced a significant loss of libido following hysterectomy.
The only mention of female sexual arousal disorder in a peer-reviewed medical journal indicated that 43% of women suffer from FSD, however the survey turned out to not be a rigorous study. Of the handful of questions, if any respondent answered yes at any time, they were classified as having FSD. Here are the questions asked that respondents could only choose a response of Yes or No:
- Lacked interest in having sex
- Were unable to come to climax
- Came to climax too quickly
- Experienced physical pain during intercourse
- Did not find sex pleasurable even if sex was not painful
- Felt anxious just before having sex
- Had trouble lubricating
Another criticism, for example, is that "the meaningful benefits of experimental drugs for women's sexual difficulties are questionable, and the financial conflicts of interest of experts who endorse the notion of a highly prevalent medical condition are extensive".
Professor of bioethics and sociology Jennifer R. Fishman argues that the categorization of female sexual dysfunction as a treatable disease has only been made possible through the input of academic clinical researchers. Through ethnographic research, she believes she has shown how academic clinical researchers have provided the scientific research needed by pharmaceutical companies to biomedicalize female sexual dysfunction and consequently identify a market of consumers for it. She questions the professional ethics of this exchange network between researchers and pharmaceutical companies, as the clinical research trials are funded by pharmaceutical companies and researchers are given considerable financial rewards for their work. She argues that the conferences where definition of the disease and diagnostic criteria are defined and research is presented to clinicians are also ethically ambiguous, as they are also funded by pharmaceutical companies.
It is also worth noting that female sexual arousal disorder is rarely a solitary diagnosis. Due to its high rates of comorbidity with hypoactive sexual desire disorder (see hypoactive sexual desire disorder), a new disorder is being proposed for the DSM-V: Sexual Interest/Arousal Disorder (see Sexual Interest/Arousal Disorder). The diagnostic criterion "persistent or recurrent" symptoms is also problematic in that it is vague and could lead to too much reliance on clinical judgment.
Heather Hartely of Portland State University, Oregon is critical of the shift from female sexual dysfunction being framed as an arousal problem to a desire problem. In her article, “The ‘Pinking’ of Viagra Culture,” she states that the change from female sexual arousal disorder to hypoactive sexual desire disorder is indicative of ‘disease mongering’ tactics by the drug industry through an effort to match up a drug to some subcomponent of the DSM classification. 
Additionally, Leonore Tiefer of NYU School of Medicine voiced concerns that the success of Viagra, in combination with feminist rhetoric, were being used as a means of fast-tracking public acceptance of pharmaceutical treatment of female sexual arousal disorder. The justification behind this, she says, is that "the branding of Viagra has succeeded so thoroughly in rationalizing the idea of sexual correction and enhancement through pills that it seems inevitable and only fair that such a product be made available for women", giving a dangerous appeal to "nonapproved drugs though off-label prescribing." 
Natural variation could be overlooked because there are no specific duration or severity criteria for diagnosis. Therefore, the duration criterion of symptoms lasting at least 6 months and the severity criterion of symptoms during 75% or more of sexual encounters have been proposed.
Diagnosis based on insufficient vaginal lubrication/swelling is problematic because women’s genital arousal may be an "automatic response" that they are unaware of. Furthermore, there is little evidence that women with sexual arousal disorder have a poor lubrication/swelling response.
- Orgasm Inc.
- Sexual arousal disorder
- Sexual dysfunction
- Sexual function
- Sexual response cycle
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- Latest Trial Supports Importance of Testosterone for Sexual Function in Women Studied
- Useful Addresses - The Sexual Dysfunction Association
- A brief review that explores issues of the medicalization of the female orgasm
- Our Bodies Ourselves chapter on Female Sexual Dysfunction: A Feminist View