Women’s Sexual Health in Midlife and Beyond – Introduction

(Published May 2005) Healthy sexuality is a topic that is coming to the forefront in our society. After decades of being closeted as taboo subjects, sexual issues and difficulties are now commonly discussed in the …

(Published May 2005)

Healthy sexuality is a topic that is coming to the forefront in our society. After decades of being closeted as taboo subjects, sexual issues and difficulties are now commonly discussed in the medical and research communities, as well as among the general public and in the mainstream media. With the approval of sildenafil (Viagra®) to treat erectile dysfunction in 1998, research into male sexuality has surged. The little blue pill brought sexuality out of the closet in much the same way that the birth control pill and the sexual revolution did in the 1960s.

Interest in male and female sexuality has increased in the past decade, particularly as pharmaceutical companies race to bring a new drug to support women’s sexual function to the marketplace. Analysts expect the market for therapies to improve women’s sexual function to grow 10 percent between 2004 and 2008,1 with growth impeded by factors such as the regulatory approval process and unexpected research outcomes. Yet women’s sexuality—particularly for midlife and older women—remains less studied and less understood than male sexuality, and many of the theories and beliefs we have about female sexuality appear to be inaccurate.

Epidemiologic data from the National Health and Social Life Survey (NHSLS) suggest that sexual problems affect 43 percent of women in the United States (compared with 31 percent of men).2 This figure has helped spur interest in the development of pharmacologic treatments for women’s sexual problems and is often referenced in discussions of women’s sexuality, yet the percentage has been assailed for a number of reasons, not the least of which is that the lead author was a consultant to Pfizer Inc. in the development of Viagra® at the time the paper was published. The statistic has also been called into question because it emerged from a reanalysis of data from 1,749 women and 1, 410 men aged 18 to 59 years old who responded to the 1992 NHSLS, a probability sample study of sexual behavior. Women who reported any sexual difficulty—lack of desire, difficulty in becoming aroused, inability to experience orgasm, anxiety about sexual performance, reaching orgasm too rapidly, pain during intercourse, or failure to derive pleasure from sex—were considered to have a sexual disorder. Unfortunately, the researchers did not inquire about the respondents’ levels of distress about these problems, which is now believed to be a key component of the diagnosis of a sexual disorder.

Despite the controversy over the veracity of this figure, it appears that women perceive themselves to have more sexual difficulties than men.2 Yet there is far less literature on functioning and treatment for females than for males: a Medline search yields approximately 5,000 references for female sexual disorders and 14,000 references for male sexual disorders (and 9,000 and 17,000, respectively, when the word “dysfunction” is used in place of “disorders”). The assessment of sexual problems in women has often been neglected in clinical trials due to the lack of sensitive and reliable outcome measures, because there is no defining physical event to measure arousal and orgasm as there is for men with penile erection.3 On a more basic level, female sexual problems have been overlooked due to the lack of clear agreement on the definition of terms such as “desire,” “satisfaction,” and “orgasm.” Sexual functioning has also often been an “add-on” element of trials rather than a direct focus.

This, too, is changing. Researchers and providers now recognize that women are very different from men in terms of their sexual response. They are challenging existing beliefs about female sexual response, and several models have been proposed to elucidate that response. These models are the subject of some discussion and controversy because female sexual functioning involves not only physiologic mechanisms (e.g., genital vasocongestion) but psychosocial mechanisms (e.g., feelings about the interpersonal relationship).4-6 Amidst the confusion, it is clear that female sexuality is a complex and evolving area of interest and discovery, and existing paradigms do not apply to all women. Female sexual problems must be approached with a focus on the individual and an emphasis on whether a particular problem causes distress to the individual woman.This focus must extend beyond physical issues to encompass the emotional and relationship milieu in which the problem exists.

Challenging Existing Beliefs About Women’s Sexual Response8
Recently, a group of international experts from multiple disciplines was gathered by the American Foundation for Urologic Disease to review data on women’s sexuality and reconceptualize some of the existing beliefs about female sexual response. Their reasoning and proposed modifications acknowledge the evolving understanding of female sexual function and incorporate a female-centric view of sexuality. Below is a recap of the prevailing beliefs the panel members identified and the corresponding changes they proposed.

Belief 1: Organic sexual problems can be separated from psychogenic problems.
Challenge: Sexual disorders in women may involve multiple psychological, interpersonal, and biologic/organic causes, and these influences are not always separate entities.

Belief 2: The primary reason women engage in sexual behavior is conscious or subliminal awareness of sexual desire (e.g., sexual thoughts or sexual fantasies).
Challenge: Women appear to be motivated to have sex for highly complex and varied reasons. Women in new relationships are more likely to experience spontaneous desire—in the form of
sexual thoughts and fantasies—than are women in established relationships, who may infrequently think of sex.

Belief 3: Sexual desire always precedes sexual arousal.
Challenge: It is now recognized that arousal often occurs before desire for women, or that women may experience desire and arousal simultaneously. Again, desire is not the only reason that women engage in sexual activity; they have a wide variety of other motives, including a wish to be intimate with their partner.

Belief 4: Women’s sexual arousal can be characterized by genital vasocongestion, vaginal lubrication, and an awareness of genital throbbing and tingling.
Challenge: Recent experience suggests that many women who have genital signs of arousal don’t feel subjectively aroused—and many women may not even be aware of the physiological changes that occur in their bodies when they are aroused. Even if they are aware of genital and breast vasocongestion, the changes may not correlate with increased vaginal engorgement as measured by vaginal photoplethysmography. Still, vaginal lubrication typically occurs even when women don’t desire or enjoy sexual stimulation.

Belief 5: The sexual response of women remains stable over time and circumstance.
Challenge: The sexual response of women varies naturally over the lifespan and is influenced by a host of factors, including the context of sexual interactions, pregnancy and menopause, medical conditions, and psychological factors (most notably the interpersonal relationship). Research suggests that a normative, gradual decline in sexual interest and response occurs with aging and natural menopause.

Belief 6: Women feel distress when they experience changes in their sexual response.
Challenge: Many women do not feel distress when they lose interest in sex or experience a lack of response. Unless women do feel distress, these problems are not really problems and are of little clinical relevance.


  1. Sexual dysfunction: Study: female sexual dysfunction drug market to grow 10 percent over next 5 years. Drug Week. December 5, 2003.
  2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544, 1174.
  3. Rosen RC. Assessment of female sexual dysfunction: review of validated methods. Fertil Steril 2002;77(suppl 4):S89-S93.
  4. Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001;98:350-353.
  5. Basson R. A model of women’s sexual arousal. J Sex Marital Ther 2002;28:1-10.
  6. Berman JR, Bassuk J. Physiology and pathophysiology of female sexual function and dysfunction. World J Urol 2002;20:111-118.
  7. Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003;32:193-208.
  8. Basson R, Leiblum L, Brotto L, et al. Definitions of women’s sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynecol 2003;24:221-229.
Dr. Kate Gundy physician with over 20 years of clinical experience in obstetric and gynecologic care. She has additional training and expertise in integrative medicine, medical acupuncture, menopause, female sexual problems, pelvic pain, vulvar pain, and vulvovaginal and gynecologic dermatologic disorders. She has authored work in peer-reviewed journals relevant to her field, including those related to gynecology, women’s health and sexuality, integrative medicine, female chronic pain, and sexual pain.

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