Female Sexual Frustration: Abandoning the labels for a new pleasure paradigm 

Picture this: You are a 35-year-old heterosexual woman, married to the same man for eight years. It’s Saturday night, the kids are in bed, and you and your hubby are engaged in some fabulous foreplay. But your mind is wandering. Worries of work assignments, daycare schedules, and due bills distract you. You push away these thoughts and try to lose yourself in the moment. You feel your body responding. You are getting really aroused. Oh…oh…almost…then…nothing. Nothing happens. The experience feels good and you appreciate the intimacy you share with this man you have loved for so long, but where were the fireworks? Where was the orgasm?

What if this is not the first time that desire has led to arousal, to excitement, and finally to disappointment? What if you have not climaxed in a few days? Or weeks? Or what if you have never experienced an orgasm? You start worrying about why you cannot reach that elusive pleasure point that seems so easy for everyone else. What’s wrong with you? You start to dread sex with your spouse because you fear orgasm will never come. What’s a girl to do?

As a married heterosexual woman, I have experienced sexual difficulties like this from time to time. And I know many heterosexual women like myself who struggle with their own sexual pleasure. These women either don’t desire sexual activity as frequently as they used to or they don’t desire sex as frequently as their partners would like them to. Or perhaps they have difficulty getting aroused or having an orgasm. They are not alone.

Female sexual dissatisfaction is a problem for many American women. According to the 1999 National Health and Social Life Survey, 43% of women have had problems in their sex lives at one time. The number of women unhappy with their sexual experiences is likely to increase as the 41 million baby boomer women reach menopause. Although many doctors and therapists agree that female sexuality is an important issue to address, disagreement abounds on what constitutes a problem and, if there is a problem, how to resolve it. Unfortunately, little sex positive information is available.

Both the mind and the body are involved in the sexual experience. When a woman experiences an orgasm, the smooth muscles in the clitoris and labia relax, allowing blood to fill the clitoris and vagina. The vagina also secretes lubrication throughout the process. The entire process is triggered when nerve cells from the brain send messages to the genital area. The degree of intensity differs for each woman and there are no defined requirements for orgasm to occur. But many women experience difficulty in having an orgasm because the clitoris and vagina fail to fill with blood. In addition, the psychological issues that affect a woman’s orgasm include emotional, physical or sexual abuse, early psychological trauma, poor relationships, substance abuse, depression, anxiety, and psychiatric illnesses. Emotional factors include feelings of inadequacy, sadness, anger, and a sense of failure. Psychotropic medications may also inhibit an orgasm.

A Physical Problem?

According to an article by Nancy Phillips in American Family Physician, many physicians are not properly trained to treat sexual difficulties and the whole topic makes them uncomfortable. Margaret Nusbaum and Carol Hamilton cite in an article in American Family Physician that only 35% of primary care physicians often or always take a sexual history of their patients. Many physicians fail to ask their patients about their sexual history because they are embarrassed, they do not feel prepared to ask such personal questions, or they do not believe that the patient’s sexual history is related to the patient’s current complaint.

Of the doctors who are comfortable discussing sexual difficulties, many focus on the physical component of female sexual response to resolve this dilemma. Medical doctors are attempting to map out the path of an orgasm from the brain to the clitoris. Researchers are also developing mechanical devices to stimulate female genitalia. In April 2000 the FDA approved the Eros-CTD (clitoral therapy device), the only authorized machine for the treatment of female sexual dysfunction (FSD). The Eros is a battery operated gadget, about the size of a computer mouse, which works like a vacuum to increase blood flow to the clitoris and promote lubrication in the vagina. The Eros is available by prescription only and costs about $400. According to an article by Diane Martindale in New Scientist, women who tried the Eros device liked it so much that they refused to return them after the study!

But none of this research compares to the time and money that has been invested in creating vasoactive drugs to increase female libido and enhance sexual pleasure for women. Ever since the introduction of Viagra for men in 1998, society has become more comfortable discussing sexual concerns. Viagra helps men achieve an erection by slowing down the breakdown of nitric oxide, which relaxes the smooth muscles in the penis. This magic blue pill has proven to be a financial success, too. Doctors (and pharmaceutical companies) wondered if such a potion would help women climax since nitric oxide is also found in female genitalia. Early studies suggested that Viagra helped women with arousal disorder by relaxing the smooth muscles in the clitoris, resulting in increased genital sensation, lubrication, and arousal. But the results proved no more effective than the placebo. After eight years of study on 3,000 subjects, in February of last year the makers of Viagra gave up on creating a “female Viagra.”

Dysfunction as a Mental Disorder

Meanwhile, psychologists and psychiatrists continue to examine other contributors to sexual difficulties. The Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR, 2000) is currently used to diagnose sexual problems. Through the use of diagnostic categories and criteria, mental health practioniers determine if a client’s symptoms meet the requirements needed to diagnose and treat a mental illness. Sexual disorders are listed in the DSM-IV-TR in Axis I under the category Sexual and Gender Identity Disorders. With an emphasis on psychological as opposed to physiological causes, this category further divides sexual dysfunctions into desire disorders, arousal disorders, pain disorders, dysfunctions due to a general medical condition, substance-induced sexual dysfunction, and sexual dysfunction not otherwise specified.

This classification system follows the triphasic model, originally developed by Masters and Johnson (1966) and continued by Kaplan (1979), which describes sexual response through the stages of arousal to desire to orgasm. The DSM-IV-TR contains qualifications for various FSDs that may occur at any point in the triphasic model. According to the American Psychological Association, the six most commonly diagnosed dysfunctions are: (a) Hypoactive Sexual Desire Disorder, which occurs with reduced libido when the client does not actively desire sex, yet does not actively resist an initiating partner; (b) Sexual Aversion Disorder, which occurs when the client rejects all genital sexual contact either through fear or anger; (c) Female Sexual Arousal Disorder, which includes lack of lubrication and genital sensation; (d) Female Orgasmic Disorder, signaled by a woman having difficulty achieving orgasm through intercourse or stimulation; (e) Dyspareunia, a sexual pain disorder in which intercourse causes vulvar, vaginal, or pelvic pain; and (f) Vaginismus, the other sexual pain disorder in which involuntary spasms of the perineal muscles prevent vaginal penetration. All classifications are further specified as lifelong or acquired, generalized or situational, and due to psychological, biological, or combined factors. Healthy women can experience any of these symptoms on occasion; it only becomes a dysfunction when it reoccurs and causes interpersonal distress. Clients frequently fail to fit into any particular category or fall into several.

Limitations of DSM Classification

Treating female sexual problems as it does male sexual dysfunction, DSM-IV-TR assumes that women follow a strict pattern of arousal to plateau to orgasm. But many women simply do not function this way and most do not separate desire from arousal. Women’s sexuality tends to be more fluid and malleable, whereas men’s arousal is more automatic. Various causes for FSD include problems that are physical (e.g., diabetes, obesity, and other biological diseases), emotional (e.g., stress, depression, guilt, fear of pregnancy), sociocultural, political, economic (e.g., poor sex education, fatigue from family and work obligations) and partner/relationship related (e.g., differences in sexual appetite). Yet the DSM classifications for female sexual dysfunction use measures of arousal, vaginal lubrication, and orgasm as predictors for female sexual dysfunction. These techniques focus on biological causes, ignoring crucial emotional information in the definitions of female sexual problems.

In a 1999-2000 survey performed by John Bancroft et al, researchers questioned 987 women between the ages of 20 and 65 years and asked them about any sexual problems they might have. They examined various possible causes for sexual problems including stress, fatigue, age, relationship difficulties, detrimental sexual histories, early traumatic sexual experiences, and physical or hormonal effects. They concluded that 24.4% of women reported distress in some aspect of their sexuality. Mental health, level of education, general emotional well being, and their relationship with their partner were the best predictors of distress. Socioeconomic factors, particularly a recent loss of income, provided another stress indicator that contributed to sexual problems.

While doctors assume they can diagnose and treat sexual problems without regard to the relationships in which they occur, many women care less about physical arousal than subjective arousal, and women’s complaints frequently focus on difficulties that are not included in the DSM classifications. For example, many women have sexual difficulties due to lack of intimacy or fear of losing or angering their partner. For women, simply medicalizing the problem will not solve anything.

Still, the DSM-IV classifications may bring relief to people by giving the conditions increased recognition and providing a framework in which people can better understand them. The classification also gives legitimacy to the conditions, which makes them eligible for insurance coverage. Yet the categorization of sexuality into medical terms also normalizes and stigmatizes of people with “abnormal” levels of desire and orgasms. Sexual variations from the norm are treated as diseases and labeled as dysfunctions. Interestingly enough, the current DSM-IV-TR sexual dysfunctions were developed by 19 experts in female sexual disorders in 1999 at a meeting of the Sexual Function Health Council of the American Foundation for Urologic Disease. Pharmaceutical companies, including Pfizer Inc., Proctor & Gamble Pharmaceuticals, and Eli Lilly/ICOS Pharmaceuticals, supported the conference.

A New View

The medicalization of sexuality views desire as a universal biological drive. Medical diagnoses provide treatments that focus on “fixing” the individual through therapy, pharmaceuticals, and stimulation exercises. The goal is to change the individual, not society. This essentialist viewpoint ignores cultural and historical factors, such as the social boundaries of men and women. Men have power over women and this power transfers into the bedroom. If a woman is not sexually satisfied, why do experts immediately assume there is something wrong with her? The problem might not be internal, but due to external factors. Without an examination these, the specific meanings and purposes involved in sexual activity remain unknown.

Fortunately, a new paradigm is emerging. In 2000 a group of clinicians and social scientists began developing an alternative perspective of women’s sexual problems. Participants took a feminist viewpoint and created a new standard for female sexual dissatisfaction that Leonore Tiefer describes as “discontent with any emotional, physical, or relational aspect of sexual experience.” By combining biological and social influences, this view emphasizes sociopolitical and relationship causes for women’s sexual problems including political inequality, lack of sex education, and the prevalence of depression in women. This feminist alternative encourages women to identify their own sexual problems and provides no “normal” pattern of behavior for comparison. The New View of Women’s Sexual Problems outlines four categories: (a) sexual problems that result from sociocultural, political, or economic factors; (b) those related to partner and relationship issues; (c) those created by individual psychology; and (d) those caused by medical or physical factors.

Furthermore, the New View includes a new classification system that avoids the labels and stigmas associated with the DSM. The new system eliminates the guilt placed on the individual. According to Tiefer, this new paradigm focuses on prevention of female sexual problems through increased education, access to healthcare, and political equality. The New View also demands increased public and research attention to the complexity of female sexual problems.

The opening story described the frustration of a heterosexual woman who desired orgasms. According to DSM-IV-TR, which assumes a heterosexual model of sexual behavior, orgasm is the goal for everyone. But is an orgasm required for fulfillment? Most women would say no. By focusing on achieving the “normal” amount of desire and experiencing orgasm during sexual activity, the medical model can reinforce stereotypes that foster impossible expectations for female sexual experiences. This stereotype implies that sexual intercourse is required for “real” sex to occur and that orgasm is necessary for “good” sex to take place. Men have become so preoccupied with pleasing their partners that women feel obligated to climax. But women (and their male partners) cannot realistically expect women to climax each time!

If doctors applied The New View paradigm, there would be less normalizing and stigmatization of female sexuality. Women would be given the opportunity to explore the full potential of their sexual pleasure and attack barriers, be they cultural, political, economic, medical, physical, relationship related, or individual based. For this married heterosexual women, that’s a huge turn on.

Rachel Pearson is a graduate student in psychology at Wichita State University, studying female sexual pleasure in Midwestern women. She can be reached at rachel.pearson@wichita.edu.