By Lead writer: Louise Sloan
February 29, 2016

couple-sex-therapist-dysfunctionWomen's sex problems were long ignored; are we overcompensating?(PHOTODISC/GETTY IMAGES)

When a woman with a sex problem sits down with a doctor or sex expert, they're up against centuries of sexist stereotypes—and a raging debate about how to undo those stereotypes.

Uneven diagnosis and treatment is still a problem: While a man with a sexual dysfunction is likely to be taken seriously and given treatment by his doctor, women are likely to be told to "relax," according to sexual medicine experts and frustrated patients alike, suggesting the problem may be "all in her head."

But does this mean that "female sexual dysfunction" is underdiagnosed? Or are some doctors going overboard, slapping the word dysfunction on anything that doesn't fit within a narrow definition of normal? The debate continues, with profound effects on women's sexual health and health care.

What's normal?
According to a widely cited 1999 analysis published in the Journal of the American Medical Association, 43% of all women (and 31% of men) surveyed reported experiencing an episode of a sexual problem, such as lack of interest in sex, difficulties with orgasm or erection, or finding sex painful. Such troubles were labeled "sexual dysfunction," and researchers said it's a "significant public health concern." Treatments must be found, they said—especially for women.

But is it really dysfunction if it's happening to almost half of all women? Or is it actually normal? "We can't as physicians tell people what is normal," says Irwin Goldstein, MD, director of San Diego Sexual Medicine and the editor in chief of The Journal of Sexual Medicine. Yet sex drives and sexual response that falls short of that nonexistent "normal" have spawned a lucrative industry of sex-related pharmaceuticals and sexual health centers, like the one Dr. Goldstein himself runs.

One side charges "creeping medicalization"
A New York Times article responding to the 1999 study questioned whether classifying occasional periods of low desire as "dysfunction" was an example of "creeping medicalization." (The article also noted that two of the survey's authors had been paid consultants to Pfizer, the maker of Viagra.) Some sexuality experts share the concern with "medicalization":

"The problem is with telling women that the normal ebbs and flows of their desire or their hormonal state are 'dysfunction,'" says Joy Davidson, PhD, a New York City–based psychologist who's on the board of directors of the American Association of Sexuality Educators, Counselors and Therapists. "If you say for two weeks out of the past year you had no interest in sex ... Well, maybe you were stressed out at work, maybe you were pissed off at your husband. Maybe you had the flu! You can be a very sexually healthy, sexually vital person, but there may be times when your sex drive is low. That's not a dysfunction; that's life!"

Leonore Tiefer, PhD, a psychiatry professor at NYU School of Medicine with more than 35 years of experience as a sexologist, goes so far as to call the idea of female sexual dysfunction "disease-mongering," and she has spearheaded a campaign against it. (She's talking about "dysfunctions" of desire and arousal, not about sexual pain, which she acknowledges can be a medical issue.)

"Sexuality is much more a cultural matter than it is a biological matter," Dr. Tiefer asserts. A woman might lack desire for a host of nonmedical reasons: because she's been sexually abused, or has been taught that sex is dirty, or because she's not that attracted to her partner, or she's angry at him, or she's just too tired because she's a full-time worker and full-time mom, getting no help with the housework. And losing desire and sexual function after menopause is just a natural part of life, not necessarily a dysfunction that requires medical treatment and the side effects that often come along with pharmaceuticals.

  Next Page: Just because sex problems are natural doesn't make them OK

[ pagebreak ]Just because sex problems are natural doesn't make them OK
"Hurricanes, AIDS, and earthquakes are all natural, but not desirable," counters sexual medicine specialist Andrew Goldstein, MD, an associate professor at George Washington University. He asks: How dare a doctor deny a woman's wish to get back her sexual pleasure? A woman in the audience at one of Dr. Tiefer's lectures about the naturalness of losing libido after menopause reportedly protested, in the question-and-answer session afterwards: "But I liked sex!"

The medical doctors who treat sexual health problems do acknowledge that many sexual problems are socially, culturally, or emotionally based. In fact, an American Academy of Family Physicians guide to treating female sexual dysfunction notes that "sexuality incorporates family, societal, and religious beliefs, and is altered with aging, health status, and personal experience. In addition, sexual activity incorporates interpersonal relationships—each partner bringing unique attitudes, needs, and responses into the coupling."

So are sex problems psychosocial or biological?
"I think both issues are real," says Marjorie Green, MD, director of the Mount Auburn Female Sexual Medicine Center in Cambridge, Mass., and a clinical instructor at Harvard Medical School. Dr. Green says she prescribes therapy as often as she prescribes drugs.

All the sexual medicine practitioners interviewed by agreed that cultural and emotional issues are, in fact, the most common cause of low libido and orgasm problems. But they point out that sex is also a biological matter, strongly controlled and affected by the neurological, vascular, and endocrine systems—i.e., our brains, nervous systems, blood flow, and hormones. Things that go wrong in any of those areas can cause sexual distress. And scientists are finding that our emotions actually cause chemical changes in our bodies.

Biology and psychology overlap in the study of sex drive and sexual function more than in most other areas of human health.