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In Healthy Women with FSAD Genital Response is not Impaired. Response to “Genital Responsiveness in Healthy Women—What about Subjective Genital Engorgement?”
Letters to the Editor
295
In Healthy Women with FSAD Genital Response is not Impaired. Response to “Genital Responsiveness in Healthy Women— What about Subjective Genital Engorgement?” DOI: 10.1111/j.1743-6109.2008.01069.x
In our recent study published in this journal, we investigated whether medically healthy pre-and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems [1]. The authors criticize our study for adhering to physiological criteria (partial or total lack of vaginal lubrication and vaginal dryness during sexual activity) in diagnosing female sexual arousal disorder (FSAD) and state that this limited definition biases our study. We agree that such a definition is too limited. In fact, their comment supports our views and our findings. The authors may have overlooked our reasoning in the introduction that despite efforts of pharmacological companies to develop treatments to remedy a “vasculogenic deficit”, despite increasingly louder voices saying that many women’s sexual arousal difficulties are of organic etiology, and despite the physiologic definition of FSAD in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), there is not much evidence to date that impaired genital responsiveness plays a significant role in women’s sexual arousal problems. In the DSM-IV, FSAD is defined as a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement [2]. So, by carefully comparing genital responses to sexual stimulation of women with and without sexual arousal difficulties, adhering to the DSM-IV definition of FSAD, we would be able to evaluate the validity of this definition. We reasoned that if sexual stimulation results in a significant increase in vaginal vasocongestion, and/or does not differ from that of women without sexual problems, impaired genital responsiveness would almost certainly be irrelevant. Hence, we did not adhere to physiological criteria for FSAD because we believe that pleasurable genital sensations are irrelevant, but because this is how FSAD is officially defined. The women with sexual arousal problems in our study were carefully diagnosed with FSAD according to DSM-IV criteria, and in a similarly careful way, we determined absence of sexual problems in the women in the
control group. Of note, the DSM-IV focus on physiological criteria in defining FSAD—which involved abandonment of the subjective criterion that was part of the DSM-III-R definition of FSAD—was mandated in order for the DSM-IV to be congruent with the International Statistical Classification of Diseases (ICD-9) and to maintain male–female similarity in diagnostic categories [3–4]. In their interesting description of the evolution of criteria sets in the DSM, Segraves and colleagues relate that in preparing for the DSMIV, literature reviews of published data at that time suggested that erectile disorder should be identified solely by the absence of a physiological response to sexual stimulation. Although the literature suggested that the subjective criteria for female arousal disorder be retained, this review was overruled for the two reasons mentioned above. This was an unfortunate decision, given that a growing body of evidence that evolved after publication of the DSM-IV indicates inconsistent correlation between subjectively experienced sexual arousal and physiological changes associated with that arousal [5]. So in contrast to these authors’ suggestion, our study intended to show, and it did so successfully as far as we are concerned, that the definition of female sexual arousal disorder in the DSM-IV is not only too limited, but invalid and unworkable. Support for the idea that this definition is invalid was derived from the lack of a difference in genital response to explicit visual sexual stimulation between the two groups of women. Even though our two groups were likely to be more homogeneous and differences between our groups were likely to be greater than was the case in comparable studies, this was the seventh study that failed to find differences in vaginal vasocongestion between women with and without FSAD. We also stated that the DSM-IV definition of FSAD is unworkable. We did so for two reasons. First, for most women, even those without sexual problems, it is difficult to accurately assess genital cues of sexual arousal [6]. Yet, the DSM-IV definition of sexual arousal disorder requires such a subjective assessment of physiological events. Second, J Sex Med 2009;6:294–299
296 the group of women the DSM-IV definition refers to may even be virtually nonexistent. Women with a somatic condition explaining the sexual arousal difficulties do not qualify for one of the four primary diagnoses, including FSAD, even though the presence of a somatic condition that affects sexual response may be among the most important predictors for impaired genital responsiveness, with highest levels of sexual distress found in these women [7]. Not presence of sexual arousal problems but presence of a somatic condition (e.g., radical hysterectomy for cervical cancer) may be the most important determinant of impaired genital responsiveness [8]. Finally, it is incorrect that we “failed to mention lack of pleasurable sensation in the genital area”. We extensively questioned women about their sexual feelings, including the presence of genital sensations. For the FSAD group, the sexual arousal problems had to be primary, including (but not limited to) absent or strongly impaired genital arousal response as per DSM-IV. Table 1 of the article lists the percentage of women with FSAD who never experienced sexual arousal during partner sex in years prior to the study (20.7%); the remainder of these women almost never experienced sexual arousal during sex. Moreover, the only differences that were found between women with and without FSAD were in the subjective domain. FSAD women not only scored lower than the control group on feelings of sexual arousal, genital sensations, and sensuality, they also experienced less positive (and more negative) affect, suggesting that subjective indices of arousal are more discriminative than genital response. In conclusion, current empirical evidence strongly suggests that for medically healthy women, sexual dysfunction is not about genital response but about emotional response to sexual stimuli and situations. In these women, impaired genital responsiveness is not a valid diagnostic criterion. Consequently, we believe that the DSM-IV criteria for sexual arousal disorder are in need of revision. In this study, we proposed that in women
J Sex Med 2009;6:294–299
Letters to the Editor with sexual arousal disorder, lack of adequate sexual stimulation, with or without concurrent negative affect, underlies the sexual arousal problems. We hope that the findings of this study be taken into account by the Sexual Dysfunctions Subcommittee of the DSM-V Workgroup. Ellen Laan Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam Amsterdam, The Netherlands Rik Van Lunsen OBGYN, Academical Hospital Amsterdam Amsterdam, The Netherlands References
1 Laan E, van Driel E, van Lunsen RHW. Genital responsiveness in healthy women with and without sexual arousal disorder. J Sex Med 2008;5:1424–35. 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: American Psychiatric Press; 1994. 3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd edition. text revision. Washington, DC: American Psychiatric Press; 1987. 4 Segraves R, Balon R, Clayton A. Proposal for changes in diagnostic criteria for sexual dysfunctions. J Sex Med 2007;4:567–80. 5 Laan E, Everaerd W. Determinants of female sexual arousal: Psychophysiological theory and data. Annu Rev Sex Res 1995;6:32–76. 6 Laan E, Everaerd W, Both S. Female sexual arousal disorders. In: Balon R, Segraves RT, eds. Handbook of sexual dysfunctions. New York: Marcel Dekker Inc; 2005:123–54. 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 Maas CP, ter Kuile MM, Laan E, Tuynman CC, Weyenborg PT, Trimbos JB, Kenter GG. Objective assessment of sexual arousal in women with a history of hysterectomy. Br J Obstet Gynaecol 2004;111: 456–62.
295
In Healthy Women with FSAD Genital Response is not Impaired. Response to “Genital Responsiveness in Healthy Women— What about Subjective Genital Engorgement?” DOI: 10.1111/j.1743-6109.2008.01069.x
In our recent study published in this journal, we investigated whether medically healthy pre-and postmenopausal women with sexual arousal disorder are less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems [1]. The authors criticize our study for adhering to physiological criteria (partial or total lack of vaginal lubrication and vaginal dryness during sexual activity) in diagnosing female sexual arousal disorder (FSAD) and state that this limited definition biases our study. We agree that such a definition is too limited. In fact, their comment supports our views and our findings. The authors may have overlooked our reasoning in the introduction that despite efforts of pharmacological companies to develop treatments to remedy a “vasculogenic deficit”, despite increasingly louder voices saying that many women’s sexual arousal difficulties are of organic etiology, and despite the physiologic definition of FSAD in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), there is not much evidence to date that impaired genital responsiveness plays a significant role in women’s sexual arousal problems. In the DSM-IV, FSAD is defined as a persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement [2]. So, by carefully comparing genital responses to sexual stimulation of women with and without sexual arousal difficulties, adhering to the DSM-IV definition of FSAD, we would be able to evaluate the validity of this definition. We reasoned that if sexual stimulation results in a significant increase in vaginal vasocongestion, and/or does not differ from that of women without sexual problems, impaired genital responsiveness would almost certainly be irrelevant. Hence, we did not adhere to physiological criteria for FSAD because we believe that pleasurable genital sensations are irrelevant, but because this is how FSAD is officially defined. The women with sexual arousal problems in our study were carefully diagnosed with FSAD according to DSM-IV criteria, and in a similarly careful way, we determined absence of sexual problems in the women in the
control group. Of note, the DSM-IV focus on physiological criteria in defining FSAD—which involved abandonment of the subjective criterion that was part of the DSM-III-R definition of FSAD—was mandated in order for the DSM-IV to be congruent with the International Statistical Classification of Diseases (ICD-9) and to maintain male–female similarity in diagnostic categories [3–4]. In their interesting description of the evolution of criteria sets in the DSM, Segraves and colleagues relate that in preparing for the DSMIV, literature reviews of published data at that time suggested that erectile disorder should be identified solely by the absence of a physiological response to sexual stimulation. Although the literature suggested that the subjective criteria for female arousal disorder be retained, this review was overruled for the two reasons mentioned above. This was an unfortunate decision, given that a growing body of evidence that evolved after publication of the DSM-IV indicates inconsistent correlation between subjectively experienced sexual arousal and physiological changes associated with that arousal [5]. So in contrast to these authors’ suggestion, our study intended to show, and it did so successfully as far as we are concerned, that the definition of female sexual arousal disorder in the DSM-IV is not only too limited, but invalid and unworkable. Support for the idea that this definition is invalid was derived from the lack of a difference in genital response to explicit visual sexual stimulation between the two groups of women. Even though our two groups were likely to be more homogeneous and differences between our groups were likely to be greater than was the case in comparable studies, this was the seventh study that failed to find differences in vaginal vasocongestion between women with and without FSAD. We also stated that the DSM-IV definition of FSAD is unworkable. We did so for two reasons. First, for most women, even those without sexual problems, it is difficult to accurately assess genital cues of sexual arousal [6]. Yet, the DSM-IV definition of sexual arousal disorder requires such a subjective assessment of physiological events. Second, J Sex Med 2009;6:294–299
296 the group of women the DSM-IV definition refers to may even be virtually nonexistent. Women with a somatic condition explaining the sexual arousal difficulties do not qualify for one of the four primary diagnoses, including FSAD, even though the presence of a somatic condition that affects sexual response may be among the most important predictors for impaired genital responsiveness, with highest levels of sexual distress found in these women [7]. Not presence of sexual arousal problems but presence of a somatic condition (e.g., radical hysterectomy for cervical cancer) may be the most important determinant of impaired genital responsiveness [8]. Finally, it is incorrect that we “failed to mention lack of pleasurable sensation in the genital area”. We extensively questioned women about their sexual feelings, including the presence of genital sensations. For the FSAD group, the sexual arousal problems had to be primary, including (but not limited to) absent or strongly impaired genital arousal response as per DSM-IV. Table 1 of the article lists the percentage of women with FSAD who never experienced sexual arousal during partner sex in years prior to the study (20.7%); the remainder of these women almost never experienced sexual arousal during sex. Moreover, the only differences that were found between women with and without FSAD were in the subjective domain. FSAD women not only scored lower than the control group on feelings of sexual arousal, genital sensations, and sensuality, they also experienced less positive (and more negative) affect, suggesting that subjective indices of arousal are more discriminative than genital response. In conclusion, current empirical evidence strongly suggests that for medically healthy women, sexual dysfunction is not about genital response but about emotional response to sexual stimuli and situations. In these women, impaired genital responsiveness is not a valid diagnostic criterion. Consequently, we believe that the DSM-IV criteria for sexual arousal disorder are in need of revision. In this study, we proposed that in women
J Sex Med 2009;6:294–299
Letters to the Editor with sexual arousal disorder, lack of adequate sexual stimulation, with or without concurrent negative affect, underlies the sexual arousal problems. We hope that the findings of this study be taken into account by the Sexual Dysfunctions Subcommittee of the DSM-V Workgroup. Ellen Laan Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic Medical Center, University of Amsterdam Amsterdam, The Netherlands Rik Van Lunsen OBGYN, Academical Hospital Amsterdam Amsterdam, The Netherlands References
1 Laan E, van Driel E, van Lunsen RHW. Genital responsiveness in healthy women with and without sexual arousal disorder. J Sex Med 2008;5:1424–35. 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: American Psychiatric Press; 1994. 3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd edition. text revision. Washington, DC: American Psychiatric Press; 1987. 4 Segraves R, Balon R, Clayton A. Proposal for changes in diagnostic criteria for sexual dysfunctions. J Sex Med 2007;4:567–80. 5 Laan E, Everaerd W. Determinants of female sexual arousal: Psychophysiological theory and data. Annu Rev Sex Res 1995;6:32–76. 6 Laan E, Everaerd W, Both S. Female sexual arousal disorders. In: Balon R, Segraves RT, eds. Handbook of sexual dysfunctions. New York: Marcel Dekker Inc; 2005:123–54. 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 Maas CP, ter Kuile MM, Laan E, Tuynman CC, Weyenborg PT, Trimbos JB, Kenter GG. Objective assessment of sexual arousal in women with a history of hysterectomy. Br J Obstet Gynaecol 2004;111: 456–62.