Marita P. McCabe1
(1)
Institute for Health and Ageing, Australian Catholic University, Melbourne, Australia
Marita P. McCabe
Email: marita.mccabe@deakin.edu.au
Keywords
RelationshipsBiologyEtiologyMindfulness therapyCognitive behavior therapyInternet therapyMedical treatments
26.1 Points of Focus
· Need for an understanding of etiology in order to develop treatments for FSD.
· Biological, psychological, and relationship factors are likely to contribute to FSD.
· New treatment approaches involve mindful-based therapy and Internet therapy.
26.2 Introduction
Female sexual dysfunction (FSD) including female orgasmic disorder, female sexual interest arousal disorder, and genito-pelvic pain (APA, 2013) [1] causes significant concerns for women and has an impact on their relationships as well as their overall quality of life. This chapter discusses the factors that contribute to FSD, as well as models of how these various factors interact with one another to exacerbate these conditions. Recent advances in the treatment of FSD will also be considered, with a particular focus on mindfulness-based therapy and therapy in an online format.
26.3 New Information on the Etiology of FSD
Current understandings of the causes of sexual dysfunction acknowledge the contribution of biological, psychological, and social factors consistent with a biopsychosocial approach. For example, a study by Kontula and Haavio-Mannila [2] found evidence for the role of biological and psychosocial factors in sexual functioning in that, among both men and women, positive sexual functioning was associated with good health, positive sexual self-esteem, and a sexually skillful partner.
There has been limited research on the biological causes of sexual dysfunction in women. The biological causes of sexual dysfunction in men, in particular erectile dysfunction (ED), have received a great deal of research attention in recent years. This literature has established the role of several variables including age, disease, and drug use in the development of male sexual dysfunction. Similar research studies need to be conducted among women with FSD.
Numerous drugs have been implicated in the development of sexual dysfunction. Pharmacological agents used for treating nonsexual disorders, such as antidepressant medication, have been found to be associated with sexual dysfunction [3, 4]. In addition, recreational drugs, cigarette smoking, and alcohol have been found to negatively affect sexual functioning [5, 6].
A comprehensive review of the psychological and interpersonal factors that contribute to sexual dysfunction has been published by McCabe et al. [7]. This review evaluates the role of each developmental, individual, and relationship factor, and the interactions between them, in the etiology of sexual dysfunction. The model that includes these broad categories of etiological factors (see Fig. 26.1) was initially developed by McCabe [8]. The model begins with the premise that both individuals in a relationship bring a range of personal characteristics into their relationship. These characteristics may stem from a variety of sources, including developmental experiences (i.e., past experiences in the individual’s life, especially experiences relevant to sexual activity such as a history of sexual abuse) and current aspects of the individual’s functioning (e.g., depression, body image, and stress). These factors influence what each individual brings to the relationship generally and the sexual relationship specifically. For example, an individual may experience depression, which has a negative impact on the relationship, and this, in turn, may reduce the individual’s sexual desire for his/her partner. As a result of this withdrawal, the partner may feel rejected from both the relationship and from sexual interaction, which exacerbates both the relationship and sexual problems. Once this occurs, treatment focused on one individual may not be successful in resolving the sexual problems, as both individuals in the relationship are now affected. As a result, therapy is most likely to be effective if it involves both partners in the relationship.
Fig. 26.1
Model to explain the development of sexual dysfunction within a relationship [8]
In this interactional model of sexual dysfunction, developmental, individual, and relationship factors influence one another. In addition, cognitions—that is, the interpretations that individuals place on events in the relationship—are crucial [9]. The meaning individuals give to sexual events (e.g., interpreting a partner’s ED as rejection) is seen to be more important in predicting sexual dysfunction than the event itself. Also important is the meaning individuals give to nonsexual aspects of the relationship (e.g., interpreting a partner’s depression-related withdrawal as rejection). Most importantly, if these evaluations are negative and are not expressed to the partner directly, the model proposes that they might be expressed indirectly in the form of a sexual dysfunction (e.g., a loss of sexual desire for the partner).
26.4 Female Sexual Dysfunction and Relationships
As noted above, biological, psychological, and interpersonal factors may all affect a woman’s normal sexual functioning/response and consequently contribute to the development and maintenance of FSD. A recent Australian study found that interpersonal factors were more important to women’s experience of sexual desire, whereas biological and individual (psychological) characteristics were more strongly associated with genital arousal and orgasmic function [10]. In a recent study conducted by King, Holt, and Nazareth [11], the most commonly perceived causes of sexual difficulties cited by women, regardless of whether they were assigned a diagnosis of FSD, were relationship difficulties. Research has furthermore indicated that women diagnosed with HSDD are more likely to have negative feelings about the quality of their relationship, particularly related to poor interpersonal communication and a lack of intimacy within their relationship in general [12].
It has been shown that, in general, women place greater emphasis on relationships as a context for sexual feelings and behaviors than do men [13]. This emphasis may be a result of differences in socialization between genders; women are socialized to place an emphasis on emotional connection (with a partner) as a prerequisite for sexual expression [14].
The causal association between FSD and relationship satisfaction remains elusive at present. For example, whereas desire problems can lead to interpersonal conflict [15], a poor relationship with a partner predicts low levels of sexual desire [16]. Research findings often suggest a bidirectional association between interpersonal factors such as relationship and sexual satisfaction, intimacy, communication, unresolved conflict, and partner sexual dysfunction and a woman’s sexual desire [17]. Clearly then, there is a need to acknowledge and address such factors when assessing this aspect of women’s sexuality.
Emotional intimacy between partners serves as a foundation for healthy sexual functioning and may be one of the primary interpersonal factors contributing to a woman’s sexual response [18]. Higher levels of intimacy have been associated with greater levels of sexual satisfaction and orgasm among heterosexual couples in long-term relationships [19, 20]. A critical task in the treatment of sexual dysfunction is to promote a change in the couple’s sexual style that focuses on emotional intimacy as a core process [18]. Some authors have suggested that the relatively poor treatment success for problems in sexual desire is due to an inadequate recognition of, and attention to, the relational aspects of these problems [21]. Research findings demonstrating that the quality of the relationship between partners improves following successful treatment of the disorder in sexual desire support this assertion [12].
26.5 New Treatment Approaches to FSD
Developments in the area of sexual pharmacology, particularly following the introduction of Viagra™ by Pfizer onto the market for the treatment of ED in 1998, have arguably resulted an increased biological reductionism of FSD, with an emphasis on physiological processes and a focus on women’s genital performance [22]. Sex therapists warn that taking a purely medical approach to the treatment of female sexual problems is unlikely to be successful, if psychosocial and interpersonal contributors remain unexamined [23].
A major barrier to the development of clinical research and practice has been the absence of a well-defined, broadly accepted diagnostic framework and classification for FSD [24], and this problem is also reflected in the fact that fewer treatment options are currently available for women than for men [25]. It has been suggested that including an assessment of a woman’s emotional experience within her sexual context is necessary to facilitate a complete understanding of sexual dysfunction [2]. An evaluation of the context in which sexual interactions occur (or do not currently occur) is necessary in order to tailor an effective treatment intervention that addresses the multitude of factors associated with the woman’s sexual dysfunction.
26.6 Mindfulness
A recent and promising addition to the cognitive behavior therapy (CBT) approach for FSD involves the inclusion of mindfulness—a Buddhist meditation practice [26–32]. Mindfulness techniques facilitate nonjudgmental observation and present-moment awareness and, in the context of FSD, help to decrease cognitive and affective distractions and performance anxiety during sexual activity and increase women’s attention and awareness of pleasurable sensations [33, 34].
To date, five studies have evaluated the incorporation of mindfulness training into group interventions for women with FSDs. In the first study [28], a mindfulness-based CBT intervention was delivered to a group of 26 women seeking treatment for acquired sexual desire and/or arousal difficulties. This treatment group reported significant improvements in sexual desire and sexual distress at posttest, as well as improvements in perception of genital arousal despite a lack of change in objective sexual arousal. The second study [29] involved the delivery of a mindfulness-based CBT intervention to a group of 22 women with early-stage gynecological cancer seeking treatment for acquired sexual arousal difficulties. This treatment group reported significant improvements in sexual desire, arousal, orgasm, satisfaction, and sexual distress. Trends toward improvement were also reported for both objective and perceived genital arousal, and women reported a significant improvement in overall well-being.
The third study [30] evaluated the effectiveness of a mindfulness-based CBT intervention for a group of 31 female survivors of endometrial or cervical cancer who reported sexual desire and/or sexual arousal difficulties. This study involved a waitlist control group, and results demonstrated that the women in the treatment group reported significant improvements in all areas of sexual response, as well as a trend toward improvement on scores of sexual distress, as compared to the control group. Women’s ability to perceive genital arousal during an erotic film also increased significantly in the treatment group, despite no change in objective sexual arousal, and improvements were maintained at 6-month follow-up [30].
Upon further inspection of Brotto and colleagues’ [28] results from the mindfulness-based CBT intervention, it was found that women with a history of sexual abuse had greater levels of improvement on various measures of sexual function and distress as compared to those without a history of sexual abuse. To further explore these results, the fourth study [31] compared the effectiveness of a mindfulness-based intervention to a CBT intervention for 22 partnered women with sexual difficulties, associated distress, and a history of childhood sexual abuse. Results suggested that women in the mindfulness-based treatment group reported significantly greater levels of subjective sexual arousal at posttest as compared to the CBT group and that both treatment groups experienced significant decreases in sexual distress [31].
It has also been theorized that mindfulness training may benefit women with sexual pain disorders [35, 36]. There are currently no quantitative data to support this hypothesis, but qualitative findings from a pilot study assessing the use of mindfulness-based approaches for women with provoked vestibulodynia, a chronic pelvic pain condition, suggest that participants benefited from the intervention and experienced a greater sense of control over pain management [30].
The fifth study implemented the Pursuing Pleasure (PP) program which was an Internet-based intervention for FSD [37]. The PP program introduced mindfulness in a nonsexual context first and then made the exercises more sensually and sexually oriented. This gradual introduction of mindfulness gave women the opportunity to learn basic mindfulness skills and troubleshoot any problems that arose, before incorporating mindfulness into sexual activity. Mindfulness training for FSDs slotted well into sensate focus, which also begins with a focus on nonsexual aspects of the practice and then gradually becomes more sexually oriented. From the experiences of women in the PP studies, it appears that mindfulness offers the following unique additions to traditional sensate focus: (1) Mindfulness training teaches women how to cultivate greater present-moment awareness and focus during sensate focus exercises. (2) Mindfulness exercises teach women new skills for managing cognitive and affective distractions during sexual activity. (3) Mindfulness training helps women develop the ability to manage distressing thoughts or emotions triggered before, during, or after sex. (4) Mindfulness practice can lead to a heightened awareness of genital arousal during sexual activity. (5) A mindful stance during sensate focus encourages a less judgmental stance toward self and partner. (6) Mindful awareness allows for a greater focus on letting go of expectations and predictions about sex and the outcome of sexual activity (e.g., orgasm, lubrication). Therefore, mindfulness training appears to offer women benefits above and beyond those offered by traditional sensate focus alone, and mindfulness can easily be incorporated into sensate focus exercises after basic mindfulness skills are acquired.
26.7 Internet-Based Treatments
Online CBT and Female Sexual Dysfunction
In comparison to the number of studies investigating face-to-face treatment effects of FSD, only two studies were located that have used the Internet as a treatment modality for women. Jones and McCabe [38] conducted a study evaluating the effectiveness of an Internet-based CBT program titled Revive, for women experiencing various FSDs within a heterosexual relationship. A total of 39 women participated in the study (17 in the treatment group and 19 in the control group). Revive consisted of sensate focus, communication exercises, and unlimited e-mail contact with a therapist. The main aim of the e-mail contact was to address maladaptive cognitions as well as individual and relationship problems impacting sexual functioning [38]. The program consisted of five modules, with each module expected to take approximately 2 weeks to complete. Partners were expected to participate in the sensate focus and communication exercises.
Female sexual functioning and relationship functioning were assessed pretest, posttest, and at a 3-month follow-up. It was found that the women who completed the Revive program improved significantly on measures of sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and pain compared to those in the control group, although 33 % of participants were still experiencing sexual problems more than 50 % of the time after treatment completion [38]. The treatment group also reported significantly greater improvements in sexual intimacy, emotional intimacy, and communication, but not for overall relationship satisfaction. Gains remained stable over the 3-month follow-up period and some participants reported further gains in sexual functioning. These results provide preliminary support for the use of Internet-based psychological therapy for mixed female sexual dysfunctions as an alternative to face-to-face sex therapy.
The second study was conducted by Hucker and McCabe [37] and evaluated the PP program discussed above. It was an online, mindfulness-based, CBT program for FSD. The program contained sensate focus, communication exercises, and unlimited e-mail contact with a therapist. PP also utilized online chat groups as a platform for cognitive therapy and social support. As well as being designed to improve women’s sexual functioning, the program targeted relationship factors involved in FSD. Women who completed the PP program demonstrated significantly greater improvements in all aspects of sexual functioning as well as sexual intimacy, emotional intimacy, and communication as compared to the control group. This is consistent with past evaluations of the online treatment for female sexual dysfunction [38] and is not surprising given that the program consisted of communication- and intimacy-based exercises. Despite these improvements, the treatment group did not report significantly greater improvements in overall relationship satisfaction as compared to the control group, and this is also consistent with prior research [38].
26.8 Medical Treatments
In recent years, the focus of treatment for FSD has shifted from predominantly psychologically based techniques toward a more medical approach [25, 39–41]. For instance, a recent review of behavioral and CBT treatments for FSD indicated that there have been some recent studies, but that most treatment outcome studies have focused on medical interventions [42]. The discovery of effective pharmacological agents for male erectile dysfunction has led researchers to attempt to develop similar agents for females [43].
An extensive review of the literature on the effectiveness of pharmacological treatments for women found mixed results, although in the majority of cases, these approaches were found to be largely unsuccessful [25, 44, 45]. The female sexual response is vastly different from that of males, and unlike their male counterparts, the potential role of hormonal factors and various medical treatments on the sexual interest and activity of women remains unclear [40]. A medical approach to the treatment of sexual disorders in women fails to take into account the many individual factors and the quality of the relationship described by women as being related to the development of their dysfunction [39, 44, 46].
Only one published clinical trial supports the use of sildenafil for the treatment of female sexual arousal disorder in a sample of 51 young premenopausal women [47]. In contrast, a well-controlled clinical trial involving 583 women showed no difference in levels of sexual arousal between those who received drug sildenafil and a placebo group. Chives and Rosen [48] conducted a review of 16 studies that examined the effectiveness of PDE5i on female sexual functioning and found a general lack of efficacy of these agents. The authors attributed this lack of efficacy to gender differences in the concordance between physiological and psychological arousal in men and women. In regard to other medical interventions, a number of studies have found the use of a transdermal testosterone patch to be effective in the treatment of low sexual desire among naturally menopausal women [49, 50], as well as those who experience either an oophorectomy or hysterectomy [51]. Flibanserin has also been shown to be effective for the treatment of low sexual desire among premenopausal women through a series of a number of randomized controlled trials [52–54] as well as an open-label extension study over a period of 52 weeks [55]. In relation of women with major depressive disorder (MDD), gepirone-ER has been shown to be effective for low sexual desire [56]. Further, since women with these disorders are frequently taking SSRIs, Moll and Brown [57] conducted a review of the literature that found that the use of monoaminergic agents (e.g., bupropion, buspirone, and ropinirole) was effective in treating the sexual dysfunction associated with both MDDs as well as the use of these SSRIs.
The medical model of FSD tends to emphasize quantity, performance, and objective measures (e.g., frequency of orgasm and adequate lubrication) over the quality of sex and measures of subjective experience (e.g., pleasure, satisfaction, and intimacy) which women describe as being particularly relevant in their motivation to engage in sexual activity [38, 39]. As noted by Al-Azzawi et al. [58], there are both pharmacological and non-pharmacological treatments available for women with female sexual dysfunction. Based on this literature, their recommendation was that non-pharmacological treatment that focuses on lifestyle and psychosexual therapy should be trialled first. Undoubtedly, pharmacotherapy may play a role in the treatment of a limited number of sexual disorders, but the use of these treatments for women requires further development.
26.9 Conclusion
In order to treat FSD effectively, it is important to have a clear understanding of the nature of the problem(s) as well as the etiology of the various disorders. There have been recent promising developments in both mindfulness-based therapy and Internet therapy. As for sexual dysfunctions in men, it is likely that the most effective approach for FSD will be shown to be a combination of a medical and psychological intervention. Substantially more research is required for us to be confident in the development of such a treatment program.
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