Female Sexual Health: An Overview
Female Sexual Response (FSR)
Female Sexual Response (FSR) is a dynamic process that is influenced by biological, psychological, sociocultural, and other factors. There are several models that describe female sexual response. All of these models include the concepts of desire, arousal, orgasm, and resolution:
Desire refers to increased sexual thoughts and fantasies, and interest in participation in sexual activity.
Arousal refers to both the cognitive (mental) manifestations of excitement, as well as the physiologic manifestations.
Orgasm is a process of physiological release of sexual tension.
Resolution is a gradual return to the baseline state.
Multiple Models of Female Sexual Response
Models about the Female Sexual Response help us to better understand the multidimensional nature of sexual response and sexual dysfunction.
The landmark research by Masters & Johnson in the 1960s developed a 4-phase linear model of sexual response, which includes excitement (arousal), plateau, orgasm, and resolution.1 This model assumed that a sexually functional woman is always responsive to sexual stimulation.2 No indication was given to the importance of sexual desire or libido. This model was modified by Kaplan to include sexual desire (libido).3
Rosemary Basson later developed a circular model that explains female sexual response as a cycle in an intimacy-based model.4 This model is based on key elements of emotional intimacy, sexual stimulation, and spontaneous sexual hunger in a nonlinear, overlapping cycle that includes both mental and physical components.5 A recent study that assessed women's choice of female sexual response model from those discussed here found that women who were sexually functional were significantly more likely to endorse Masters and Johnson or Kaplan models.6 Women who had sexual dysfunction were significantly more likely to endorse Basson's model.7
Unlike the other influential models, the biopsychosocial model of female sexual response takes into account multiple etiologic factors and determinants that include the interpersonal, psychological, physiological, or biological, as well as the sociocultural.8 This model includes four major overlapping components and related causes in female sexual response:
Biological—Physical health, neurobiology, and endocrine function
Psychological—Impaired self-image, performance anxiety, and depression
Sociocultural—Upbringing, cultural norms, and expectations
Interpersonal—Quality of current and past relationships, intervals of abstinence, life stressors, finances
Examples of biological factors include physical health, neurobiology, and endocrine function; the psychological include performance anxiety and depression; the sociocultural include upbringing, cultural norms, and expectations; and the interpersonal, quality of current and past relationships, intervals of abstinence, life stressors, and finances.9
Sexual Tipping Point Model
The concept of a “variable set point," or Sexual Tipping PointTM, illustrates the multidimensional nature of sexual dysfunctions10—including physiological, organic, and cultural contributors to sexual function and dysfunction.11 The sexual tipping point is the threshold for a sexual response that can vary within and between individuals and during any given sexual experience.12 The balance between excitatory and inhibitory factors determines whether someone is receptive to a sexual encounter and/or finds that encounter pleasurable and satisfying.13 This model identifies "physiological & organic" and "physiological & cultural" factors as having both excitatory and inhibitory (mental and physical) contributions to the tipping point of sexual function and dysfunction.14
Female Sexual Dysfunction (FSD)
Female Sexual Dysfunction (FSD) was first defined in the 1952 Diagnostic and Statistical Manual of Mental Disorders (DSM).15 Since then, three full revisions of the definitions have occurred, leading us to the current definition and classification in the DSM IV TR. FSDs can occur at any stage in the female sexual response (i.e., desire, arousal, orgasm) and must include the following nomenclature:
The DSM-IV-TR divides female sexual dysfunctions (FSDs) into 4 categories, all of which must be persistent or recurrent, cause "marked distress" or "interpersonal difficulty," and must not be better accounted for by another Axis I disorder and not due exclusively to the direct physiological effects of a substance (e.g. medications) or a general medical condition.16
The primary disorders relate to:
Sexual desire, which includes hypoactive sexual desire disorder (HSDD) and sexual aversion disorder
Sexual pain, which includes dyspareunia and vaginismus17
The ICD-9 codes are included for each disorder. You will notice that HSDD and both pain disorders, dyspareunia and vaginismus, have two ICD-9 codes each.18
302.71 is for HSDD and 799.81 for decreased libido
625.0 is for dyspareunia and 302.76 for psychogenic dyspareunia
625.1 is for vaginismus and 306.51 is for psychogenic vaginismus19
1. Masters WH and Johnson VW. Human Sexual Response. Boston:Little Brown;1966.
2. Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin N Am. 2006;334:515-526.
3. Kaplan HS. Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. New York:Brunner/Mazel;1979.
4. Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98(2):350-353.
5. Basson R.
6. Sand M, Fisher WA. Women’s endorsement of models of female sexual response: the nurses’ sexuality study. J Sex Med. 2007;43:708-719.
7. Sand M et al.
8. Althof SE, Leiblum SR, Chevret-Measson M, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2005;26:793-800.
9. Rosen RC, Barsky JL. Normal response in women. Obstet Gynecol Clin N Am. 2006;334:515-526.
10. Perelman MA. A new combination treatment for premature ejaculation: a sex therapist’s perspective. J Sex Med. 2006;36:1004-1012.
11. Perelman MA. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007; 4(suppl 4):280-290.
12. Perelman MA. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007; 4(suppl 4):280-290.
13. Perelman MA. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007; 4(suppl 4):280-290.
14. Perelman MA. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007; 4(suppl 4):280-290.
15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Text Revision. Washington, DC: American Psychiatric Press; 2000.
16. American Psychiatric Association
17. American Psychiatric Association
18. American Psychiatric Association
19. American Psychiatric Association