Combined sexual arousal Absent or markedly reduced feelings of sexual There is minimal sexual excitement disorder arousal (sexual excitement and sexual pleasure) (subjective arousal) from any type of from any type of stimulation and absent or stimulation—erotic material, stimulating impaired genital sexual arousal (vulval swelling the partner, genital and nongenital and lubrication). stimulation. There is no awareness of the reﬂexive genital vasocongestion.
Subjective sexual arousal Absent or markedly reduced feelings of sexual Despite lack of sexual excitement/ disorder arousal (sexual excitement and sexual pleasure) subjective arousal, lubrication is noted by from any type of stimulation. Vaginal lubrication the woman or partner. Intercourse is and other signs of physical response still occur. comfortable without use of external lubricant.
Genital arousal disorder Absent or impaired genital sexual arousal–minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital sexual stimuli.
Subjective arousal (sexual excitement) from nongenital stimuli (erotica, stimulating the partner, receiving breast stimulation, kissing) is key to this diagnosis. Early studies indicate reduced vasocongestion in some but not all cases. Loss of sexual sensitivity of physiologically congested tissues accounts for others.
From Basson R, Wierman M, van Lankveld J, et al. Summary on the recommendations on sexual dysfunction in women. J Sex Med 2010;7:314–326, with permission.
concepts and/or referral to psychologist or counselor for the same, prescription of medications for chronic pain, prophylaxis for overgrowth of candidiasis when this is relevant, and referral to a pelvic muscle physiotherapist. Referral for intensive therapy may be indicated for further pain management, including learning the skills of mindfulness, further exploration of CBT, for couple counseling if the relationship cannot cope with the stress, or occasionally, to a gynecologist specializing in vulvar surgery if vestibulectomy is considered.
The larger surveys find approximately 10% of women report ongoing sexual dysfunction that is particularly upsetting, while a further 20% report sexual problems that are less distressing (4,90). Comorbidity of low desire and subjective arousal along with infrequent or absent orgasm is the most common presentation (18,91). Postmenopausal vaginal dryness and associated dyspareunia affects some 15% to 30% of women with marked cultural differences to the extent that this leads to bothersome sexual difficulties (92). Lack of lubrication and associated dyspareunia is reported by 5% to 25% of younger women with marked cultural differences leading to resulting sexual distress (92). Introital dyspareunia from PVD, the most common cause of dyspareunia in premenopausal women, is thought to affect some 15% of women (93). Isolated lack of orgasm despite high arousal is of unknown prevalence because studies generally include women with low arousal alongside their lack of orgasm.
No nonsexual rewards: Feels used, anxious re: her lack of response. Even less motivated to repeat the experience Few reasons for sex—minimal emotional closeness Not willing to find/be receptive Few useful sexual stimuli Inappropriate context Intercourse focus motivatesNo sexual satisfaction No subjective Arousal Low self-image Depression Minimal arousal—no responsivedesire Spontaneous “innate” desire absent Processed
Figure 11.3 Breaks in the circular sex response cycle subsequent to infertility testing.