What is missing in our understanding of female sexual dysfunction?

Highlights

• A foundational understanding of healthy female sexual function is profoundly lacking, which has hindered the development of effective therapies for dysfunction.
• Female sexual response is highly individualized, involving a complex interplay of biological, psychological, and social factors centralized in the brain.
• Clinicians must help patients redefine "normal" sexual function, as expectations are often shaped by media and change throughout a woman's life.
• Challenging stereotypes, clinicians should recognize that female sexual desire is not always spontaneous and can be responsive to arousal and stimuli.
• Low libido may present as an individual problem, but it can often be a couple's issue stemming from mismatched sexual expectations.

Expert Insights

An incomplete understanding of healthy female sexual function is the most significant gap impeding progress in the diagnosis and management of female sexual dysfunction (FSD). Experts agree that a history of under-researched physiology, coupled with the application of outdated or inappropriate sexual response models, has led to underdeveloped therapies and unrealistic expectations for both patients and clinicians. To address FSD effectively, physicians must pivot from a reductionist view to a more nuanced, individualized, and biopsychosocial framework.

Deconstructing 'Normal' and the Myth of Spontaneous Desire

A primary obstacle in understanding FSD is the persistent and often inaccurate definition of "normal" sexual function. Dr. Catherine Leclair observes that women's constructs of normalcy are heavily influenced by social media, movies, and past assumptions rather than medical education. This is compounded by the historical extrapolation of male sexuality onto women. Dr. Tami Rowen specifically critiques the stereotype that all women desire sex spontaneously, calling it one of the "worst" misconceptions. She emphasizes that desire can also be receptive, highlighting the highly individualized nature of the female sexual response. This sentiment is echoed by Dr. Leclair, who points to the pioneering work of Rosemary Besson on responsive desire as a critical step forward.

Furthermore, clinicians must recognize that sexual expression is not static. "Sexual expression changes over a woman's lifetime, just like other parts of health and psyche," Dr. Leclair states, noting that a 25-year-old’s experience is not the same as a 55-year-old’s. Long-term monogamy also influences response. The key takeaway, according to Dr. Leclair, is the urgent need for "public awareness and education to help people understand what 'normal' can be," a responsibility that falls heavily on providers to redefine expectations with their patients.

The Brain as the Central Mediator of Sexual Function

According to Dr. Rowen, the brain is the "body's biggest sex organ," and its central role in sexual function is often underappreciated. She explains that desire involves an intricate interplay of biological, psychological, and social factors, all of which are processed and interpreted by the brain. This is crucial for understanding not only desire and arousal but also pain. "You may have a stimulus in the vagina, but it's the brain that registers pain," she explains, noting that patients with chronic pain syndromes experience stimuli differently. This neuropsychological perspective underscores why a one-size-fits-all approach is bound to fail and reinforces the necessity of individualized care that considers the patient's entire context.

Reframing Low Libido and the Limits of Pharmacotherapy

Low libido remains the most commonly reported dysfunction, yet it is also one of the most complex and difficult to "fix." Dr. Leclair cautions against the pursuit of a simple solution, noting her experience since 1999 with various approaches. "If it were easy, we likely would have found a fix by now," she asserts. This complexity suggests a fundamental issue in how the problem is framed. As she posits, "We may be looking for easy fixes for something that isn't actually broken because we're defining it wrong or holding unrealistic expectations."

"We may be looking for easy fixes for something that isn't actually broken because we're defining it wrong or holding unrealistic expectations." Dr. Catherine Leclair

This perspective shifts the clinical focus from a purely medical problem to a relational or contextual one. Dr. Leclair notes that low libido often becomes a problem for a woman because it is a problem for her partner. The issue may not be a lack of desire, but a discrepancy in desire within the relationship, creating stress and conflict. This reframes the condition as a "couple problem" more than an individual pathology, requiring a different set of counseling and management strategies that move beyond a prescription pad.

The Foundational Need to Study Function

Ultimately, progress in treating FSD is contingent on a deeper understanding of healthy function. Dr. Deborah Bartz argues that this is the fundamental missing piece. "Fundamentally, we lack a solid understanding of what contributes to healthy female sexual function, largely because it has been profoundly understudied," she states. She describes female sexual function as an "incredibly complex clinical outcome" with numerous contributing factors that vary considerably between patients. Until the basics of function are better understood, Dr. Bartz concludes, "it is understandable that management and therapies... have been underdeveloped and have had limited success."

"To understand dysfunction, we first need to understand function." Dr. Deborah Bartz