Editorials
When Does a “Less Than Perfect” Sex Life
Become Female Sexual Dysfunction?
Brenda S. Gierhart, MD
See related article on page 755.
Dr. Gierhart is from the Division of Metabolism and
Endocrinology Products, Center for Drug Evaluation
and Research, U.S. Food and Drug Administration,
Silver Spring, MD; GIERHARTB@cder.fda.gov.
This editorial was prepared by Dr. Gierhart in her
private capacity. No official support or endorsement
by the Food and Drug Administration is intended or
should be inferred. The views presented do not
necessarily reflect those of the Food and Drug Ad-
ministration.
© 2006 by The American College of Obstetricians
and Gynecologists. Published by Lippincott Williams
& Wilkins.
ISSN: 0029-7844/06
750 VOL. 107, NO. 4, APRIL 2006
I t may be easier to define female sexual dysfunction by what it is not,
rather than by what it actually is. Most health care professionals would
probably agree that there is no sexual dysfunction if a woman reports
being satisfied with her sexual life and denies having any sexual problems
or personal distress due to sexual issues. However, if a woman reports
having a sexual life that is less than perfect, at what point does she have
sexual dysfunction? Specifically, does a woman have sexual dysfunction if
she reports that she has a “little bit of a problem,” “somewhat of a
problem,” or “very much of a problem” when asked whether she has 1 or
any combination of 4 specific sexual problems?
In this issue of Obstetrics & Gynecology, Addis et al1 report the results
from posing 5 questions about sexual activity, sexual problems, and
sexual satisfaction to 2,109 women aged 40 – 69 years who were enrolled
in RRISK: Reproductive Risk factors for Incontinence Study at Kaiser. In
one question, the women were asked how much of a problem lack of
sexual interest, inability to relax and enjoy sexual activity, difficulty in
becoming sexually aroused, or difficulty in having an orgasm had been
during the past 12 months. The 5 possible responses were “not a
problem,” “little bit of a problem,” “somewhat of a problem,” “very much
a problem,” and “not applicable.”
When presenting their conclusions, the authors seem as uncertain as
the rest of us about how to define female sexual dysfunction. Under
“Results,” they report that the prevalence of sexual dysfunction was 45%
in the entire group, 33% in those who reported sexual activity, and 24%
if they included only those responses of “somewhat of a problem” and
“very much a problem.” So if the reader defines female sexual dysfunc-
tion as having any degree of 1 of 4 sexual problems during the past year,
then the prevalence rate in this population was 45%. If the reader believes
that a woman can only have sexual dysfunction if she is sexually active,
then the prevalence rate in this population drops to 33%. And if the reader
defines female sexual dysfunction as having at least “somewhat of a
problem,” then the prevalence rate of sexual dysfunction in this same
population was only 24%. So what was the true prevalence of female
sexual dysfunction in this population? Under “Methods,” the authors
define participants in their study as having sexual dysfunction if they
responded “somewhat of a problem” or “very much a problem” to at least
1 of the 4 listed sexual problems. Thus, by their definition of female
sexual dysfunction, the prevalence rate in their population was 24%.
However, in their abstract, the authors’ conclusion is that middle-aged
and older women engage in satisfying sexual activity and one-third
reported problems with sexual function. We now face the same problem
that we started with, because before the reader can interpret this
OBSTETRICS & GYNECOLOGY
conclusion, a decision must be made: when do “prob-
lems with sexual function” become female sexual
dysfunction?
I offer my opinion that the definition of female
sexual dysfunction is such a problem because female
sexual dysfunction does not exist as a diagnosis. I
believe that it is a spectrum of disorders with exten-
sive overlap between the disorders. Even experts in
the field concede that there is uncertainty as to what
exactly constitutes a sexual disorder.2 An additional
controversy is whether the pharmaceutical industry
has “created” the disease of female sexual dysfunc-
tion, because too easily, difficulties become dysfunc-
tions and dysfunctions become disease.3 Perhaps the
best way to move forward with research in this area is
to accept that although the definition of female sexual
dysfunction continues to evolve, it currently consists
of 4 recognized components: decreased sexual desire,
decreased sexual arousal, dyspareunia, and persistent
difficulty in achieving or inability to achieve orgasm,
any of which must be associated with personal dis-
tress, as determined by the affected women.4 This
definition of female sexual dysfunction is somewhat in
agreement with the International Classification of
Diseases, Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, and 1999 Consensus Develop-
ment Conference classifications and could be used by
researchers as a standard definition. Because the
prevalence of female sexual dysfunction in any pop-
VOL. 107, NO. 4, APRIL 2006
ulation will be highly dependent upon how it is
defined, the reader is advised to approach all female
sexual dysfunction prevalence studies with caution
until researchers accept a standard definition.
After reading this scientific article, the reader may
ask additional questions. Is it valid to conclude that a
woman has female sexual dysfunction based upon a
self-reported response to one retrospective global
question? Can women accurately recall and summa-
rize their sexual life over the last 12 months? Was the
validated Medical Outcomes Study sexual problem
question asked in this study no longer validated
because the authors changed the time duration from
the past 4 weeks to the past 12 months? Good
research always provokes more questions than it
answers.
REFERENCES
1. Addis IB, Van Den Eeden SK, Wassel-Fyr CL, Vittinghoff E,
Brown JS, Thom DH. Sexual activity and function in middle-
aged and older women. Obstet Gynecol 2006;107:755–64
2. Basson R. Sexuality and sexual disorders. Clin Updates Wom-
ens Health Care 2003;II:1–94.
3. Moynihan R. The making of a disease: female sexual dysfunc-
tion. BMJ 2003;326:45–7.
4. U.S. Department of Health and Human Services, Food and
Drug Administration, Center for Drug Evaluation and
Research. Guidance for industry. Female sexual dysfunction:
clinical development of drug products for treatment. Draft
guidance. May 2000. p. 1. Available at: http://www.fda.gov/
cder/guidance/3312dft.htm. Retrieved January 11, 2006.
Gierhart Female Sexual Dysfunction 751