Sexual Dysfunction in Women

Female sexual dysfunction is prevalent but remains a mysterious field in psychiatry. In this book Dr Marta Meana, a renowned sex researcher and therapist, enlightens us on the world of female sexual difficulties. The author guides us from basic descriptions to the theories, giving us a panoramic view of the spectrum of sexual dysfunction in women. She then brings us back to the practical aspects of diagnosis and treatment, which are of utmost importance to our clinical practice. The first section of this book describes the various conditions pertaining to sexual dysfunction in women. It focuses on the 6 categories of sexual dysfunction listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. These were hypoactive sexual desire disorder (HSDD), sexual aversion disorder, female sexual arousal disorder (FSAD), female orgasmic disorder, dyspareunia, and vaginismus (the last 2 are not due to a medical condition). A brief introduction of the traditional models of sexual response is given. However, the author points out that these models may not adequately depict the diverse experiences of women, and thus new models are being proposed to suggest a more complex process, e.g. the incentive-motivation model and Basson’s model. She moves on to a meticulous review of the diagnostic descriptions of each of these disorders of interest. It is inspiring to note that sexual interest / arousal disorder is the new diagnostic category proposed for the coming Diagnostic and Statistical Manual of Mental Disorders. This category would subsume the current diagnoses of HSDD and FSAD with the rationale that “neither the empirical literature nor women themselves reliably distinguish desire from arousal, and the high degree of comorbidity between the two diagnoses makes their separation questionable.” This rich section also covers the epidemiology, course, prognosis, differential diagnosis, and co-morbidities of female sexual dysfunction, beautifully. The second section is a concise account of the theories and models of sexual dysfunction, namely Barlow’s cognitive-affective model, dual-control model, Sexual Tipping Point model, inter-system approach, and new view approach. All current models appreciate the diversity of sexual experience, the mind-body integration, and the multi-determined nature of sexual function. The author demonstrates the complex architecture of the aetiologies of female sexual dysfunction in the third section of this book, which sheds light on diagnoses and treatment indications. The risks and dysfunctionmaintaining factors are analysed using the biomedicalpsychological-social model. Prescription medications are common risk factors for female sexual dysfunction and present a dilemma for the clinicians. We should be inspired by the author’s innovative comment: “...sexual side effects of necessary medications can be targeted by cautious yet creative strategies on the part of the prescribing physician.” The latter part of this section presents us with numerous astonishing psychological and social factors related to female sexual dysfunction. It is worth noting that self-focus is crucial to sexual performance and can be either positive or negative. The author states that “...the way a woman feels about herself may be even more important to her sexual function than the way her partner feels about her.” This psychological factor is magically linked to a social factor, the sexless motherhood script. Psychoanalysis referred to a Madonna-whore complex and, not surprisingly, women also have a difficult experience seeing themselves fulfilling the dual roles of lover and mother. After a relaxing overview of the basics, the author takes us to the climax of this book: treatment of female sexual dysfunction. Even at the beginning of planning treatment, we may encounter many challenges including paucity of randomised controlled trials examining treatment outcomes, clinician self-efficacy, and barriers to general assessment. The author guides us through the stage 1 of treatment: assessment, education, setting goals, and reducing distress. She states that “...despite the ubiquitous presence of sexual themes in contemporary media, misinformation and myths about sex abound.” It is important for the clinicians to help the patient to clear up these misconceptions as early as possible, not to mention his or her own! In addition, the author depicts how the trans-theoretical model of Prochaska and Prochaska (1999) can aid the assessment of the patient’s stage of readiness for treatment, which can provide helpful information for treatment planning. She emphasises that “...the ultimate goal of therapy for sexual problem is sexual and relationship satisfaction...”, independent of the frequency and nature of the sexual activity. Stage 2 of treatment consists of cognitive restructuring, emotional regulation, stimulus control and behavioural activation, and building relationship skills. This stage is described in depth, resembling a manual of psychotherapy, which can be particularly helpful to our clinical practice. The treatment ends with stage 3: consolidation of gains and relapse prevention. A detailed account of the specific assessment and treatment components of each of the disorders of interest follows. Dysfunction-specific medical treatment is also discussed. The author ends this section with some useful tips in carrying out treatment. In contrast to other psychological interventions, “...perceived pressure from the therapist can create another layer of performance anxiety.” This book is a concise and detailed clinical guide. “Nearly everyone will experience sexual difficulties at some point in the course of their lives.” — to this, I totally agree. However, this field remains a relatively ‘untouchable area’ to most clinicians. This book empowers us to actively and sensitively engage in the multidisciplinary treatment of sexual disorders, and becomes a pleasure to read!