Differences between men and women in the sexual response
system: the clinical consequences for management of arousal disorders
Rik HW van Lunsen and Ellen TM Laan
Dept Sexology & Psychosomatic Ob/Gyn, Academic Medical
Centre, University of Amsterdam, The Netherlands
In the last decades research in the field of male sexual
dysfunctions has been dominated by studies that use the genital sexual response,
the erection, as the major endpoint The main reason for this is that men tend to
use their erection as indicator for their arousal state. In men without sexual
problems, correlations between penile circumference change and subjective report
are usually fairly high. Men with psychogenic erectile dysfunction, however,
tend to underestimate their sexual responses. The introduction of 5PDE
inhibitors as enhancer of the genital response and the physiological
similarities between the male and the female sexual system have led to the
presumption that female sexual arousal disorders (FSAD) should be approached in
the same way as erectile dysfunction and could be seen as a predominantly
vasculogenic disease. In line with this genital approach to sexual arousal
problems of women the current classification system of the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines female
sexual arousal entirely in terms of genital indices of a sexual response, namely,
the lubrication-swelling response. The definition of female sexual arousal
disorder (FSAD) is consistent with this definition. In clinical practice,
however, more often it is the lack of subjective sexual arousal that leads women
to seek treatment. Women are, in contrast to men, relatively unaware of their
genital sexual responses and tend to define sexual arousal in terms of their
subjective feeling state. Only a severe inhibition or complete absence of a
physical sexual response indirectly leads to complaints by the discomfort and
pain that is the result. Diminished physical responsivity is rarely described in
terms of perceived incomplete, or absence of, lubrication and/or swelling.
In women experiencing arousal problems, the lack of a systematic
relation between awareness of genital responses and feelings of arousal is even
more apparent in comparison with women without sexual problems. Their subjective
experience of sexual arousal is determined less by feedback from their genitals
than by the intensity and appraisal of the sexual stimulus and other contextual
factors. In the laboratory pre- and postmenopausal women with FSAD and without
known organic disease have similar genital responses as women without arousal
problems and moreover on a subjective level do not benefit of enhancement of
genital reponses by means of 5PDE inhibitors. Men come from Mars and women from
Venus; their bodies show similarities but in the way subjective appraisal of
sexual arousal is processed their brains and their genitals interact in a
completely different way. Treatment modalities and medications suitable for men
have no clinical relevance whatsoever for women. FSAD does not exist. Women need
approaches that increase central arousal and take into account context related
variables and quality of sexual stimuli. While men often have to learn to focus
less on their genitals, women should often be more aware of their personal
prerequisites for being able to respond to sexual stimuli and should learn not
to engage in sexual intercourse when not sufficiently aroused.
Literature
Lunsen HW van, Laan E. Genital vascular responsiveness and
sexual feelings in midlife women: psychophysiologic, brain, and genital imaging
studies. Menopause 2004;11(6):741-8.
Nappi R. Salonia A. Traish AM. van Lunsen RHW. Vardi Y. Kodiglu
A. Goldstein I. Clinical biologic pathophysiologies of women’s sexual
dysfunction. Journal of Sexual Medicine 2005;2(1):4-25.