A number of studies have explored the factors that contribute to female sexual arousal disorder and female orgasmic disorder. The data relating to both the psychological and the physical domain will be evaluated below. In the psychological domain, the impact of past (childhood, adolescence) and current events - both within the individual and within the current relationship - will be considered.

Impact of Events During Childhood and Adolescence
Most studies that have assessed the impact of childhood experiences on female sexual dysfunction are methodologically flawed. They rely on retrospective recall, which is particularly problematic when emotional responses to the event as well as the actual occurrence of the event are being reported. Intervening events, as well as one’s current perspective on the situation, may influence both the recall and the impact of the event. Studies have frequently been limited by small sample sizes and no control groups, which makes generalizability of results and attribution of causality difficult.

Difficulties in the process of socialization during childhood have been cited as important predictors of adult sexual dysfunction. Watters and colleagues (1985) claimed that misconceptions about sex, negative attitudes toward sexual pleasure, and problems with sexual orientation or gender identity may result from the family of origin and may negatively influence sexual functioning in adulthood. Adult attitudes and behaviors are purportedly due to sexual scripts that are developed during childhood as a result of parental attitudes toward sex (Hof and Berman 1986). In reviews of the literature, it has been claimed that sexual dysfunction in adulthood is a consequence of sexual abuse during childhood (Cahill et al. 1991; Talmadge and Wallace 1991). However, both of these reviewers based their conclusions on studies that were largely clinical investigations, with little or no attempt to sample representative groups of adults. Although it can be claimed that a large proportion of dysfunctional adults have experienced sexual abuse during childhood, in the absence of corresponding data from nondysfunctional samples, attributions of causality cannot be made. McCabe and Cobain (1998) found no differences in the reporting of problems during childhood between a group of women presenting to a university clinic for treatment of arousal disorder or orgasmic disorder and a group of women from the general population who were not experiencing either of these two disorders.

Kilpatrick (1986) suggested that it may not be the actual incidence of sexual experience during childhood that is associated with sexual dysfunction, but rather the environment in which that experience occurs. This proposal is supported by Heiman et al. (1986), who found that an important factor discriminating sexually functional from dysfunctional women was the woman’s emotional relationship with her mother. It may also be the interpretation placed on events, rather than the occurrence of events, that is different for sexually functional and dysfunctional women. Dysfunctional women may be more likely to react negatively to childhood and adolescent sexual experiences, to have difficulty in adjusting to the occurrence of these events, or to blame the events for their current difficulties. Further research is needed to clarify these associations. Until confirmed in more rigorous studies, claims of associations between childhood events and sexual functioning in adulthood must be treated with caution.

The contribution of adolescent experiences or attitudes to adult sexual dysfunction has received little attention. Heiman et al. (1986) found that the type of relationship in which first intercourse occurred had an impact on adult sexual functioning for females but not for males. However, Leitenberg et al. (1989) found that the level of sexual activity during adolescence had no impact on adult levels of sexual satisfaction, sexual arousal, or sexual dysfunction. McCabe and Cobain (1998) found that women experiencing either orgasmic or arousal dysfunctions were more likely than women without such problems to report sexual abuse and negative attitudes toward sex during adolescence. The differences in these findings may relate to the fact that the studies measured different aspects of the adolescent experience and sampled different populations. These findings do suggest, however, that it may be the context in which the experiences occur and how the person evaluates the experiences, not simply whether or not such experiences took place, that determine whether childhood and adolescent sexual experiences affect adult functioning.

Current factors that may affect sexual functioning can be divided into intrapersonal (individual) factors and interpersonal (relationship) factors.

Individual Factors
There has been little investigation of the impact of individual factors on sexual dysfunction in women. Such factors include stress, levels of fatigue, gender identity, health, and other individual attributes and experiences that may alter sexual desire or response. Although Obstfeld et al. (1985) established that gender identity had no impact on sexual functioning, the influence of other individual factors requires further exploration. The impact of fatigue and stress on sexual functioning in women is not clear, although recent data would suggest that these factors may be increasing in importance in their contribution to sexual dysfunction among women (McCabe 1994). With women more frequently assuming the multiple roles of full-time worker, mother, wife, and housekeeper, and with the attendant stresses and strains associated with these multiple roles, there is increasingly less time and energy available for a satisfying sexual relationship. These variables may result in higher levels of sexual dysfunction among women.

Relationship Factors
A substantial body of research has explored the role of interpersonal factors in sexual dysfunction among women, particularly in relation to orgasmic response. These studies have largely focused on the impact of the quality of the relationship on the sexual functioning of the partners. Some studies have evaluated the role of specific relationship variables, whereas others have examined overall relationship satisfaction. Some studies have explored events; others have focused on attitudes as an empirical measure of relationship functioning. Subject populations have varied from distressed couples to sexually dysfunctional clients to those in satisfied relationships.

Intimacy between partners has been cited as an important ingredient in sexual relationships, particularly in sexual desire (e.g., McCarthy 1995). McCabe (1997) demonstrated that women with arousal and orgasmic problems also evidenced lower levels of social and recreational intimacy - and, to a lesser extent, sexual intimacy - with their partners than did women without these problems. Although the direction of this relationship between intimacy and sexual functioning is difficult to determine, it is likely to be circular, with sexual problems increasing the emotional distance between the partners, which in turn exacerbates the level of the sexual dysfunction.

Communication between partners seems to play an important part in both the quality of the marital relationship and the level of sexual dysfunction among women. A general lack of communication and a difficulty in communicating preferences for various types of sexual interactions have been demonstrated among sexually dysfunctional couples (Hoch et al. 1981; Pietropinto 1986). K. R. Spector and Boyle (1986) found that even among couples with high levels of relationship satisfaction, lack of communication was strongly associated with sexual dysfunction. Roffe and Britt (1981) found evidence for high levels of hostility among couples seeking sexual dysfunction therapy. However, they also found that a lack of expressiveness and low levels of affection within the relationship contributed to sexual dysfunction. Hulbert (1991) found that sexually assertive women were more likely to experience high sexual desire, arousal, and sexual satisfaction. In contrast, Heiman et al. (1986) found no difference in the communication patterns of sexually functional and dysfunctional couples. It is difficult to interpret these conflicting results. Perhaps it is the way in which the sexual interaction and lack of communication within the relationship are viewed that relates to sexual dysfunction among women rather than the objective interaction and communication patterns. McCabe (1991) developed a model that explains the importance of cognitive processes in the development and maintenance of sexual dysfunction. This model proposes that both individuals evaluate the quality of the relationship (along with the intergenerational and individual attributes they bring to the relationship), and this leads to an emotional response (e.g., anger, anxiety, contentment, happiness), which, in turn, influences sexual response. If the emotional response is negative, then the sexual response is likely to be negatively affected, thus leading to sexual dysfunction (e.g., orgasmic disorder, arousal disorder). More data need to be gathered in order to empirically evaluate the accuracy of this model in explaining the role of the various contributing factors in the development of specific sexual dysfunctions.

The importance of subjective appraisal in sexual dysfunction has been considered in other areas. For example, Beck and Barlow (1984) and Barlow (1986) proposed that it is the ways in which arousal levels are recognized and labeled, rather than actual levels of physiological arousal, that best predict the onset and maintenance of sexual dysfunction. Poor interpersonal relationships do seem to have an impact on sexual functioning, but the subjective appraisal of such conflict may be more important in predicting sexual dysfunction than the objective levels of relationship functioning.

Physical Factors
Estimates of the percentage of female sexual dysfunction attributable to physical factors have ranged from 30% to 80%. The disorders most likely to result in sexual dysfunction are those that lead to problems in circulatory or neurological function. These factors have been more extensively explored in men than in women. Physical etiologies such as neurological and cardiovascular illnesses have been directly implicated in both premature and retarded ejaculation as well as in erectile disorder (Hawton 1993), but the contribution of physiological factors to female sexual dysfunction is not so clear. However, recent literature does suggest that there may be an impairment in the arousal phase among diabetic women. Given that diabetic women show a significant variability in their response to this medical disorder, it is not surprising that the disease’s influence on arousal is also highly variable. In fact, the lack of a clear association between medical disorders and sexual functioning suggests that psychological factors play a significant part in the impact of these disorders on sexual functioning (Melman et al. 1988).

A woman with a physical illness or disability may anticipate failure in becoming aroused or achieving orgasm, and this may lead to avoidance of sexual activity or heightened levels of anxiety prior to and during sex. Related to this response is the fear of harm or damage that may be perceived to be associated with sexual activity. Reluctance to engage in sexual activity may also stem from a poor body image or depression (either clinical depression or a disturbed mood state) associated with the illness. Both of these factors may be apparent in conditions involving physical changes to a woman’s body, such as mastectomy, burns, or loss of mobility.

The response of the partner and the impact of the illness on the relationship may also affect a woman’s sexual response. The extra stresses and strains that develop as a result of adjusting to the illness may lead the partner to withdraw or to express anger toward the patient. If sexual functioning was impaired prior to the illness, the patient’s or the partner’s reactions to the illness and the illness’s subsequent impact on the relationship may further exacerbate the sexual problem.

Menopause results in physical changes for all women that include a decrease in vaginal lubrication and thinning of the walls of the vagina (Roughan et al. 1993; Salamonsen 1997). These physical changes are most apparent among women who do not use hormone replacement therapy. Despite these physical changes, however, some women experience little impairment of their sexual functioning or their enjoyment of sex. The extent of change in sexual functioning at menopause seems to be related to previous sexual functioning, current attitudes toward sex, and attitudes toward menopause (Segraves and Segraves 1995).

Drugs may also have an impact on sexual functioning. Clinicians must exercise care when assessing the impact of drugs, because it can be difficult to differentiate the effects of medication from those of the physical condition. For example, although antihypertensives may affect arousal, the influence of untreated hypertension on sexual dysfunction also seems to be severe. The major drugs that have been implicated in sexual dysfunction are tricyclic antidepressants, antihypertensives, and major tranquilizers; however, exactly how these agents affect sexual functioning is not yet understood.

The search for a drug capable of enhancing women’s sexual arousal and orgasmic frequency has so far been unsuccessful. Early work suggested that large doses of androgens led to an increase in sexual arousal and sexual gratification among women (Salmon and Geist 1943). However, more recent literature indicates that the androgen dosages necessary to significantly affect a woman’s sexual response would have unacceptable virilizing side effects (Hawton 1993).

Case Example

The following case example demonstrates the importance of understanding etiological factors that contribute to sexual disorders in women in formulating a treatment approach.

Presentation
Mrs. C was a 29-year-old woman who presented with an inability to experience orgasm during intercourse, a limitation she found distressing. Her sexual relationship with her husband (to whom she had been married for 3 years) was very good and had been nonproblematic before they began living together. Mrs. C reported that although she currently experienced orgasm during about 25% of her sexual interactions with her husband, she had never experienced it during intercourse, either now or in previous relationships. At present, she seldom masturbates, and she did so only rarely in the past.

Intergenerational Factors
Mrs. C came from a lower-middle-class socioeconomic background. She had grown up in an intact family and had an older brother. Mrs. C’s parents were Protestant, and religion was an important factor in her early life. Although she was allowed to ask questions and talk about sex in the home, discussion was not encouraged. Mrs. C’s parents did not display physical affection, either to each other or to their children.

In adolescence, Mrs. C did not experience negative responses to menstruation and did not experiment with masturbation (although she did later, when she was in her mid-20s). She had a steady boyfriend when she was 17, and this developed into a sexual relationship, although she felt both guilty and anxious about intercourse and regarded it as unpleasant. Otherwise, there were no other unpleasant or traumatic sexual experiences during this time.

Individual Factors
Mrs. C had been sexually responsive and orgasmic with masturbation with her husband before they formed a permanent relationship. Currently, however, she indicated negative feelings about sexual fantasy, sexual secretions, masturbation, oral-genital contact, and intercourse, neither positive nor negative feelings about her genital area and menstruation, and positive feelings about foreplay (these data were obtained from a questionnaire using a 5-point Likert scale). She regarded sex as important in their relationship and looked for a certain equality in both sexual and nonsexual activities. Mrs. C lived a busy professional life, often with meetings or further study outside working hours. She frequently felt fatigued and was concerned about her level of interest in sex. Mrs. C did not feel good about her body and reported that she found it uncomfortable when her partner looked at her during sexual activity.

Relationship Factors
Within the current relationship, there were conflicts that had not been satisfactorily resolved about the division of household labor and the amount of time spent at work. Mrs. C resented the fact that her husband did not do his fair share of household tasks. These feelings were experienced most strongly because she felt that since she had a more demanding job and earned a higher salary than her partner, he should make a greater contribution to the running of the household. She also felt guilty about the amount of time she devoted to her work, and suspected that the stress and fatigue that resulted from this work commitment contributed to her sexual problems. These matters were not discussed with her husband. Furthermore, Mrs. C was not able to tell her husband what she liked or disliked about sex, or to express preferences, and she wished that their general pattern of communication could be more open and direct. She feared that her sexual difficulties were seriously affecting other aspects of their relationship.

Physical Factors
Mrs. C had no significant illnesses or disabilities and was not on any medication. She had an occasional glass of wine when she went out, but she did not usually drink at home.

Summary

This case example highlights the importance of obtaining a thorough assessment of the presenting problem and variables that may contribute to the problem. It is important not only to identify the nature of the presenting problem but also to determine the frequency of the difficulty, the circumstances under which it occurs, and the length of time it has been in place. The reaction of the woman - and, if relevant, of her partner - to the problem is also important in determining the nature of the disorder to be treated.

That her husband’s career took precedence over hers and that Mr. C assumed no responsibility for the running of the household were two issues that irritated Mrs. C. Her ambivalence about expressing her own sexuality, together with her husband’s anxieties about sex, seemed to have allowed the sexual relationship to become the microcosm in which many of these broader issues found expression.

This case example also illustrates the need to obtain a thorough assessment of the factors that may be associated with the dysfunction. Repressive attitudes in Mrs. C’s family of origin seem to have had an impact on her current attitudes toward sex and things associated with sexual activity. Mrs. C’s lifestyle and values, as well as her relationship with her husband, also seemed to be contributing factors. At the assessment stage, determining the exact contribution of each of these factors to the sexual difficulties is not always possible. However, it is important to evaluate each of these areas so that their possible role can be explored at the early stages of therapy.