Commentary: Female sexual dysfunction is a real but complex problemBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5336 (Published 30 September 2010) Cite this as: BMJ 2010;341:c5336
- Sandy Goldbeck-Wood, associate specialist in psychosexual medicine1, specialty doctor in obstetrics and gynaecology2
When the desire for sex goes persistently missing, a few women may be untroubled but many become unhappy. Some are unhappy because they miss the pleasure, physical release, and emotional intimacy that sex can provide or because a lack of sex stands in the way of having children. Sometimes their unhappiness is social or relational: because they fear hurting, rejecting, frustrating, angering, and perhaps even losing their partner. Many endure sexual unhappiness for long periods alone, feeling too embarrassed, ashamed, unentitled, mistrustful, or hopeless to ask for help. It is difficult to speak to a strange doctor about such private distress; more difficult still given that many fear embarrassing their doctor.1 2
So women who consult doctors about sexual problems are those for whom the unhappiness has become so intractable, or is causing so many physical or relational problems, that they are forced into the open. Some present a sexual problem directly, others indirectly through secondary symptoms such as depression, recurrent vaginal discharge, or chronic pelvic pain.3
Faced with a woman in tears whose libido has disappeared and who is terrified of losing her partner, doctors can feel immense pressure to provide an immediate, effective solution. Given that most doctors understand more about biological illnesses and treatments than other possible causes of sexual difficulty and that most medical research is biological in focus, it is not surprising that we often reach first for oestrogen creams, testosterone patches, phosphodiesterase 5 inhibitors, antidepressants, or dilators—anything halfway plausible to defend us from the naked embarrassment of our therapeutic impotence. It is easy to see how the pressure for immediate solutions, combined with our biological bias and offers of research funding, leads to the kind of collaboration with the drug industry that has worked well for other illnesses, despite its relative inefficacy in this area.
Moynihan’s research points to an improperly intimate research relationship between industry and clinicians, distorting the research agenda and casting doubt over even the most basic prevalence data.4 5 His research clarifies, helpfully, both the conflicts of interest at work and the relative paucity of good quality evidence for pharmacological solutions to women’s sexual problems. However, his argument that female sexual dysfunction is an illness constructed by pathologising doctors under the influence of drug companies will fail to convince clinicians who see women with sexual dysfunction, or their patients. Women who have struggled to overcome the psychological and cultural barriers to requesting help with their sexual difficulties will not welcome the argument that they are to be “left alone”; patronising normalisation will serve them no better than ineffective medication.
The problem is one of oversimplification. Sex is, par excellence, a biopsychosocial experience, and attempts to split these elements, however intellectually or politically convenient, are doomed to fail. Many factors can contribute to low libido, few of them treatable with drugs. Traumatic experiences, physical or mental illness, unexpressed feelings within a relationship, pressure to conform to religious or media ideals of womanhood, or general unhappiness in wider life can all disturb a woman’s relationship with her partner, or with her own body. It is welcome, therefore, that the Diagnostic and Statistical Manual of Mental Disorders is revising its definitions of female sexual dysfunction to reflect contextual factors,4 and unsurprising that the best available evidence (levels 3, 4 and 5) supports the use of a multidisciplinary or biopsychosocial approach to treatment.6
The methodological challenges to such research are considerable. Experts from disparate disciplines such as gynaecology, psychotherapy, sociology, or psychiatry are divided by history, culture, language and research methodology, and sometimes by mutual suspicion and competition.7 Outcome studies are notoriously difficult to design and conduct in ways that meet high evidence standards while respecting the complexity of sexual life.8 9 Many studies have focused narrowly on genital function or performance, for example, and overemphasised frequency of various sexual acts, neglecting more subtle measures of satisfaction or health related quality of life. Even defining a good treatment outcome can be challenging. More studies of interdisciplinary approaches are needed, using methods that allow subjective, lived experience to be studied, rather than dismissed as a contaminant.10
Moynihan points away from overinvestment in pharmaceutical solutions that ignore both aetiology and evidence. His book points clinicians, researchers, and funding bodies towards the most realistic treatments using the most appropriate methods—those which respect the biopsychosocial complexity of the problem.11 We owe these women something more respectful than ineffective medication or patronising false reassurance. At the least, this may be an honest acknowledgment of our, and medicine’s, limitations to deal with a real problem. At best, we can offer them the interdisciplinary treatments most likely to help. This means leaving the comfort zones of biology, medication, and familiar research methodologies, and designing studies which reflect the complexity of sexual life, and respect lived experience.
Where to go for information on better help
Institute of Psychosexual Medicine (www.ipm.org.uk)—Provides training in psychosexual medicine for doctors in the UK
British Association of Sexual and Relationship Therapy (www.basrt.org.uk)—A specialist charity that provides information on sexual problems, access to psychosexual therapists, and useful resource links
British Association for Behavioural and Cognitive Psychotherapies (www.babcp.com)—Information on training, accreditation, supervision, and access to cognitive behavioural therapists in the UK, with links to similar organisations in other countries
British Society for Sexual Medicine (www.bssm.org.uk)—Promotes research and education on sexual dysfunction. Membership allows access to peer reviewed publications
Cite this as: BMJ 2010;341:c5336
Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; She works as a specialist doctor in psychosexual medicine, within the NHS and with a small private practice. She is a member of the Institute of Psychosexual Medicine (IPM), a trainer for the IPM, and edits the IPM’s journal, IPMJ. She also has training in psychotherapy, and a longstanding interest in psychosomatic aspects of sexual and reproductive health.