CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Annual Review of Clinical Psychology
History of the Treatment of
Female Sexual Dysfunction(s)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
Peggy J. Kleinplatz1,2
1
Faculty of Medicine, University of Ottawa, Ottawa, Ontario K1G 5Z3, Canada;
email: kleinpla@uottawa.ca
2
School of Psychology, University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
Annu. Rev. Clin. Psychol. 2018. 14:2.1–2.26
Keywords
The Annual Review of Clinical Psychology is online at
clinpsy.annualreviews.org
female sexual dysfunction, female sexuality, low desire, sex therapy
https://doi.org/10.1146/annurev-clinpsy-050817084802
Abstract
c 2018 by Annual Reviews.
Copyright All rights reserved
This article reviews the history of the treatment of women’s sexual problems
from the Victorian era to the twenty-first century. The contextual nature of
determining what constitutes female sexual psychopathology is highlighted.
Conceptions of normal sexuality are subject to cultural vagaries, making it
difficult to identify female sexual dysfunctions. A survey of the inclusion,
removal, and collapsing of women’s sexual diagnoses in the Diagnostic and
Statistical Manual of Mental Disorders from 1952 to 2013 illuminates the biases
in the various editions. Masters and Johnson’s models of sexual response and
dysfunction paved the way for the diagnosis and treatment of women’s sexual
dysfunctions. Their sex therapy paradigm is described. Conceptions of and
treatments for anorgasmia, arousal difficulties, vaginismus, dyspareunia, and
low desire are reviewed. The medicalization of human sexuality and the
splintering of sex therapy are discussed, along with current trends and new
directions in sexual health care for women.
2.1
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Contents
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE VICTORIAN ERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WOMEN’S PSYCHOLOGICAL PROBLEMS AS ROOTED
IN GYNECOLOGICAL DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FREUD AND THE DIAGNOSIS AND TREATMENT OF HYSTERIA
IN PSYCHOANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FREUD ON ORGASM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MID-CENTURY AMERICA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE DIAGNOSES AND TREATMENTS OF WOMEN’S SEXUAL
PROBLEMS 1952–2013: FROM THE OBJECTIVE TO THE
SUBJECTIVE AND BACK AGAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MASTERS AND JOHNSON AND THE BEGINNINGS OF MODERN
SEX THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE 1970S: THE REDISCOVERY OF THE CLITORIS AND THE RIGHT
TO FEMALE SEXUAL PLEASURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SEXUAL DESIRE DISORDERS AND THE FAILURE OF SEX THERAPY . . . . . .
WHEN A WOMAN HAS A SEXUAL DYSFUNCTION, WHAT EXACTLY
IS IT THAT REQUIRES TREATMENT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE FEMINIST SEX WARS: FROM SEXUALITY AS EMPOWERING
TO SEX AS DANGEROUS TO WOMEN AND GIRLS . . . . . . . . . . . . . . . . . . . . . . .
POLYPHARMACY, IATROGENIC SEXUAL DYSFUNCTIONS,
AND SILENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
THE FRAGMENTATION OF THE FIELD AND IMPLICATIONS FOR THE
TREATMENT OF WOMEN’S SEXUAL PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . .
THE MEDICALIZATION OF SEXUALITY AND THE TREATMENT
OF “FEMALE SEXUAL DYSFUNCTIONS” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHANGES TO THE DIAGNOSTIC NOSOLOGY FROM THE DSM-III TO
THE DSM-5: IMPLICATIONS FOR TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . .
From Vaginismus and Dyspareunia to Genito-Pelvic Pain/Penetration Disorder . . .
From Female Sexual Arousal Disorder and Hypoactive Sexual Desire Disorder
to Female Sexual Interest/Arousal Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RECENT TRENDS AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2
2.3
2.4
2.5
2.6
2.6
2.6
2.8
2.10
2.11
2.12
2.12
2.13
2.14
2.15
2.18
2.18
2.19
2.20
INTRODUCTION
Victorian era: a
period corresponding
to the reign of Queen
Victoria (1837–1901),
known for sexual
hypocrisy and double
standards
HSDD: hypoactive
sexual desire disorder
2.2
This article will survey the history of the treatment of women’s sexual problems from the late
Victorian era to the present. Some of these problems have been formally identified and diagnosed
as female sexual dysfunctions (e.g., anorgasmia) or disorders (e.g., hypoactive sexual desire disorder, or HSDD); others refer to psychological problems that were assumed to originate (primarily)
in women’s sexuality (e.g., hysteria) prior to the existence of nosologies for female sexual dysfunction. This review will intertwine social history with notions of womanhood, conceptions of
psychopathology, diagnostic classification systems, and the treatment of women’s sexual problems
both before and after the advent of the field of sex therapy.
The history of the treatment of Female Sexual Dysfunction is inextricably bound up with the
history of sexology, female sexuality, and conceptions and diagnoses of male and female sexual
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
problems. Any attempt to understand this history requires grappling with clinical and psychosocial
conceptions of female and male sexuality, the lack of consistent and cohesive conceptions of normal
versus psychopathological sexuality, and the vagaries of the diagnostic criteria used historically for
the female and male sexual dysfunctions and disorders.
One cannot discuss the history of the treatment of Female Sexual Dysfunction in the same way
that one could discuss the history of the treatment of appendicitis (the infection of an organ found
in the lower right quadrant of the abdomen). There is considerable agreement as to the signs and
symptoms of appendicitis. The history of treatment of appendicitis is akin to the history of the
development of surgical interventions; despite the many changes that occurred in this domain,
there was never an argument about whether or not the appendix exists, where it is located, the
seriousness of appendicitis, or whether to treat it.
By contrast, there is considerable debate about what constitutes a sexual dysfunction; what
the correct reference points are for understanding sexuality in general and sexual difficulties in
particular; what the correct reference points might be for distinguishing normal sexual function
from sexual dysfunction; whether sexual dysfunctions exist outside of normative performance
standards; whether or not we can understand female sexual dysfunctions at all, given that male
sexuality has long been held as the standard for sexuality per se; whether there is such a thing
as “female sexual dysfunction” as a unitary entity versus “female sexual dysfunctions” (just as
there are “male sexual dysfunctions” and no one would know what to make of the term “male
sexual dysfunction”); the extent to which objective signs versus subjective symptoms determine
whether a dysfunction is present; the seriousness of the problems; who is to determine whether
or not a woman is in need of treatment; what methods ought to be employed in the course of
treatment; what ought to be the goals of treatment; and what outcome criteria—and determined
by whom—would suggest that the treatment was successful.
Hysteria: a popular
diagnosis of the
nineteenth and
twentieth centuries,
primarily of women,
later replaced by
dissociative identity
disorder and somatoform/somatization
disorders
THE VICTORIAN ERA
Victorian sexual ethics were dominated by the belief that sexuality was in need of control—not
expression. This was hardly a new idea. Over the previous 2,000 years or so, Western sexual
repression had largely been justified and sanctified in terms of Christian teachings. Socially unacceptable sexual desires and behaviors were judged as sinful. However, a major shift occurred
during the Enlightenment, when science substituted from religious teachings as the arbiter of
sexual and other morality.
Whereas some streams within Western traditions had long held that sex was a wife’s privilege
and a husband’s responsibility (e.g., Jewish teachings, Puritan codes), during the Victorian era a
variety of social and intellectual currents converged to create the new belief that sex was a husband’s
privilege and a wife’s responsibility (Groneman 2000, Sussman 1976). In the post-Enlightenment
era, for the first time beliefs about the need for sexual restrictions were no longer justified in terms
of sin but rather substantiated by Victorian notions of the natural sciences. Specifically, male sexual
excesses were to be avoided out of fear of “spermatorrhea,” ostensibly a disease characterized by
an imbalance of bodily fluids in the male body, which in turn was caused by too much ejaculation.
Krafft-Ebing, author of the lurid but influential Psychopathia Sexualis in 1886, pronounced that
men were to ejaculate only when absolutely necessary for purposes of procreation; otherwise, they
would be at risk of the ravages of spermatorrhea, including feeblemindedness, madness, and even
death (Krafft-Ebing 1965).
This line of thinking became an important part of the foundations of psychology. For example,
Benjamin Rush, the great pioneer of the mental hygiene movement, fought for those suffering from
madness to be seen as mentally ill and treated with compassion rather than as sinners to be subject
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.3
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
to punishment and exorcism. However, Rush was among those Americans who spearheaded and
championed the fight against spermatorrhea.
How is any of this relevant for female sexuality or for the treatment of female sexual dysfunctions? The role of the good woman in this narrative was to constrain not only her own sexuality but
also that of her husband. The Victorian ideal was said to be “a lady in the parlour and a whore in
the bedroom”—both roles suited to fulfilling the needs of her husband (Pearsall 1969). This is in
keeping with the Victorian view of female sexuality as subsidiary to male sexuality. Male sexuality
was perceived as the reference point for sexuality per se, and this view continues to permeate the
mental health professions to this day. Male sexuality has been perceived since the Victorian era
as more driven, more “naturally” in need of expression and release, and as the template for sexual
desire. At times, this has been explained in terms of testosterone, biomechanical factors, evolution,
or (more recently) neuroscience. Female sexual desire has been perceived as less driven/compelling
and therefore, for better or for worse, in the “normal,” feminine woman, more responsive and
therefore under better control. This means not only that female disorders have been diagnosed
and treated in terms of deviation from whatever had been perceived at a given time as normal
female sexuality, but also that normal female sexuality has been perceived as that which deviates
from and obstructs male sexual needs. These themes continue to recur in modern and postmodern
times. There was the occasional voice, most notably Ellis (1936), who would call for the study
of women’s sexuality, recognize women’s own capacity for desire and orgasm, and campaign for
female sexual equality and the liberation of women, but they were not prominent until well into
the twentieth century.
Victorian views of sexuality and its dangers permeated not only scientific and medical literature
but also the novels of the time. If “good women” were to prevent men from succumbing to
spermatorrhea, correspondingly, “bad girls” were represented in Victorian literature as those
who, having been bitten, became vampires. These insatiable women could suck a man dry and
leave him near death or, even worse, transform him, too, into one of the pale creatures of the
night. We see this image represented in the silent films of the early twentieth century and in those
of the 1930s as the irresistible vamps portrayed by Theda Bara, Marlene Dietrich, Jean Harlow,
etc. (LaSalle 2000). (When they reappear in the more sexually conservative 1950s as the femme
fatales Lana Turner, Barbara Stanwyck, or Ava Gardner, they are punished, usually by death, for
their sexual temptation.)
In summary, the early years of psychology and psychiatry correspond to a period during which
Victorian ideas of male and female sexuality came to be explained in terms of what was or was not
natural; in turn, ideas of what was natural and normal came to be explained in terms of biological
science and were adopted by the founders of our fields. Please note that these nineteenth-century
ideas about basic differences between men and women came to be accepted so automatically and
uncritically that we continue to refer to men and women as “opposite sexes.”
WOMEN’S PSYCHOLOGICAL PROBLEMS AS ROOTED
IN GYNECOLOGICAL DISORDERS
The Victorian woman’s psychological problems were assumed to stem from disturbances in her
reproductive organs. This belief is suggested by diagnoses such as “hysteria,” from the Greek
for wandering womb; or, in the twentieth century, “involutional melancholia,” defined as an
endogenous depression triggered by the shriveling of the uterus at menopause. Both were listed
in the first two editions of the Diagnostic and Statistical Manual of Mental Disorders of the American
Psychiatric Association (DSM, DSM-II; Am. Psychiatr. Assoc. 1952, 1968). The treatment of
diseases linked or attributed to women’s sexuality, notably hysteria and nymphomania, was related
2.4
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
to which medical specialty held dominion over women’s minds and bodies from the nineteenth
to the twentieth century: “The underlying assumption that women were dominated by their
reproductive organs led some physicians to blame virtually all women’s diseases and complaints
on disorders of these organs” (Groneman 1994, p. 349).
Dissociative and conversion hysteria were particularly vexing; they remained in the DSM
until 1980 and were then renamed and reconceptualized as dissociative identity disorder and somatoform/somatization disorders, respectively. Nineteenth-century treatments for hysteria varied from high-fiber diets, bloodletting, cold enemas, and oophorectomies to clitoral ablation
and induction of paroxysmal convulsions (i.e., orgasms) by the physician (Groneman 1994).
The latter was sensational enough to have become the subject of a 2009 movie entitled Hysteria starring Maggie Gyllenhaal. Unfortunately, the focus of the film, the ostensible development of vibrators and their popularity in the treatment of hysteria, was far from accurate. The
treatments of hysteria and nymphomania were far more likely to be painful and punitive than
pleasurable.
Nymphomania:
a diagnosis of the
nineteenth and
twentieth centuries for
women who were very
sexually active or
displaying high sexual
desires (derogatory
connotation)
FREUD AND THE DIAGNOSIS AND TREATMENT OF HYSTERIA
IN PSYCHOANALYSIS
Although it may not have encompassed what would be called Female Sexual Dysfunction today,
Freud famously studied the origins of and treatment for hysteria. He concluded that the cause
of hysteria was unresolved trauma, often child sexual abuse, typically incest (Freud 1896). He
believed that abreaction or catharsis—that is, uncovering and dealing with the emotions that were
denied expression during the original trauma—was a crucial ingredient in treating hysteria. He
thereby introduced “the talking cure,” or what later developed into psychoanalysis. Freud presented his discovery at a conference in Vienna in 1896. Unfortunately for Freud, Krafft-Ebing,
then at the peak of his fame, was in the audience and stood up (Masson 1984), saying, “This
sounds like a fairy tale!” Kraft-Ebbing’s denunciation of Freud’s theory of the sexual abuse etiology of hysteria was devastating and risked destroying any chance that psychoanalysis would be
taken seriously. Three months later, Freud withdrew the most controversial aspect of his theory
of hysteria (incest as the primary etiology) in order to establish the credibility of psychoanalysis itself (Masson 1984). For the next 90 years or so, when women, and sometimes men, came
forward saying that they had been sexually abused in childhood, the standard mental health professional’s response was denial: No, there was no actual incest, but rather a wish so strong and
so deeply repressed for many years that the patient was incapable of distinguishing between fantasy and reality. (This notion that children fantasize about sex with their parents later appeared
in Freud’s theory of the Oedipal complex.) Treatment, therefore, consisted of having the patient eventually acknowledge that she “wanted it” but had not actually had sex with the alleged
perpetrator.
This approach stood until 1983, when Jeffrey Masson, then curator of the Freudian archives,
disclosed publicly the correspondence between Freud and Fliess, in which Freud related that he
had never stopped believing his patients’ accounts. Freud had continued to treat them as survivors
of sexual abuse, rather than as women who could not distinguish between fantasy and reality
(Masson 1984).
Other early psychoanalytic circles often focused on tangential links between women’s neuroses
and their sexuality. For example, Wilhelm Fliess posited a connection between women’s menstrual
cycles, sexually based neuroses, and nasal tissue (Freud & Fliess 1986). Fliess’s nasalogenital theory
attracted some interest, if not popularity, until his treatment—nasal surgery gone awry—resulted
in hemorrhaging rather than a cure for female sexual psychopathology.
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.5
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
FREUD ON ORGASM
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
Clitoris: the primary
female sexual pleasure
organ; the most
densely loaded organ
in the human body
with nerve endings for
touch
Before leaving Freud, his comments on women’s orgasms are worth considering in context, if
only because his theory has so often been misquoted. Freud (1905) wrote about the girl’s focus
on her clitoris as her primary erogenous zone during the phallic phase (i.e., ages 3–5). It was
rather radical for Freud in 1905 to acknowledge the center of female sexual pleasure, let alone as
it is experienced in childhood. His candor about the clitoris being the location for female selfstimulation to orgasm until the (partial) resolution of the Oedipal complex was similarly startling.
(A careful discussion of Freud’s theory of the Oedipal complex in girls and its repercussions for
sexuality in adulthood is beyond the scope of this article. It is just worth mentioning that his theory
has often been confused with Jung’s theory of the Electra complex or, worse, misunderstood as
misogynistic.) Freud wrote that in adulthood, women must switch their primary erogenous zone
from the clitoris to the vagina by virtue of the demands of procreation in marriage. This has often
been misunderstood as a repudiation of “clitoral orgasms” in favor of “vaginal orgasms” in the
“mature” woman. For Freud, it was not so clear cut. As he wrote,
When at last the sexual act is permitted and the clitoris itself becomes excited, it still retains a function:
the task, namely, of transmitting the excitation to the adjacent female sexual parts, just as—to use a
simile—pine shavings can be kindled in order to set a log of harder wood on fire. (Freud 1905, p.143)
Did Freud consider the “clitoral orgasm” as pathological? It does not appear to be so. It is not
what Freud actually wrote, but how it has been misinterpreted that has led to unnecessary “treatment” of women’s orgasms. Similarly, self-styled psychoanalysts have cited Freud’s comments
that homosexuality represented “an arrest in sexual development” (again, something that must be
read in context) while ignoring Freud’s statement that “[homosexuality] cannot be classified as an
illness” [Freud 1951 (1935)]. For Freud, same-sex attraction in men and women did not call for
therapy. The interested reader is advised to study primary sources [e.g., Freud 1905, 1951 (1935)].
MID-CENTURY AMERICA
During the first half of the twentieth century, psychodynamic thinking dominated the diagnosis
and treatment of sexual problems. Although there was no treatment for sexual dysfunctions as
such, the treatment for problems of a sexual nature or that could be traced back to psychosexual
development was psychoanalysis. This treatment aimed at substantive personality changes rather
than merely targeting symptoms, but it was time intensive and expensive.
The understanding of normal sexuality per se was revolutionized by the work of Kinsey and his
colleagues and their large-scale surveys of male sexual behavior in 1948 and female sexual behavior
in 1953, to be discussed below.
THE DIAGNOSES AND TREATMENTS OF WOMEN’S SEXUAL
PROBLEMS 1952–2013: FROM THE OBJECTIVE TO THE
SUBJECTIVE AND BACK AGAIN
Diagnoses of sexual problems exist in social context. This is never more apparent than in the
history of the inclusion or removal of female sexual dysfunctions and disorders in/from the DSM
from 1952 to 2013. The following sections will cover changes in the DSM diagnoses of female
sexual problems across the editions. These sections will be interspersed with other observations
highlighting the early and current treatments for these problems. The role of social changes from
the 1950s to the present in influencing diagnoses and treatment will be woven through as well.
The changes in the DSM are summarized in Table 1.
2.6
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
CP14CH02_Kleinplatz
Table 1
ARI
13:1
Summary of changes to DSM diagnoses of women’s sexual problems, 1952–2013
Edition
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
19 December 2017
Year
Changes to diagnoses
DSM
1952
Included involutional melancholia, frigidity, dyspareunia, nymphomania.
Homosexuality listed under personality disorders.
DSM-II
1968
Homosexuality now listed under sexual deviations.
DSM-III
1980
Homosexuality removed.
Nymphomania removed and new diagnoses added of inhibited sexual desire and sexual aversion.
“Psychosexual dysfunctions added, which now include inhibited arousal and orgasm disorders in men and
women, plus dyspareunia and vaginismus in women.
DSM-III-R
1987
Psychosexual dysfunctions renamed sexual dysfunctions. Inhibited sexual desire renamed hypoactive sexual
desire disorder.
DSM-IV
1994
No significant changes.
DSM-IV-TR
2000
No significant changes.
DSM-5
2013
Sexual aversion removed.
Dyspareunia and vaginismus removed and replaced by genito-pelvic pain/penetration disorder (GPPPD).
Female sexual arousal disorder and hypoactive sexual desire disorder now replaced by female sexual
interest/arousal disorder (SIAD, also known as FSIAD).
No similar collapsing of categories occurred for male sexual dysfunctions.
The late 1940s and early 1950s correspond to a period of relative social conservativism in the
United States. It is during this period that the first edition of the DSM was published by the
American Psychiatric Association in 1952. It was not until 1980 that psychosexual dysfunctions
were formally introduced into the DSM-III. Nonetheless, there were sexual diagnoses in the
1940s and 1950s, which were then listed in the first edition of the DSM under “Psychophysiological autonomic and visceral disorders,” which included nymphomania, dyspareunia, frigidity, and
involutional melancholia.
Women who wanted and sought out copious amounts of sexual activities were diagnosed as
nymphomaniacs, whereas the corresponding diagnosis for men was satyriasis. (Both terms come
from woodland creatures in Greek mythology.) The gender bias in the application of these diagnoses was readily apparent: Women diagnosed with nymphomania were subjected to prefrontal
lobotomies in the 1940s and 1950s; neuroleptic medications and electroconvulsive treatment followed in the 1950s and 1960s. By contrast, men who sought out lots of sex were seen as normal
men and did not receive diagnoses, let alone psychiatric treatment.
The other major diagnosis of female sexuality in the mid-twentieth century was the amorphous
frigidity. As suggested by the term, it referred generically to women who were sexually cold and
unresponsive. More specifically, it referred to women who had difficulties with arousal or orgasm
during heterosexual intercourse (and who consequently were seen to have low desire for “sex”).
At the time, marriage manuals indicated that sex ought to result in simultaneous orgasms as the
climax of intercourse. Women who did not achieve orgasm in this way were pathologized and sent
for psychoanalysis.
Kinsey’s 1953 research indicating that women did, in fact, have orgasms regularly, though not
necessarily via intercourse, was very controversial (Kinsey et al. 1953). The women he had interviewed reported prolific sexual activity before marriage, particularly manual and oral stimulation
that led to multiple orgasms. Kinsey’s critics suggested that he was deluded to believe women who
obviously could not distinguish between an orgasm and a sneeze. His revolutionary findings led
to the withdrawal of his funding in 1954, and it is widely believed that the resulting trauma led to
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.7
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
his premature death in 1956 (Bullough 1994; Pomeroy 1972, p. 382); his research also opened the
door for future sex researchers to explore further and verify his findings.
HSRC: human sexual
response cycle
MASTERS AND JOHNSON AND THE BEGINNINGS OF MODERN
SEX THERAPY
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
From 1955 to 1966, William Masters and Virginia Johnson conducted pioneering research on
the physiology of sexual response in their laboratory in St. Louis, Missouri. Participants in their
research were observed during sexual activity, and their physiologic responses were recorded on
film and via electroencephalogram, electrocardiogram, electromyogram, together with monitoring of the galvanic skin response. In addition, Masters and Johnson developed two new instruments, the penile strain gauge and the vaginal photoplethysmograph, to monitor changes in blood
flow/volume in the penis and vagina, respectively. In 1966, they published their findings, thus
providing the first physiological model of what they called the Human Sexual Response Cycle
(HSRC) (Masters & Johnson 1966). This four-phase model consists of excitement, plateau, orgasm, and resolution in both men and women. Even though it represented only the physiology
of sexual response among some individuals willing to have sex in the lab while being observed
and attached to a variety of recording paraphernalia, the HSRC became the template for normal
sexual response. It became central to the development thereafter of the diagnosis and treatment
of sexual problems.
In 1970, Masters and Johnson published their follow-up text, Human Sexual Inadequacy, where
they define sexual difficulties in terms of deviations in sexual response from the HSRC. This
template came to be enshrined in the new field of sex therapy and later in the DSM. It is also with
this book that Masters and Johnson introduced and ushered in the era of modern sex therapy.
Their diagnosis and treatment model identified three female sexual dysfunctions: anorgasmia,
vaginismus, and dyspareunia. Anorgasmia is defined as the inability to achieve orgasm; vaginismus
refers to a spasm in the outer third of the vagina that prevents penetration; and dyspareunia is
defined as pain during intercourse. These dysfunctions and their treatments are discussed further
below.
Masters and Johnson (1970) developed a new model for the treatment of sexual dysfunctions
in men and women. Prior to them, psychodynamic treatment sought to understand the origins
of sexual difficulties in the individual’s personality via long-term, insight-oriented psychotherapy. Masters and Johnson revolutionized the treatment of the sexual dysfunctions by introducing
behaviorally based, short-term, intensive treatment of the couple rather than only the identified
patient.
Their program was built around 14 days of intensive treatment in Masters and Johnson’s offices
in St. Louis, Missouri, whether or not the couple lived in St. Louis. The couple were to stay at
a hotel for two weeks, isolated from the usual demands of family, household, and work to focus
on nothing but their sexual relationship. Of course, this requirement meant that the couples were
self-selected for those with exceptionally strong motivation, lack of small children, and higher
socioeconomic status or the financial/family resources to put their lives on hold for two weeks.
This hardly mirrors the situation for most couples, especially mothers and their responsibilities
upon their return home. This issue is particularly salient given Masters and Johnson’s outcome
criteria discussed below.
The first two to three days of the program consisted of careful psychological and medical
assessment by the male and female clinicians who formed a dual-sex therapy team. Masters and
Johnson believed that sex therapy ought to be conducted by a man and a woman. Their rationale
was that only a woman could truly understand how it feels to live in a woman’s body and the
2.8
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
nature of female sexual experience, and only men could fully appreciate male sexual experience
(Masters & Johnson 1970). Similarly, in duplicating their own qualifications, one member of the
co-therapy team was to have a medical background, whereas the other was to have a background
in the mental health professions. The use of a dual-sex therapy team is expensive and scheduling
can be unwieldy. Although very few sex therapists over the last 45 years have continued in the use
of a dual-sex therapy team, much of the rest of Masters and Johnson’s program as introduced on
the third day continues to provide the foundations for current sex therapy practice.
After completion of assessment and feedback, the treatment would begin. Masters and Johnson
believed that the etiology of the sexual dysfunctions was 10% organic and 90% psychogenic,
generally originating in sex-negative psychosocial expectations. They regarded sexual functioning
as any other sort of bodily functioning, not unlike urination, defecation, or respiration (Masters &
Johnson 1986). The goal of sex therapy was to reduce any impediments, typically of a psychosocial
nature, that might interfere with sexuality so that normal sexual functioning would resume. As
such, their interventions were targeted largely at reducing the symptoms of the sexual dysfunctions.
Their major clinical innovation, the introduction of sensate focus exercises (Masters & Johnson
1970), was intended to interrupt performance anxiety and has remained a staple of sex therapy
ever since.
Sensate focus occurs in two or more stages. The first stage involves approximately 20 minutes
of one partner caressing the other, from head to toe, while excluding the breasts and genitals. Then
the partner reciprocates. These exercises have been misunderstood, as though the goal were to get
one another in the mood for sex, with each giving the other feedback as to how he or she prefers
to be touched. On the contrary, the goal is to break the performance mindset (Apfelbaum 2012)
that so hampers normal functioning. Masters and Johnson required that the mood be anything but
conventionally romantic. The partners were to be entirely nude from the outset in a well-lit room.
The purpose was not to arouse the one being caressed but rather for the toucher to touch for his
or her own pleasure. Masters and Johnson were aware that much sexual interaction is about trying
to please the partner. They wanted to allow each individual to enjoy touching for its own sake.
After the patients’ initial experiments with sensate focus, the therapists would deal with whatever resistance had arisen in the process. Once any obstacles had been challenged and overcome,
couples would be instructed in the second phase of sensate focus exercises, in which they were to
take turns caressing one another all over, including but not focusing upon the breasts and genitals
and with no attempt at orgasm. This phase is sometimes referred to as nondemand genital pleasuring. The therapy process consisted of continual daily assessment of the couple’s resistance to
the exercises followed by a return to the endeavor.
Once couples had become comfortable with this level of touch, therapy consisted of behaviorally
oriented exercises, primarily systematic desensitization tailored to the particular dysfunction. The
prototypic illustration of the treatment of female sexual dysfunctions in Masters and Johnson’s
model is women with vaginismus. Briefly, the causes of vaginismus are complex, but they tend to
include a history of trauma in the genital area including childhood sexual abuse or sexual assault
in combination with being raised in sex-negative environments with little or no sex education.
Women have often been told that penetration will be painful, just as childbirth will be afterwards.
This combination of physical trauma to the genitals plus ignorance and justifiable fear of pain
create the perfect constellation for the development of vaginismus.
In treating vaginismus, the next phase of therapy after sensate focus exercises consisted of
having the woman practice contracting and relaxing her pelvic floor muscles. She would then
insert a series of dilators, graduated in size, into her vagina. Each phase in this process would be
interspersed with daily therapy sessions over a two-week period of intensive treatment, to deal with
any difficulties or resistance. Eventually, once she was able to accommodate the largest dilator, she
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Sensate focus
exercises: Master and
Johnson’s primary
innovation and touch
exercises for the
treatment of sexual
dysfunctions
2.9
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
would be instructed to straddle her husband and lower herself onto his penis, while he was to lie
still beneath her. If this proceeded uneventfully, first she would be permitted to move above him
and then he would be permitted to thrust, too. In the final stage of treatment, they would be told
to engage in sexual intercourse in the missionary position. Once the woman was able to engage
in vaginal containment of the thrusting penis in the missionary position, therapy was deemed a
success and concluded. The success rate in Masters and Johnson’s treatment of vaginismus was
virtually 100%. Their brief, behaviorally oriented treatment has remained the foundation for
therapy of the female sexual dysfunctions to date.
Interestingly, in 1974 psychoanalyst and sex therapist Helen Singer Kaplan suggested adding
remote (meaning early or developmental) to immediate causes (e.g., performance anxiety) to the
assessment process for sexual dysfunctions. However, she noted that in her practice, Masters and
Johnson’s behavioral treatment protocol for the treatment of vaginismus was 100% effective at
teaching women to open and close their vaginal muscles autonomically; no intrapsychic investigation or treatment was warranted, except in exceptionally rare, recalcitrant cases (Kaplan 1974).
Similarly, Hawton & Catalan (1990, p. 47) later suggested, “Vaginismus is an excellent sexual
dysfunction for trainee therapists to treat because the approach is reasonably straightforward and
success is likely to result.”
It is noteworthy that there was no measurement of satisfaction or subsequent frequency of sexual
activity in the assessment of outcome. Even more strikingly, although their therapy protocol was
ostensibly designed to break the performance-oriented, conventional sexual paradigm, the ultimate
outcome goal in the treatment of the sexual dysfunctions in women (and men) was the ability to
achieve intercourse in the missionary position.
Aside from clinical or theoretical matters, Masters and Johnson’s tabulation of what constituted
a successful outcome was subsequently criticized extensively, beginning with Zilbergeld & Evans
(1980). They pointed out that Masters and Johnson defined “success” as the absence of failure.
More specifically, after the two-week intensive treatment in St. Louis, if the couple did not contact
Masters and Johnson to request further assistance for relapse at any time in the next five years, the
case was counted as a success. Zilbergeld and Evans pointed out that this absence of follow-up as
a criterion was hardly typical of the measurement of clinical outcomes.
THE 1970S: THE REDISCOVERY OF THE CLITORIS AND THE RIGHT
TO FEMALE SEXUAL PLEASURE
From the late 1960s to the early 1980s, the confluence of social, legal, and pharmacologic changes
led to a shift of emphasis from treating women’s sexual dysfunction to enhancing female sexual
pleasure. The introduction of oral contraceptives allowed women to separate procreation from
recreational sex effectively, privately, and relatively inexpensively; the dissemination of Masters
and Johnson’s work surrounding the physiology of female sexuality (among others; e.g., Sherfey
1966) created an awareness of women’s capacity for sexual response, including multiple orgasm;
and the “sexual revolution” of the late 1960s and early 1970s and the second wave of the feminist
movement combined to create a new emphasis on women’s lived sexual experience quite aside
from their function/dysfunction during sexual intercourse.
Women’s self-help health collectives such as the Boston Women’s Health Book Collective first
published in 1973 the now classic Our Bodies Ourselves, which has been in print continuously for
45 years (see Boston Women’s Health Book Collect. 2005). In 1983, the Federation of Feminist
Women’s Health Centers published A New View of a Woman’s Body, which literally put the clitoris
at the center of every diagram (see Fed. Fem. Women’s Health Cent. 1991). In 1976, Shere
Hite published a survey of women’s accounts of their own sexuality that gave voice to what they
2.10
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
preferred in sexual contact (Hite 1976). Sexologists, especially female sexologists, including sex
therapist Lonnie Barbach (1980, 1984, 2000) and sex educator Betty Dodson (1987, 2002), began to
write about and offer group workshops on women’s sexuality. Each of these books and workshop
leaders emphasized the role of the clitoris in women’s orgasms. If women who had previously
been perceived as frigid were unresponsive during penile penetration, perhaps the culprit was the
definition of “sex” itself, which had been equated with intercourse.
In the early 1970s, these sexologists declared women’s need for better sex education, beginning
with the “liberation” of masturbation (Dodson 1987). Women were more likely to have orgasms
with a partner if they had already explored their own genitalia (Barbach 1980, Heiman & LoPiccolo
1988 (1976)]. They would thereby be enabled to attain orgasm alone; by recognizing the necessity
of clitoral stimulation, they would be in a position to enjoy sexuality independently and to teach
their partners what led them to orgasm. The Zeitgeist was about freeing women from the Victorian
imagery of women as sexually passive and in need of men to awaken and arouse them. In other
words, it was a dismissal of Sleeping Beauty tales in favor of a new narrative about women’s sexual
empowerment and the rejection of traditional diagnostic categories and accompanying treatments.
Barbach went so far as to question the diagnosis of anorgasmia. She argued that there was no
such thing as a woman who could not have an orgasm—only one who had not had an orgasm yet.
She coined the term “preorgasmia” in its stead, the “cure” for which was psychoeducational counseling and bibliotherapy, not treatment of psychopathology. Sometimes this cure might include
group masturbation sessions led by Dodson herself, where the sheer act of watching and participating in communal internal and external self-stimulation were considered to promote women’s
sexual freedom.
Some conventional sex therapists were continuing to attempt to teach women how to achieve orgasm during intercourse. For example, Kaplan (1974) developed the “bridging” technique to help
women by using methods of successive approximation. The idea was to stimulate the woman’s clitoris, almost to the point of orgasm, immediately prior to penile insertion. In subsequent episodes,
her partner was to reduce the duration of this stimulation and commence penetration so as to eventually train her to have orgasms during intercourse. This objective was somewhat controversial
at a time when women were considering not only that sex need not be preceded by foreplay, but
also that sex might not require intercourse at all.
Bibliotherapy:
the use of assigned
readings in sex therapy
for psychoeducation
and to encourage
discussions in couples
SEXUAL DESIRE DISORDERS AND THE FAILURE OF SEX THERAPY
Later in the 1970s, sex therapists began to note that the most common sexual disorders, especially
among women, were no longer the mechanical difficulties described and treated so effectively
by Masters and Johnson in 1970 but were now desire disorders. Kaplan (1977) and Lief (1977)
pointed out that these problems were more complex and difficult to treat. They could not be
accounted for by glitches in the HSRC. The success rate for the treatment of these problems
was dramatically lower than the earlier successes in the simpler mechanical dysfunctions such as
vaginismus or orgasm problems.
Low desire now took on a new psychosocial importance. Whereas in 1952 the DSM had
included nymphomania, by 1980 there had been substantial cultural changes. After the sexual
revolution, “too much sexual desire” was seen as an impossibility—or, at the very least, hardly
problematic. In addition, the DSM itself had changed. Whereas the first two editions of the DSM
had been theoretically based, more specifically based in psychoanalytic thinking, the DSM-III
(Am. Psychiatr. Assoc. 1980) was ostensibly empirically based and atheoretical. As such, a genderbased/gender-biased diagnosis such as nymphomania was frowned upon and had to be removed.
In its place, however, a new diagnosis of inhibited sexual desire (ISD) was introduced for men
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.11
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
and women who did not desire sex enough. Even the term “inhibited” smacked of too much
psychoanalytic verbiage, such that by the DSM-III-R (Am. Psychiatr. Assoc. 1987), ISD was
replaced by the more neutral-sounding hypoactive sexual desire disorder (HSDD).
WHEN A WOMAN HAS A SEXUAL DYSFUNCTION, WHAT EXACTLY
IS IT THAT REQUIRES TREATMENT?
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
By 1980, the DSM-III had begun to include psychosexual dysfunctions, which now comprised
difficulties with arousal, orgasm, vaginismus, and dyspareunia as well as HSDD. But when women
(and men) had sexual problems, what was the nature of the problem, exactly? Although the editors
of the DSM claimed that they had now shifted over to an atheoretical nosology, the underlying
but hidden assumption, consistent with the dominant cultural and heterosexist bias, was that sex
itself is equated with intercourse.
The most obvious illustration of this mindset in clinical practice is the link between coital
anorgasmia, vaginismus and/or dyspareunia, and the development of low desire. Although we
tend to speak of and treat these difficulties as disparate and discrete entities, one often leads to
the other. The vast majority of women do not have orgasms as a result of penile thrusting during
intercourse. The higher density of nerve concentration in the clitoris as compared to the vagina
accounts for this difference between men and women during intercourse. Many women enjoy
sexual pleasure but do not find intercourse per se arousing (Dodson 2002, Ogden 1999); given
that they are not aroused, they may not lubricate and may therefore find intercourse painful and
unpleasant. That, in turn, may lead to their shutting down physically and emotionally and even
recoiling during intercourse. Yet our definition for sex itself remains intercourse; long after the
1970s, we are more likely than ever to refer to other sexual activities as “foreplay.” This means
that from the DSM-III to the DSM-5, women who are not aroused during “sex,” complain of
pain during “sex,” and who consequently have come to dread “sex,” will get diagnosed with and
treated for at least three seemingly different but related sexual dysfunctions.
It is revealing that the literature on sexual dysfunctions in lesbians is rather limited, with notable
exceptions (see Hall 2012), and that there are no recorded cases of pain on penetration among
women who have sex with women (Kleinplatz 1998).
THE FEMINIST SEX WARS: FROM SEXUALITY AS EMPOWERING
TO SEX AS DANGEROUS TO WOMEN AND GIRLS
By the 1980s, the pendulum had begun to swing back toward greater sexual conservativism.
Infamously, US President Ronald Reagan (1980–1988) had refused to even mention the word
“AIDS” at the height of the American epidemic.
Even advances in the field of sexology could be twisted to support conservative and prescriptive
ideologies. For example, in 1982, Ladas, Whipple, and Perry released a book on the physiology
of female orgasm entitled The G Spot, which rapidly became a massive bestseller [Ladas et al.
2004 (1982)]. The book was based on the findings three decades earlier of Ernst Gräfenberg, a
European gynecologist and Jewish refugee whose work had been overlooked and lost. Gräfenberg
had identified a sensitive area of tissue surrounding the urethra that could be palpated via the
anterior wall of the vagina. As Ladas and colleagues began to study this area, they verified his
findings and named the area “G spot” in Gräfenberg’s honor. They reported that some women
were able to experience orgasm via stimulation of this broad area of tissue, too, rather than only via
clitoral stimulation. Ladas and colleagues were delighted to be able to report on the multiplicity
of ways that women might experience pleasure.
2.12
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
It was demoralizing to these sexologists when their book reignited the frenzy over which
was the “correct” way for women to “achieve” orgasm [Ladas et al. 2004 (1982)]. Suddenly,
arguments proliferated in the media as to whether Freud had been right in suggesting that “mature”
women should have “vaginal” orgasms. The subtleties in Freud’s thinking had been lost, as had
Ladas, Whipple, and Perry’s invitation to the buffet of sexual pleasures, replaced by the new
dogma restating that women ought to have orgasms during intercourse, after all. Obviously, this
reopened the door to heterosexual couples seeking treatment for women who experienced orgasm
during self-stimulation, oral stimulation, the partner’s manual stimulation, but who reported that
she was unable to “achieve” orgasm “during sex.” However, in the aftermath of the 1960s and
1970s, sex therapists were still most likely to prescribe psychoeducational counseling rather than
recommending that she work harder to attain orgasms during intercourse.
It was also in the 1980s that the sexual liberalism of the 1960s turned into the feminist sex wars.
If the 1960s and 1970s had been about opening up female sexual options, the focus during the 1980s
was upon the dangers of male sexuality to and for women. The discourse shifted from empowering
women’s sexual freedom to the dangers of pornography and the treatment of survivors of sexual
assault and child sexual abuse (Echols 1983; Rubin 1990, 2011). There was considerable debate
about the impact of pornography on men and the likelihood that it would lead to violence against
women (Echols 1989, Hollibaugh 1989). Politics made for strange bedfellows, and it was unusual
to see that the supporters of Reagan’s Meese Commission on Pornography in 1986 included some
leaders of the feminist movement.
Jeffrey Masson’s 1984 restoration of Freud’s original thinking on the cause of hysteria helped
to make it safe for women (and men) who had been sexually abused in childhood to come forward
without fear of judgment or being trivialized. In the 1980s, considerable research (e.g., Finkelhor
1984, 2008), popular culture (e.g., Bass & Davis 2008), and clinical material (e.g., Courtois 1996,
Herman 1992) focused on the long-term effects of childhood sexual abuse on women. Interestingly, although this literature delved into the impact of incest on trust, anger, anxiety, and other
posttraumatic stress disorder symptoms, most of it paid scant attention to the effects of sexual
abuse on sexuality.
Exceptions such as Maltz & Holman (1987) were especially helpful to sex therapists in helping
clients integrate sexuality into their lives. This work entailed encouraging incest survivors to
redefine and reimagine sexuality on their own terms, that is, as an entirely different phenomenon
from what had been forced upon them before they were old enough to understand or consent.
The treatment of sexual dysfunctions such as anorgasmia, vaginismus, or low desire using traumainformed approaches allows the therapist to conceptualize the symptoms of sexual problems as
normal or even healthy adaptations to sexual abuse and assault (Maltz 2012). In such models, the
goal is not necessarily to target the symptom but to empower women to create sexual relationships
based on choice and mutuality, so that the symptom becomes obsolete and dissolves.
POLYPHARMACY, IATROGENIC SEXUAL DYSFUNCTIONS,
AND SILENCE
One other change in the 1980s outside the field of sexology had an important impact on the
incidence, etiology, development, and treatment of sexual problems. By the mid-1980s, pharmaceutical companies had begun introducing more and more medications for a rapidly aging
population. Even the youngest of the baby boomers had already reached midlife. The influx of
new drugs for hypertension, high cholesterol, and psychiatric problems, among many others, was
creating sexual side effects. By 1986, Masters and Johnson had doubled their original estimate of
10% organic etiology of sexual dysfunctions to 20% because of iatrogenic disorders (Masters &
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.13
CP14CH02_Kleinplatz
ARI
Iatrogenic disorder:
a disorder caused by
medical,
pharmacologic, or
surgical intervention
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
SSRIs: selective
serotonin reuptake
inhibitors (e.g.,
Prozac)
SNRIs: selective
norepinephrine
reuptake inhibitors
(e.g., Effexor)
Polypharmacy:
the prescription of
multiple
pharmaceutical
products concurrently,
especially common
when patients are
elderly and/or female
19 December 2017
13:1
Johnson 1986). For example, it was in the 1980s that the first of the selective serotonin reuptake
inhibitors (SSRIs), Prozac, was introduced. The SSRIs, and later the selective norepinephrine
reuptake inhibitors (SNRIs), would affect arousal, orgasm, and desire in most patients. Unfortunately, few physicians and even fewer patients were aware of their impact.
Physicians have long been reluctant to discuss sexuality with their patients (Wimberly et al.
2006). Physicians occasionally warn men about the impact of their diseases (e.g., diabetes mellitus)
or prescriptions on erectile dysfunction (a rather noticeable consequence, which prevents intercourse). The same disease processes and drugs that have an adverse impact on erections or desire
in men can have the same physiological effects on women. However, given that these effects do
not prevent intercourse in women—they only stop women from enjoying sex—physicians do not
generally tell women that the drugs they prescribe will decrease lubrication, thereby causing pain,
and will slow or prevent orgasm and reduce desire.
Although polypharmacy has increased substantially since the 1980s, and more so in women than
in men (Guthrie et al. 2015, Hofer-Dückelmann 2013), women are less informed than ever about
the sexual side effects of common drugs (Moynihan 2011, Moynihan & Mintzes 2010). During the
same period, advertisements have encouraged patients to “Ask your doctor.” Unfortunately, the
last 35 years have seen a continuing decrease in the training of medical students about sexuality
(Shindel & Parish 2013), with less readiness to deal with sexuality upon graduation (Wittenberg &
Gerber 2009). This has left women feeling more alone with their sexual problems (Spring 2015).
They report vaginal dryness, dyspareunia, secondary anorgasmia, and low desire with minimal
suspicion that they are suffering from iatrogenic disorders. As such, they introject responsibility
for their symptoms and feel inadequate or defective, while their therapists may not have the
medical or pharmacologic knowledge to identify the underlying causes. (It is an odd time indeed
when the sex therapist’s most important colleague is the experienced, curious, and knowledgeable
pharmacist!)
What is required is a better-integrated knowledge base among all clinicians dealing with sexual
problems so as to conduct thorough assessments. Health care professionals need to know and
determine when common drugs—from decongestants (which dry out all mucous membranes, not
only watery eyes) to drugs for the ubiquitous acid reflux to second-generation antipsychotics—are
creating sexual dysfunctions before telling patients that “it’s all in their heads.” We need to be
especially attuned to the role of third-generation hormonal contraceptives on women’s sexual
arousal and desire; these are the most commonly used contraceptives in North America, but
women are rarely advised of their possible role in low desire (Burrows et al. 2012, Panzer et al.
2006). Unfortunately, as discussed below, women are less likely to encounter the comprehensive
care required in the face of the increasing incidence of iatrogenic sexual dysfunctions. Here, the
splintering of the field of sexual health care is the culprit.
THE FRAGMENTATION OF THE FIELD AND IMPLICATIONS FOR
THE TREATMENT OF WOMEN’S SEXUAL PROBLEMS
In the early 1990s, a series of articles appeared in the literature foreseeing the emerging medicalization of human sexuality and with it the treatment of sexual problems (Rosen & Leiblum 1995,
Schover & Leiblum 1994, Tiefer 1996). Over the next 10 years, the concerns expressed would
be more than realized. By 1998, with the release of Viagra (discussed in detail below) the field
had begun to splinter (Kleinplatz 2003). The professional associations for the training and continuing education of sex therapists and researchers such as the American Association of Sexuality
Educators, Counsellors and Therapists (AASECT) were losing members, and journals folded.
Simultaneously, new sexual medicine societies were springing up, including the International
2.14
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Society for Sexual Medicine (ISSM), primarily populated by urologists, and the International Society for Women’s Sexual Health (ISSWSH), primarily populated by gynecologists (Kleinplatz
2012). Their journals focused on organic pathology and its treatment.
The conceptualization and treatment of women’s sexual problems was no longer necessarily
the domain of sex therapy, but might just as readily fall into the realm of sexual medicine. The
nature of the interventions that a woman might encounter upon presenting with sexual concerns
would depend largely on where she might be referred. In some cases, she might be referred to a
practitioner with a background in human sexuality, trained to be comfortable with sexual matters
and with conceptual, diagnostic, and treatment skills in the realm of sex therapy. Alternately,
she might be referred to a sexual medicine specialist skilled in the organic aspects of genital
dysfunctions but with little training in the intrapsychic, interpersonal, and psychosocial contexts
in which sexual problems are generated, identified, and situated. Unfortunately, the crossover
among these practitioners has decreased over time, with each attending separate conferences and
reading different journals, such that interdisciplinary knowledge transfer has deteriorated. What
has become less and less common is access to a clinician trained to provide comprehensive sexual
health care to the patients/clients (Moser & Devereux 2012).
The implications of the medical model as applied to sexuality are apparent both in the literature
and in practice (Giami 2000; Leiblum & Rosen 2000; Tiefer 2000, 2001; Winton 2000, 2001).
Clinical assumptions include that the problem lies within the person, especially his or her bodily
parts, rather than in the relationship or the social context; that biomedical or biomechanical
methods of treatment are appropriate, even when the origins of the problem have not been assessed
or are intrapsychic or relational; and that the goal of treatment should be symptom remediation
or control. The medical model tends to emphasize quantity, performance, and objective measures
of sex (e.g., frequency of intercourse) over quality of sex and measures of the subjective experience
(e.g., pleasure, satisfaction, intimacy) (Kleinplatz 2003, 2012).
Articles began to appear, with some psychologists saying that in order for sex therapy to be
seen as a science, health professionals needed to treat sexual dysfunctions based solely on objective
signs (Althof 2001), whereas others argued that if there are no symptoms and no distress, health
professionals ought not to diagnose, let alone treat, women’s “dysfunctions” (Nathan 2010).
A backlash against biological reductionism appeared with yet more groups and more conferences, separate from the field as a whole. Most prominent among these was the New View
Campaign, spearheaded by Leonore Tiefer. In 2000, an interdisciplinary group of 11 feminist
sexologists met in California to develop an alternative to the increasing medicalization of the field
and the soon-to-be-released DSM-IV-TR (Am. Psychiatr. Assoc. 2000). The Working Group for
the New View of Women’s Sexual Problems (2002) released its own document, which focused
on the contextual nature of women’s sexual problems. They recommended consideration and integration of contextual factors in conceptualizing and dealing with women’s sexual problems in
therapy.
THE MEDICALIZATION OF SEXUALITY AND THE TREATMENT
OF “FEMALE SEXUAL DYSFUNCTIONS”
In the 1990s, the treatment of female sexual dysfunctions was changed forever by a new treatment
for a male sexual dysfunction. In 1998, Pfizer introduced Viagra (i.e., sildenafil citrate) (Goldstein
et al. 1998), which quickly became the fastest selling medication in pharmaceutical history to that
date (Loe 2004). It took some time to realize that compliance rates were less than ideal for Pfizer
(Perelman 2000, Wise 1999). Although sildenafil citrate was extremely effective at creating harder
and longer-lasting erections in men who already felt turned on, it would not generate erections
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.15
CP14CH02_Kleinplatz
ARI
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
PDE-5:
phosphodiesterasetype-5 inhibitor (e.g.,
Viagra, Levitra, Cialis)
2.16
19 December 2017
13:1
in men who had not been stimulated and were not sexually aroused (Goldstein et al. 1998). This
meant that men would still have to communicate with their partners, and no pill could make that
happen (Kleinplatz 2004).
Nonetheless, the introduction of Viagra changed the discourse surrounding the etiology and
treatment of the sexual dysfunctions (Hartley 2006, Loe 2004). In the years leading up to the
Food and Drug Administration (FDA) approval of Viagra, the marketing department at Pfizer
worked to alter our collective understanding of the origins of what had been known as “impotence”
and was rebranded as the less pejorative and more medical “erectile dysfunction.” Whereas Masters
and Johnson had stated that the etiology of the sexual dysfunctions was 90% psychogenic and 10%
organic, Pfizer was now stating that erectile dysfunction was 90% organic and 10% psychogenic. It
is noteworthy that although the percentages were switched in the run-up to the release of Viagra,
the mindset remained either psychogenic or organic, with no room for mind-body integration.
The early astronomic sales of Viagra demonstrated how lucrative the business of treating
sexual dysfunctions could be. From that moment, the search for a “little pink pill” or a “female
Viagra” began in earnest (Moynihan & Mintzes 2010, Potts 2008, Tiefer 2001). The question
was, what exactly was it that this new drug ought to treat? While that question was temporarily
put on hold, the race was on among the pharmaceutical companies to release a drug that could
be marketed to women ( Jutel 2010, Moynihan 2003). A total of seven new drugs were developed
from 2000 to 2015 ( Jutel 2010, Tiefer 2015): Viagra for women (Harris 2004); Melanotan/PT141 (an alpha-melanocyte-stimulating hormone analog from Palatin Technologies), also known as
Bremelanotide nasal spray (Angier 2007, Dibbell 2005); Intrinsa (Proctor & Gamble), approved
in the United Kingdom and later withdrawn (Tiefer 2006); Libigel (Biosante) (Berkrot 2008);
Androgel (AbbVie), off label (Wickman et al. 2014); Lybrido and Lybridos (Bergner 2013); and
now Flibanserin/Addyi (Peterson 2010), discussed below.
Initially, Pfizer began clinical trials on the use of Viagra in women. The assumption was that
it would treat arousal difficulties in women that correspond physiologically to erectile dysfunction in men. Viagra is a vasodilator (Goldstein et al. 1998). The erectogenic drugs known as
phosphodiesterase-type-5 inhibitors (PDE-5s; e.g., Viagra, Levitra, Cialis) work by dilating the
blood vessels in the corpora cavernosa of the penis. The PDE-5s are thus very helpful drugs for
penetration. As it turned out, at the physiological level, these drugs work in women just the way
they do in men: They increase vasocongestion in the erectile tissues of the female genitalia (especially the corpora of the clitoris). However, in a society that defined sex as intercourse, swallowing
Viagra made for a swollen clitoris (and being a vasodilator, it created a sensation of congestion in
one’s genitals) but did not share the same signal value as an erect penis. It did not lead to “sex.”
After eight years of clinical trials, Pfizer gave up. When the news emerged that Viagra would
not have a comparable use in the treatment of women’s sexual difficulties as they had in men’s,
a different narrative was required. Pfizer representatives now explained that men’s sexuality was
simple—a matter of mechanics and hydraulics, whereas women’s sexuality was more “complicated”
(see comments by Jennifer Berman, cited in Harris 2004).
Beginning in the early 2000s, the race resumed for hormonal treatments and eventually, when
these too proved ineffective, for drugs that would target women’s brains (Moynihan & Mintzes
2010). The media, particularly women’s talk shows and magazines, were replete with commentators who touted the new claim that sexual desire was all about testosterone, in both men and
women. The narrative grew in popularity, despite the lack of a correlation between free testosterone levels and desire (Davis et al. 2005, Wierman et al. 2006). Several companies attempted
to have their testosterone products approved by the US FDA or by Health Canada, most notably
Proctor & Gamble’s Intrinsa testosterone patch for women in 2005. All applications were rejected
by the regulatory agencies. Intrinsa was later approved by the European Union but was withdrawn
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
in 2012. Some physicians continue to prescribe AbbVie’s topical testosterone AndroGel, approved for use in men, off label to women to boost desire, despite a lack of evidence of safety or
efficacy.
One of the slippery changes occurring along the way concerned the nature of what these
various drugs were intended to treat. As indicated above, once Viagra became a pharmaceutical
blockbuster, the temptation to find a correspondingly lucrative hit for the treatment of something
in women proved irresistible. It remained unclear, however, what dysfunction or disorder pharmaceutical companies ought to target. As such, their new catchall target became the amorphous
“female sexual dysfunction,” or “FSD” (Angel 2012). Questions about which of the DSM-IV (Am.
Psychiatr. Assoc. 1994) female sexual dysfunctions (i.e., anorgasmia, female sexual arousal disorder, vaginismus, dyspareunia, HSDD) the prospective drugs were to treat went unanswered. This
became reminiscent of the vague 1950s problem of frigidity.
Flibanserin, a drug intended to increase female sexual desire developed by BoehringerIngelheim, later sold to Sprout, had an extraordinary list of exclusion criteria (cited in FDA 2015)
for its clinical trials: depression, sexual aversion disorder, substance-induced sexual dysfunction,
dyspareunia, vaginismus, a prior history of low desire; any condition, whether psychological or
medical, which required medication in the last 30 days; partner’s organic or sexual dysfunction;
pregnancy, breastfeeding, menopause, perimenopause, postmenopause, and “an extensive list of
medications and drug classes” (FDA 2015, p. 16) including antidepressants and antianxiety drugs.
In other words, the drug was developed, or at least marketed, as if HSDD were a biomedical
disorder, existing in isolation from any psychosocial or interpersonal context. In 2009 and 2013
the drug was rejected by the US FDA and Health Canada.
Thereafter, an interesting transposition occurred. Prior to a new application to the US FDA,
the manufacturers of Flibanserin adopted the strategy of appropriating feminist discourse to create
demand for the new drug and apply pressure upon the regulatory body (New View Campaign
2014, Tiefer 2015). Why, they asked, had a series of erectogenic drugs been approved for male
sexual dysfunction (albeit the more specific erectile dysfunction) with no comparable panacea for
Female Sexual Dysfunction? What about demanding that the FDA consider fairness to women?
Sue Goldstein, an administrator who oversaw the clinical trials for the pharmaceutical developers of
Flibanserin, argued (Goldstein 2009, p. 302), “Would anyone deny a man the right to an erection?
Would anyone deny a woman the right to have her breast cancer or heart disease treated? . . . When
is it really my turn?” The slogan for this new campaign was “Even the Score.” This tactic turned the
tide. On its third application, Flibanserin was rejected, again, by the FDA advisory committee but
approved nonetheless by the FDA amid considerable controversy (Woloshin & Schwartz 2016). It
was released in October 2015. Unlike Viagra, which works on the arteries of the penis and is taken
“as needed,” Addyi is a central nervous system depressant and must be taken daily. Immediately
upon its approval, Addyi was acquired by the Canadian company Valeant Pharmaceuticals for
$1 billion. Sales have been dismal, as have been post-market data, such that Valeant withdrew
its marketing of Addyi in 2016 and was sued by Sprout (Ramsey 2016). Six months after the
release of Addyi, a meta-analysis of satisfying sexual events (SSEs) found that the drug performed
even more poorly than its manufacturers had indicated. In a study of 5,900 women, researchers
reported, “Treatment with flibanserin, on average, resulted in one-half an additional SSE per
month while statistically and clinically significantly increasing the risk of dizziness, somnolence,
nausea, and fatigue. Overall, the quality of the evidence was graded as very low for efficacy and
safety outcomes” ( Jaspers et al. 2016, p. 457).
For those who might wonder why there is such a focus on a series of drugs for the treatment
of female sexual dysfunction, the problem is that there is no funding of large-scale studies outside
pharmacologic testing (Heiman 2002): “At present, rather too much attention is being paid to
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.17
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
possible pharmacological treatments for low interest/arousal problems at the expense of research
on psychological and relational treatments” (Both et al. 2017, p. 25).
CHANGES TO THE DIAGNOSTIC NOSOLOGY FROM THE DSM-III TO
THE DSM-5: IMPLICATIONS FOR TREATMENT
From Vaginismus and Dyspareunia to Genito-Pelvic Pain/Penetration Disorder
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
In 1980, vaginismus (discussed above) was added to the DSM-III (Am. Psychiatr. Assoc. 1980)
as distinct from dyspareunia (i.e., pain on intercourse), which had been included since the first
edition of the DSM (Am. Psychiatr. Assoc. 1952). The fear of pain associated with vaginismus
and the tightening of the pelvic floor muscles immediately upon the commencement of attempted
penetration can create a self-fulfilling prophecy and result in pain. Therefore, vaginismus can
cause dyspareunia just as a history of pain upon penetration can lead to vaginismus.
There are numerous causes of pain during intercourse, from herpes to episiotomy scars and
from endometriosis to ovarian cancer. The treatment is dependent on determining the diagnosis.
It takes a focused pelvic exam for the health care provider to determine what is causing the pain.
Especially skilled gynecologists will attempt to replicate the pain in their offices to ascertain its
origin. This takes time and patience as well as the training to persevere while collaborating with
the woman in the diagnostic process. In the past, unremarkable medical findings would result in
the patient being told, in essence, that there was nothing wrong with her and that the problem
was all in her head. Unfortunately, the sex therapist’s endeavors are limited in helping a woman
whose problem has been dismissed as psychogenic.
Over the last 15 to 20 years, a new nomenclature has arisen. Many women have left their
physicians’ offices feeling new hope upon being told that the problem is vulvar vestibulitis or
provoked vulvadynia. When the woman is referred to the sex therapist, she assumes that the correct
treatment awaits. She has not, however, been told that these terms are merely Greek or Latin for
pain in the vaginal opening or vulva, respectively. She already knew that there was genital pain
before seeing her physician; the new terminology does not add new clinical information. These
terms are not diagnoses but merely descriptors of the symptom. They are akin to “sore throat,” a
descriptor that says nothing about the origin of the pain, which could be a streptococcal infection
or a virus or strain from overuse, among other things.
Beginning in 1999, Binik and his team wrote a series of influential articles questioning whether
the diagnoses of vaginismus or dyspareunia belonged in the DSM (Binik 2005, 2009a,b; Binik et al.
1999). Binik and colleagues pointed out that other types of nonspecific pain and the accompanying
anxiety (e.g., headaches or back pain) were not included in the DSM. They called for a medical
workup to ascertain the cause of the pain and to treat it. Ideally, in cases in which medical treatment is not sufficient, a multidisciplinary health care team including mental health professionals
should be included to provide comprehensive health care. Binik asked why dyspareunia and vaginismus were singled out among pain syndromes to be classified as sexual-mental disorders rather
than diagnosed and treated as any other medical problem. Why should pain in the genitals be
stigmatized? Furthermore, he indicated that some cases of “dyspareunia” were not limited to pain
during sexual activities but might also occur as a woman crossed her legs, walked, or engaged in
sports. More importantly, argued Binik, when patients present with migraines, physicians cannot
do much about the cause of the migraines but they can certainly treat the pain. Why were women
with genital pain not receiving the same care and treatment (Binik et al. 1999)?
By 2009, Binik (2009a,b) called for dyspareunia and vaginismus to either be removed from
the DSM or, at the very least, to be integrated into one classification, namely genito-pelvic
2.18
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
pain/penetration disorder (GPPPD). In 2013, the DSM-5 (Am. Psychiatr. Assoc. 2013) was released, and GPPPD was included. The standard of care at present, at least in theory, is for the
woman to be examined by a physician to determine the diagnosis; by a sex therapist to deal with the
lack of sex education and corresponding anxiety as well as any history of trauma or other factors
that might precipitate fear; and by a pelvic floor physiotherapist to provide hands-on treatment
of genital-pelvic constriction (Bergeron et al. 2002).
In actual practice, it is now rather common for women to be seen by a primary care physician
or gynecologist who concludes relatively quickly that there is some sort of problem in the genitals
related to intercourse. Rather than sorting out the cause of the pain and its relationship to penetration, the physician will refer the patient to pelvic floor physiotherapy immediately. The pelvic
floor physiotherapist will then proceed to do a more thorough assessment, may provide hands-on
(literally) treatment such as myofascial release, and will then introduce, instruct, and assist with
dilator treatment. As originally recommended by Masters and Johnson (1970), once the woman
is able to insert the largest dilator, she is ready for sexual intercourse.
The physical therapy treatment facilitates the woman’s use of dilators. However, it fails to
explore the concerns of the woman attached to the vaginal tissue. Is pelvic floor constriction a
problem to be treated per se, or is it also an opportunity to provide psychoeducational counseling
for the young woman who believes that enjoying “too much sex” will make her a “loose woman”?
What about the woman who has been sexually assaulted and needs to deal with the psychological
aspects of the aftermath? What about the psychological aspects of gynecological cancers and fear
of death that can present as GPPPD? For decades, gynecological textbooks have indicated that
even when a physician cannot perform a pelvic exam, he or she can diagnose vaginismus just by
looking: The external genitalia of a woman with vaginismus will resemble a woman’s pursed lips
saying “no.” Perhaps instead of teaching women how to override or “bypass” their feelings so
that they can “tolerate a phallic size object” (Kaplan 1987, p. 99), we might consider listening to
the unspoken message communicated via their bodies. Rather than training women to relax their
muscles, with or without pelvic floor physiotherapy, we might want to pay closer attention to the
feelings and cognitions that underlie their pain and constriction (Kleinplatz 1998, Shaw 1994).
GPPPD:
genito-pelvic
pain/penetration
disorder (formerly
vaginismus and
dyspareunia)
FSAD: female sexual
arousal disorder
FSIAD: female sexual
interest/arousal
disorder (formerly
FSAD and HSDD)
From Female Sexual Arousal Disorder and Hypoactive Sexual Desire Disorder
to Female Sexual Interest/Arousal Disorder
A second major change from the DSM-IV to the DSM-5 is the collapsing of two distinct categories
that had been in the DSM-IV, specifically female sexual arousal disorder (FSAD) and HSDD, into
the female sexual interest/arousal disorder (FSIAD). FSAD had been introduced in the DSM-III
in 1980 as inhibited sexual excitement and subsequently renamed FSAD in the DSM-IV. It had
generally been treated with a focus on lack of lubrication during heterosexual intercourse by prescribing a lubricant. The subjective aspects of low arousal had typically been ignored clinically,
even though the typical cause of lack of lubrication is inadequate stimulation (or lack of a woman’s
preferred types of stimulation). In the DSM-IV and DSM-5, the corresponding arousal and desire
disorders in men, namely erectile dysfunction and HSDD, remain distinct categories. It is noteworthy that in 1980, after the sexual revolution, part of the rationale for eliminating nymphomania
and satyriasis was the rejection of gender-biased diagnoses. However, in 2013, was it politically
correct to reinstitute male-female differences?
What was the rationale for collapsing these diagnoses in women but not in men? What are the
implications for treatment?
A major issue is that women often present in therapy without being able to distinguish between
lack of arousal and lack of desire (Brotto 2010, Graham 2009). When a woman complains of “not
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.19
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
feeling much during sex,” “not seeing what all the fuss is about,” or “not being as into sex” as her
partner, it is initially unclear whether there is a lack of arousal, lack of desire, or both. There are
concerns about operationally defining sexual desire, the ‘‘significant overlap’’ between arousal and
desire (Brotto 2010, p. 221), and the notion that women’s sexual desire may be more fundamentally
responsive than receptive (Basson 2001, 2002, 2010). It seems ironic that the new nosology takes
us back to the classifications of the 1950s, in which the notion that men and women are essentially
different predominated, together with the belief that women’s sexuality was both murkier and
more complex than men’s (Kleinplatz 2011).
The decision to collapse the two categories has led to considerable debate (cf. Balon & Clayton
2014, Graham et al. 2014). There had been arguments as to whether women would lose access
to treatment for HSDD once these were collapsed into FSIAD. This disagreement seems ironic,
given that treatments for both FSAD and HSDD have been weak (Leiblum 2010).
In addition, there has been some question as to whether women or men can distinguish arousal
from desire (Kleinplatz 2011). Obviously, in young, healthy men, an erection is the major cue
for arousal—and with it, sexual desire. It is, however, the exceptions that prove the rule: Absent
an erection, as can happen with age or with disease (for example with peripheral neuropathy
in cases of advanced diabetes), men often report loss of desire. It is their partners who report
missing any form of sexual interaction. Men are often quizzical in the face of partners who seek
sexual activity when reliable erections can no longer be attained. It may take experience in sex
therapy and in recognizing other emotional and physical cues before men can identify their own
desire and capacity for orgasm as distinct from their (lack of ) erections.
As was the case with vaginismus and dyspareunia, sometimes there may be a causal link between
FSAD and HSDD. Low arousal during sex may lead to lack of satisfaction, which may result in a
lack of desire for the next time. Correspondingly, engaging in sex without desire in order to please
one’s partner or maintain relational harmony can backfire. Ironically, the recommendation that
women should enter into sexual activity devoid of desire emerged both in sex therapy and in the
popular press in 2001. At that time, Basson (2001, 2002, 2010) introduced a model that suggested
that unlike men, many women were incapable of spontaneous desire but only responsive desire.
These women were advised to “just do it” to keep their sex lives active notwithstanding their lack
of sexual interest (Weiner-Davis 2003).
As indicated by McCarthy & McCarthy (2014), when one choses to engage in sex on the odd
occasion for the sake of the relationship but without sexual desire, it will be received as a goodwill
gesture and perhaps reciprocated when necessary. But if one engages in sex without sexual desire
more than 15% of the time in hopes that desire will emerge along the way, it will likely lead to
resentment eventually (McCarthy & McCarthy 2014). The initially well-intentioned choice can
affect the quality of sex and create the silent desire to “just get it over with”; that approach in turn
can eventuate in a sexual relationship death spiral, where each unfulfilling sexual experience makes
the poor quality of the next one increasingly predictable (Kleinplatz 2011).
From this point of view, eliding arousal and desire is a clinical mistake. Although patients may
not present with distinct complaints, it is the clinician’s responsibility to assess for and disentangle
arousal from desire. Only by identifying the source of the difficulty will therapists be able to
improve the quality of the sex and thereby replace dread with desire (Kleinplatz 2010, 2016).
RECENT TRENDS AND FUTURE DIRECTIONS
Current trends reflect the continuing divergence in training and clinical orientation among health
care professionals. New directions in sexual medicine include cosmetic procedures such as laser
2.20
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
treatments for tightening of vaginal tissues as well as labiaplasty to make one’s labia minora more
symmetrical (though it is not clear what sexual dysfunctions these procedures are intended to
treat); the “O shot”, an injection into the anterior vaginal wall, intended to plump it up to increase
the likelihood of “vaginal orgasms”; and the use of Botox into the pelvic floor nerves to stop women
with vaginismus/GPPPD from clenching their vaginal muscles and obstructing penetration (Pacik
2010).
On the other hand, some sex therapists are attempting to reintroduce sensate focus exercises
to new generations who are unclear as to Masters and Johnson’s original intent (Weiner & AveryClark 2017). Others are attempting to strengthen the field by integrating sex therapy with systemic
psychotherapy models focusing on the relational aspects of sexual difficulties (Hertlein et al. 2016).
Still others are introducing mindfulness techniques (Brotto & Goldmeier 2015, Brotto et al. 2013)
in the treatment of GPPPD. Therapists are advised to be wary of reinforcing old, normative
performance standards despite the use of appealing new mindfulness techniques (Barker 2013,
2017). Finally, some therapists reject the notion that such “disorders” as low desire are in need
of treatment; perhaps they reflect good judgment consistent with the disappointing caliber of the
individuals’ sex lives (Shaw 2012). In such cases, what is called for is promoting optimal erotic
intimacy (Kleinplatz 2010, 2016, 2017).
DISCLOSURE STATEMENT
The author is not aware of any affiliations, memberships, funding, or financial holdings that might
be perceived as affecting the objectivity of this review.
ACKNOWLEDGMENTS
I would like to thank Charles Moser, PhD, MD, for his helpful comments on an earlier draft of
this manuscript.
LITERATURE CITED
Althof SE. 2001. My personal distress over the inclusion of personal distress. J. Sex Marit. Ther. 27(2):123–25
Am. Psychiatr. Assoc. 1952. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 1st ed.
Am. Psychiatr. Assoc. 1968. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 2nd ed.
Am. Psychiatr. Assoc. 1980. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 3rd ed.
Am. Psychiatr. Assoc. 1987. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 3rd ed., rev.
Am. Psychiatr. Assoc. 1994. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 4th ed.
Am. Psychiatr. Assoc. 2000. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: Am.
Psychiatr. Publ. 4th ed., text rev.
Am. Psychiatr. Assoc. 2013. Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: Am. Psychiatr.
Publ. 5th ed.
Angel K. 2012. Contested psychiatric ontology and feminist critique: “Female Sexual Dysfunction” and the
DSM. Hist. Hum. Sci. 25(4):3–24
Angier N. 2007. The search for the female equivalent of Viagra. New York Times, April 10
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.21
CP14CH02_Kleinplatz
ARI
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
Represents a classic text
used commonly in
bibliotherapy for
women experiencing
difficulty with orgasm,
emphasizing the role of
the clitoris.
2.22
19 December 2017
13:1
Apfelbaum B. 2012. On the need for a new direction in sex therapy. In New Directions in Sex Therapy: Innovations
and Alternatives, ed. PJ Kleinplatz, pp. 5–20. New York: Routledge. 2nd ed.
Balon R, Clayton AH. 2014. Female sexual interest/arousal disorder: a diagnosis out of thin air. Arch. Sex.
Behav. 43:1227–29
Barbach L. 1980. Women Discover Orgasm. New York: Free Press
Barbach L. 1984. For Each Other. New York: Signet Books
Barbach L. 2000. For Yourself: The Fulfillment of Female Sexuality. New York: Signet Books
Barker M-J. 2013. Towards a critically informed mindful therapy. Eur. J. Psychother. Couns. 15:163–73
Barker M-J. 2017. Mindfulness in sex therapy. In The Wiley Handbook of Sex Therapy, ed. Z Peterson, pp. 483–
502. New York: Wiley
Bass E, Davis L. 2008. The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse. New York:
Harper & Row
Basson R. 2001. Using a different model for female sexual response to address women’s problematic low sexual
desire. J. Sex Marit. Ther. 27(5):395–403
Basson R. 2002. A model of women’s sexual arousal. J. Sex Marit. Ther. 28(1):1–10
Basson R. 2010. Women’s difficulties with low sexual desire, sexual avoidance, and sexual aversion. In Handbook
of Clinical Sexuality for Mental Health Professionals, ed. SB Levine, CB Risen, SE Althof, pp. 159–79. New
York: Routledge/Taylor & Francis. 2nd ed.
Bergeron S, Brown C, Lord M-J, Oala AM, Binik YM, Khalife S. 2002. Physical therapy for vulvar vestibulitis
syndrome: a retrospective study. J. Sex Marit. Ther. 28:183–92
Bergner D. 2013. Unexcited? There may be a pill for that. New York Times Magazine, May 22. http://www.
nytimes.com/2013/05/26/magazine/unexcited-there-may-be-a-pill-for-that.html
Berkrot B. 2008. BioSante CEO keeps eye on elusive prize. Business News, Jan. 18. http://www.reuters.com/
article/ousiv/idUSN1820768520080118
Binik YM. 2005. Should dyspareunia be retained as a sexual dysfunction in DSM-V? A painful classification
decision. Arch. Sex. Behav. 1(34):11–22
Binik YM. 2009a. The DSM diagnostic criteria for dyspareunia. Arch. Sex. Behav. 39:292–303
Binik YM. 2009b. The DSM diagnostic criteria for vaginismus. Arch. Sex. Behav. 39:278–91
Binik YM, Meana M, Berkley K, Khalifé S. 1999. The sexual pain disorders: Is the pain sexual or is the sex
painful? Annu. Rev. Sex Res. 10:210–35
Boston Women’s Health Book Collect. 2005. The New Our Bodies, Ourselves: A Book by and for Women. New
York: Simon & Schuster
Both S, Weijmar Schultz W, Laan E. 2017. Treating women’s sexual desire and arousal problems. In The
Wiley Handbook of Sex Therapy, ed. Z Peterson, pp. 11–31. New York: Wiley
Brotto LA. 2010. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Arch. Sex.
Behav. 39(2):221–39
Brotto LA, Basson R, Carlson M, Zhu C. 2013. Impact of an integrated mindfulness and cognitive behavioural
treatment for provoked vestibulodynia (IMPROVED): a qualitative study. Sex. Relatsh. Ther. 28:3–19
Brotto LA, Goldmeier D. 2015. Mindfulness interventions for treating sexual dysfunctions: the gentle science
of finding focus in a multitask world. J. Sex. Med. 12:1687–89
Bullough VL. 1994. Science in the Bedroom: A History of Sex Research. New York: Basic Books
Burrows LJ, Basha M, Goldstein AT. 2012. The effects of hormonal contraceptives on female sexuality: a
review. J. Sex. Med. 9:2213–23
Courtois C. 1996. Healing the Incest Wound. New York: W.W. Norton
Davis SR, Davison SL, Donath S, Bell RJ. 2005. Circulating androgen levels and self-reported sexual function
in women. JAMA 294(1):91–96
Dibbell J. 2005. Is the world ready for libido in a nasal spray? Now entering Phase 3 clinical trials:
the first real, honest-to-God, horny-making, body-shaking, equal-opportunity aphrodisiac. Nymag.com.
http://www.nymag.com/lifestyle/sex/annual/2005/15061/index.html
Dodson B. 1987. Sex for One: Joy of Self-Loving. New York: Crown
Dodson B. 2002. Orgasms for Two. New York: Harmony
Echols A. 1983. The new feminism of yin and yang. In Powers of Desire: The Politics of Sexuality, ed. A Snitow,
C Stansell, S Thompson, pp. 439–59. New York: Monthly Rev. Press
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
Echols A. 1989. The taming of the Id: feminist sexual politics, 1968–83. In Pleasure and Danger: Exploring
Female Sexuality, ed. CS Vance, pp. 50–72. London: Pandora Press
Ellis H. 1936. Studies in the Psychology of Sex. New York: Random House
FDA (Food Drug Adm.). 2015. Joint meeting of the Bone, Reproductive and Urologic Drugs Advisory Committee
(BRUDAC) and the Drug Safety and Risk Management (DSaRM) Advisory Committee. FDA Brief. Doc.,
June 4, Silver Spring, MD
Fed. Fem. Women’s Health Cent. 1991. A New View of a Woman’s Body. New York: Simon & Schuster
Finkelhor D. 1984. Child Sexual Abuse: New Theory and Research. New York: Free Press
Finkelhor D. 2008. Childhood Victimization. New York: Oxford Univ. Press
Freud S. 1896. The aetiology of hysteria. In Standard Edition of the Complete Works of Sigmund Freud,
Vol. 3, pp. 191–221. London: Inst. Psychoanal.
Freud S. 1905. On Sexuality: Three Essays on the Theory of Sexuality and Other Works. London: Penguin Books
Freud S. 1951 (1935). Historical notes: a letter from Freud. Am. J. Psychiatry 107(10):786–87
Freud S, Fliess W. 1986. The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887–1904. Cambridge, MA:
Belknap Press
Giami A. 2000. Changing relations between medicine, psychology and sexuality: the case of male impotence.
J. Soc. Med. 37:263–72
Goldstein I, Lue T, Padma-Nathan H, Rosen R, Steers W, Wicker P. 1998. Oral sildenafil in the treatment
of erectile dysfunction. New Engl. J. Med. 338:1397–404
Goldstein SW. 2009. My turn. . . finally. J. Sex. Med. 6:301–2
Graham CA. 2009. The DSM diagnostic criteria for female sexual arousal disorder. Arch. Sex. Behav. 39(2):240–
55
Graham CA, Brotto LA, Zucker KJ. 2014. Response to Balon and Clayton 2014: Female sexual interest/arousal
disorder is a diagnosis more on firm ground than thin air. Arch. Sex. Behav. 43:1231–34
Groneman C. 1994. Nymphomania: the historical construction of female sexuality. Signs 19(2):337–67
Groneman C. 2000. Nymphomania: A History. New York: Norton
Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. 2015. The rising tide of polypharmacy and
drug-drug interactions: population database analysis 1995–2010. BMC Med. 13:74
Hall M. 2012. Beyond forever after: narrative therapy with lesbian couples. In New Directions in Sex Therapy:
Innovations and Alternatives, ed. PJ Kleinplatz, pp. 285–302. New York: Routledge. 2nd ed.
Harris G. 2004. Pfizer gives up testing Viagra on women. New York Times, Feb. 28, p. C1
Hartley H. 2006. The “pinking” of Viagra culture. Sexualities 9(3):363–78
Hawton K, Catalan J. 1990. Sex therapy for vaginismus: characteristics of couples and treatment outcome.
Sex. Marit. Ther. 5:39–48
Heiman J. 2002. Sexual dysfunction: overview of prevalence, etiological factors, and treatment. J. Sex Res.
39(1):73–78
Heiman J, LoPiccolo J. 1988 (1976). Becoming Orgasmic: A Sexual and Personal Growth Program for Women.
New York: Prentice Hall
Herman JL. 1992. Trauma and Recovery. New York: Basic Books
Hertlein KM, Weeks GR, Gambescia N, eds. 2016. Systemic Sex Therapy. New York: Routledge
Hite S. 1976. The Hite Report. New York: Dell Publ.
Hofer-Dückelmann C. 2013. Gender and polypharmacotherapy in the elderly: a clinical challenge. In Sex and
Gender Differences in Pharmacology, ed. V Regitz-Zagrosek, pp. 169–82. Berlin: Springer
Hollibaugh A. 1989. Desire for the future: radical hope in passion and pleasure. In Pleasure and Danger:
Exploring Female Sexuality, ed. CS Vance, pp. 401–10. London: Pandora Press
Jaspers L, Feys F, Bramer WM, Franco OH, Leusink P, Laan ET. 2016. Efficacy and safety of Flibanserin for
the treatment of Hypoactive Sexual Desire Disorder in women: a systematic review and meta-analysis.
JAMA Int. Med. 176(4):453–62
Jutel A. 2010. Framing disease: the example of female hypo-active sexual desire disorder. Soc. Sci. Med. 70:1084–
90
Kaplan HS. 1974. The New Sex Therapy. New York: Brunner/Mazel
Kaplan HS. 1977. Hypoactive sexual desire. J. Sex Marit. Ther. 3(1):3–9
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Describes Freud’s
beginnings in
psychoanalysis,
revolving around the
roots of hysteria in
trauma and its
treatment via catharsis.
Written by a
psychodynamic
therapist, adds remote
causes to the
understanding of sexual
problems and
emphasizes the
assessment of the
etiology of sexual
problems.
2.23
CP14CH02_Kleinplatz
ARI
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
Represents the classic
survey of female
sexuality that redefined
the image of women in
the 1950s.
Contains critiques of
conventional sex
therapy paradigms and
asks master clinicians of
different stripes to
illustrate how they work
with sexual problems.
Provides an overview of
the complexity and
multidetermined nature
of sexual desire
difficulties; contains
excellent case studies.
Provides the original
description of Masters
and Johnson’s model of
the human sexual
response cycle.
Defines sexual
dysfunctions and
invented the field of sex
therapy as a brief,
behaviorally oriented
program for couples.
Presents a popular
cognitive-behavioral
approach to helping
couples work as a team
in dealing with low
desire in men or
women; useful as an
adjunct for sex therapy.
2.24
19 December 2017
13:1
Kaplan HS. 1987. The Illustrated Manual of Sex Therapy. New York: Brunner/Mazel. 2nd ed.
Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. 1953. Sexual Behavior in the Human Female.
Bloomington: Indiana Univ. Press
Kleinplatz PJ. 1998. Sex therapy for vaginismus: a review, critique and humanistic alternative. J. Humanist.
Psychol. 38(2):51–81
Kleinplatz PJ. 2003. What’s new in sex therapy: from stagnation to fragmentation. Sex Relatsh. Ther. 18(1):95–
106
Kleinplatz PJ. 2004. Beyond sexual mechanics and hydraulics: humanizing the discourse surrounding erectile
dysfunction. J. Humanist. Psychol. 44:215–42
Kleinplatz PJ. 2010. “Desire disorders” or opportunities for optimal erotic intimacy. In Treating Sexual Desire
Disorders: A Clinical Casebook, ed. SR Leiblum, pp. 92–113. New York: Guilford
Kleinplatz PJ. 2011. Arousal and desire problems: conceptual, research and clinical considerations or the more
things change the more they stay the same. Sex Relatsh. Ther. 26(1):3–15
Kleinplatz PJ. 2012. Advancing sex therapy or is that the best you can do? In New Directions in Sex
Therapy: Innovations and Alternatives, ed. PJ Kleinplatz, pp. xix–xxxvi. New York: Routledge.
2nd ed.
Kleinplatz PJ. 2016. Optimal erotic intimacy: lessons from great lovers. In Handbook of Clinical Sexuality for
Mental Health Professionals, ed. S Levine, S Althof, C Risen, pp. 318–30. New York: Routledge. 3rd ed.
Kleinplatz PJ. 2017. An existential-experiential approach to sex therapy. In The Wiley Handbook of Sex Therapy,
ed. Z Peterson, pp. 218–30. New York: Wiley
Krafft-Ebing RV. 1965. Psychopathia Sexualis. New York: Paperb. Libr.
Ladas AK, Whipple B, Perry JD. 2004 (1982). The G Spot. New York: Holt
LaSalle M. 2000. Complicated Women: Sex and Power in Pre-Code Hollywood. New York: St. Martin’s Press
Leiblum SR. 2010. Introduction and overview: clinical perspectives on and treatment for sexual desire
disorders. In Treating Sexual Desire Disorders: A Clinical Casebook, ed. SR Leiblum, pp. 1–22. New
York: Guilford Press
Leiblum SR, Rosen RC. 2000. Introduction: sex therapy in the age of Viagra. In Principles and Practice of Sex
Therapy, ed. SR Leiblum, RC Rosen, pp. 1–13. New York: Guilford Press. 3rd ed.
Lief HI. 1977. Inhibited sexual desire. Med. Aspects Hum. Sex. 7:94–95
Loe M. 2004. The Rise of Viagra: How the Little Blue Pill Changed Sex in America. New York: New York Univ.
Press
Maltz W. 2012. Sex therapy with survivors of sexual abuse. In New Directions in Sex Therapy: Innovations and
Alternatives, ed. PJ Kleinplatz, pp. 267–84. New York: Routledge. 2nd ed.
Maltz W, Holman B. 1987. Incest and Sexuality: A Guide to Understanding and Healing. Lexington, MA:
Lexington Books
Masson JM. 1984. The Assault on Truth: Freud’s Suppression of the Seduction Theory. New York: Penguin
Masters WH, Johnson VE. 1966. Human Sexual Response. Boston: Little, Brown
Masters WH, Johnson VE. 1970. Human Sexual Inadequacy. New York: Bantam Books
Masters WH, Johnson VE. 1986. Sex Therapy on Its Twenty-Fifth Anniversary: Why It Survives. St. Louis, MO:
Masters and Johnson Inst.
McCarthy B, McCarthy E. 2014. Rekindling Desire: A Step-by-Step Program to Help Low-Sex and
No-Sex Marriages. New York: Brunner/Routledge
Moser C, Devereux M. 2012. Sexual medicine, sex therapy, and sexual health care. In New Directions in Sex
Therapy: Innovations and Alternatives, ed. PJ Kleinplatz, pp. 127–40. New York: Routledge. 2nd ed.
Moynihan R. 2003. The making of a disease: female sexual dysfunction. Br. Med. J. 326(7379):45
Moynihan R. 2011. Is your mum on drugs? When “de-prescribing” may be the best medicine. Br. Med. J.
343:d5184
Moynihan R, Mintzes B. 2010. Sex, Lies and Pharmaceuticals: How Drug Companies Plan to Profit from Female
Sexual Dysfunction. Vancouver: Greystone Books
Nathan S. 2010. When do we say a woman’s sexuality is dysfunctional? In Handbook of Clinical Sexuality for
Mental Health Professionals, ed. S Levine, C Reisen, S Althof, pp. 95–110. New York: Brunner-Routledge.
2nd ed.
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
19 December 2017
13:1
New View Campaign. 2014. Fact sheet 3: feminism and “FSD”: the appropriation and misuse of feminist rhetoric by
Big Pharma is reprehensible. Prepared for FDA Meet. Female Sex. Dysfunct., White Oak, MD, Oct. 27–
28. http://newviewcampaign.org/userfiles/file/3%20FACT%20SHEET-%20Feminism%20and%
20FSD.pdf
Ogden G. 1999. Women Who Love Sex. Boston: Womanspirit Press
Pacik PT. 2010. When Sex Seems Impossible: Stories of Vaginismus and How You Can Achieve Intimacy. Manchester,
NH: Odyne Publ.
Panzer C, Wise S, Fantini G, Kang D, Munarriz R, et al. 2006. Impact of oral contraceptives on sex hormonebinding globulin and androgen levels: a retrospective study in women with sexual dysfunction. J. Sex.
Med. 3:104–11
Pearsall R. 1969. The Worm in the Bud: The World of Victorian Sexuality. Toronto: MacMillan
Perelman MA. 2000. Integrating Sildenafil: its impact on sex therapy. Sex. Dysfunct. Med. 1(4):98–104
Peterson M. 2010. Boehringer sex pill fails to win U.S. panel’s backing. Bloomberg News, June 18. http://www.
bloomberg.com/news/2010-06-18/boehringer-female-libido-booster-may-not-work-fda-staffsays.html
Pomeroy WP. 1972. Dr. Kinsey and the Institute for Sex Research. New York: Harper & Row
Potts A. 2008. The female sexual dysfunction debate: different “problems,” new drugs—more pressures? In
Contesting Illness: Processes and Practices, ed. P Moss, K Teghtsoonian, pp. 259–80. Toronto: Toronto Univ.
Press
Ramsey S. 2016. Valeant is being sued by the backers of “female Viagra”— and its secret pharmacy is at the
heart of the complaint. Business Insider, Nov. 2. http://www.businessinsider.com/sprout-investorsfile-lawsuit-against-valeant-2016-11
Rosen RC, Leiblum SR. 1995. The changing focus of sex therapy. In Case Studies in Sex Therapy, ed. RC
Rosen, SR Leiblum, pp. 3–17. New York: Guilford
Rubin GS. 2011. Deviations: A Gayle Rubin Reader. Durham, NC: Duke Univ. Press
Rubin L. 1990. Erotic Wars: What Happened to the Sexual Revolution? New York: Harper Collins
Schover LR, Leiblum SR. 1994. Commentary: the stagnation of sex therapy. J. Psychol. Hum. Sex. 6:5–30
Shaw J. 1994. Treatment of primary vaginismus: a new perspective. J. Sex Marit. Ther. 20(1):46–55
Shaw J. 2012. Approaching sexual function in relationship: a reward of age and maturity. In New Directions in
Sex Therapy: Innovations and Alternatives, ed. PJ Kleinplatz, pp. 175–94. New York: Routledge. 2nd ed.
Sherfey MJ. 1966. The Nature and Evolution of Female Sexuality. New York: Vintage Books
Shindel AW, Parish SJ. 2013. Sexuality education in North American medical schools: current status and
future directions. J. Sex. Med. 10(1):3–18
Spring L. 2015. Older women and sexuality—Are we still just talking lube? Sex. Relatsh. Ther. 30(1):4–9
Sussman N. 1976. Sex and sexuality in history. In The Sexual Experience, ed. BJ Saddock, HI Kaplan, AM
Freedman, pp. 7–70. Baltimore, MD: Williams & Wilkins
Tiefer L. 1996. The medicalization of sexuality: conceptual, normative, and professional issues. Annu. Rev.
Sex Res. 7:252–82
Tiefer L. 2000. Sexology and the pharmaceutical industry: the threat of co-optation. J. Sex Res. 37(3):273–83
Tiefer L. 2001. The selling of "female sexual dysfunction.” J. Sex Marit. Ther. 27(5):625–28
Tiefer L. 2006. Female sexual dysfunction: a case study of disease mongering and activist resistance. PLOS
Med. 3(4):e178
Tiefer L. 2015. Women’s sexual problems: Is there a pill for that? In The Wrong Prescription: How Medicine and
Media Create a “Need” for Treatments, Drugs and Surgery, ed. J Chrisler, M McHugh, pp. 147–60. Santa
Barbara, CA: Praeger
Weiner L, Avery-Clark C. 2017. Sensate Focus in Sex Therapy: The Illustrated Manual. New York: Routledge
Weiner-Davis M. 2003. The Sex-Starved Marriage. New York: Simon & Schuster
Wickman JM, Groves A, Wiggins L, Patel N. 2014. Androgen therapy in women. US Pharm. 39(8):42–46
Wierman ME, Basson R, Davis SR, Khosla S, Miller KK, et al. 2006. Androgen therapy in women: an
Endocrine Society Clinical Practice guideline. J. Clin. Endocrinol. Metab. 91(10):3697–710
Wimberly YH, Hogben M, Moore-Ruffin J, Moore SE, Fry-Johnson Y. 2006. Sexual history-taking among
primary care physicians. J. Natl. Med. Assoc. 98(12):1924–29
www.annualreviews.org • Treatment of Female Sexual Dysfunction(s)
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)
2.25
Annu. Rev. Clin. Psychol. 2018.14. Downloaded from www.annualreviews.org
Access provided by University of Reading on 01/23/18. For personal use only.
CP14CH02_Kleinplatz
ARI
Presents an attempt to
combat the increasing
medicalization of female
sexual problems by
contextualizing their
occurrence.
2.26
19 December 2017
13:1
Winton MA. 2000. The medicalization of male sexual dysfunctions: an analysis of sex therapy journals. J. Sex
Educ. Ther. 25(4):231–39
Winton MA. 2001. Gender, sexual dysfunctions and the Journal of Sex & Marital Therapy. J. Sex Marit. Ther.
27:333–37
Wise TN. 1999. Psychosocial effects of sildenafil therapy for erectile dysfunction. J. Sex Marit. Ther. 25(2):145–
50
Wittenberg A, Gerber J. 2009. Recommendations for improving sexual health curricula in medical schools:
results from a two-arm study collecting data from patients and medical students. J. Sex. Med. 6(2):362–68
Woloshin S, Schwartz LM. 2016. US Food and Drug Administration approval of Flibanserin: Even the score
does not add up. JAMA Int. Med. 176(4):439–42
Working Group for the New View of Women’s Sexual Problems. 2002. A new view of women’s sexual
problems. Women Ther. 24(1/2):1–8
Zilbergeld B, Evans M. 1980. The inadequacy of Masters and Johnson. Psychol. Today 14(3):29–30
Kleinplatz
Review in Advance first posted on
January 22, 2018. (Changes may still
occur before final publication.)