sexual dysfunction (FSD) affects about 43% of women at some point
in their lifetime. The four sub-types identified by the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) are desire,
arousal, orgasmic, and pain disorders related to sexual functioning.
The purpose of this research was to investigate the prevalence of
FSD in a college population and then to identify ways to address this
issue. The results indicate that a total of 47% of the women surveyed
using the Female Sexual Functioning Index have a high probability
of struggling with FSD. The highest percentage of women struggle specifically
with orgasmic disorder (26.4%). These high percentages call for immediate
attention. Research on a college-aged population must be added to
the body of research on female sexual dysfunction. Then to attempt
to combat this issue, greater access to sexuality education and a
heightened awareness of its impact on our society need to be addressed.
of Female Sexual Dysfunction among College Students
dysfunctions are defined as “disorders in which people cannot respond
normally in key areas of sexual functioning” (Comer, 2002, p. 309).
Up to 43% of the general female population either currently struggles
with, or has struggled with a form of sexual dysfunction at some time
(Laumann, Paik, & Rosen, 1999; as cited in Rosen, R., Brown, C.,
Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., Ferguson, D., &
D’Agostini, R., Jr., 2000). Sexual dysfunction among women is rarely
discussed and greatly overlooked. In my Abnormal Psychology course,
when we discussed sexual dysfunction, it was apparent that there was
a plethora of information about male sexual dysfunction, but very
little on female sexual dysfunction. I was curious, so I spoke with
a member of the counseling staff at my school. I was interested in
what counselors did for a female student struggling with sexual dysfunction:
did they have pamphlets, or other resources, or what kinds of talk
therapy did they use? I was told that women on my campus do not struggle
with sexual dysfunction unless there is a history of abuse. This assertion
was troubling, so I decided to investigate the matter on my own. What
follows is an examination of current literature on the topic of female
sexual dysfunction (FSD) and a study I conducted on my college campus
to determine the prevalence of FSD.
One event that sparked
much attention among psychologists occurred in 2001: the International
Consensus Development Conference on female sexual dysfunction (Basson,
R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., Fourcroy,
J., et al., 2001). The purpose of this conference was to explore the
definitions and classifications of female sexual dysfunction, and
deal with current assessment problems. Those at the meeting also attempted
to provide identifiable endpoints for evaluation and determine the
most pressing areas for future research. In many ways, the definitions
that they provided are not different from those in the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric
Association, 1994); in fact, the categories were purposely retained
for past and future research continuity. However, a new classification
category of a sexual pain disorder was created: noncoital sexual pain
disorder. The definitions that were determined to be the most representative
of current clinical practice and research are detailed in Table 1.
Table 1: Descriptions
of the Classified Sexual Dysfunction Disorders
sexual desire disorder is the persistent or recurrent deficiency
(or absence) of sexual fantasies/thoughts, and/or desire for
or receptivity to sexual activity, which causes personal distress.
disorder is the persistent or recurrent phobic aversion to and
avoidance of sexual contact with a sexual partner, which causes
disorder is the persistent or recurrent inability to attain
or maintain sufficient sexual excitement, causing personal distress,
which may be expressed as a lack of subjective excitement, or
genital (lubrication/swelling) or other somatic responses.
is the persistent or recurrent difficulty, delay in or absence
of attaining orgasm following sufficient sexual stimulation
and arousal, which causes personal distress.
is the recurrent or persistent genital pain associated with
is the recurrent or persistent involuntary spasm of the musculature
of the outer third of the vagina that interferes with vaginal
penetration, which causes personal distress.
pain disorder is recurrent or persistent genital pain induced
by noncoital sexual stimulation.
Each of these diagnoses is subtyped as A—lifelong verses acquired
type, B—generalized versus situational type and C—etiologic origin
(organic, psychogenic, mixed, unknown).
(Basson, et al.,
This conference sparked
an explosion of commentary on the conference, on its methods and/or
biases, and on current research practices (Kameya, 2001; Plaut, 2001;
Tiefer, 2001; Vroege, Gijs, & Hengeveld, 2001). The topic of female
sexual dysfunction is very appropriate for public, professional dialogue.
One common thread throughout the many commentaries was that there
is simply not enough research on the subject. Most of the articles
that emerged following the conference were commentaries, literary
reviews and informative articles, such as Binik, Y., Reissing, E.,
Pukall, C., Flory, N., Payne, K., & Khalife, S. (2002) article
titled, “The female sexual pain disorders: Genital pain or sexual
dysfunction?” There were very few actual studies. The few studies
that were conducted have explored the development and testing of new
questionnaires to measure FSD (Quirk, F., Heiman, J., Rosen, R., Lann,
E., Smith, M., & Boolell, M., 2002; Rosen et al., 2000). There
were also studies that compared the psychometric properties of the
available methods of self-report (Daker-White, 2002; Dennerstein,
Anderson-Hunt, & Dudley, 2002).
According to the
current research, FSD is beginning to be viewed as a medical problem
instead of, or in addition to, a completely psychological one. Current
research into the possible benefits of Viagra for women, other medications
or herbs to increase arousal, and such things as vacuum therapy seem
promising (Bancroft, 2002; Billups, K., Berman, L., Berman, J., Metz,
M., Glennon, M., & Goldstein, I., 2001; Williams & Leiblum,
2002). Bancroft urges caution in prescribing Viagra to solve women’s
sexual problems. She cites three issues to consider in the medicalization
of FSD: differences between men and women in sexuality, sex therapy,
and the difference between a sexual problem and a sexual dysfunction.
Current research is also starting to examine the effect of certain
medical problems or operations on sexual functioning (Aksaray, Yelken,
Kaptonaoglu, Oflu, & Özaltin, 2001; Burchardt, M., Burchardt,
T., Anatasiadis, A., Kiss, A., Baer, L., Pawar, R., de la Taille,
A., Shabsigh, A., & Shabsigh, R., 2002; Hutcherson, 2002). These
highlight issues such as hypertension, hysterectomies, cancer, and
obsessive compulsive disorder.
Looking at sexual
functioning difficulties as a purely medical problem, however, does
not take into account the social and interpersonal influences on a
person. Often there are greater issues that are being ignored or passed
over when a pill is prescribed, for both men and women. There are
other solutions to the dilemma of FSD than a medical model. Many include
skills training, talk therapy, and the inclusion of the woman’s partner
in therapy. There is evidence suggesting that increased education,
a positive sexual upbringing, and realistic social expectations about
sex lead to women who are more orgasmic (Williams & Leiblum, 2002).
by Heiman (2002) investigated the success of the current treatments
available for FSD. She found that treatments for orgasmic disorders
were the most efficacious, and treatments for pain disorders were
possibly efficacious. Heiman concluded that:
As this and other
articles indicate, both medical and psychological treatments for FSD
need to be considered.
questions still remain in the field of female sexual dysfunction.
One involves the question of priorities: Should the desired outcome
of research be a diminished prevalence of FSD through prevention,
or should research focus on finding a better treatment? There are
no easy answers, and everyone has their own biases. An increased amount
of both kinds of research is needed, but the short-term question remains,
“What can be done right now?”
Past research indicates
that sex education could be very helpful in treatment of FSD. The
ideal target of sex education is one that is old enough to have had
some sexual experimentation, but young enough to allow for the greatest
impact of education. This population is concentrated on college campuses.
Before starting a large-scale attempt at sex education and striving
to make self-exploration socially acceptable for women, it would be
very informative to explore the prevalence of FSD on the college campus.
This population has often been overlooked; instead, current studies
have focused on peri- and post-menopausal women.
of this research was to explore the prevalence of FSD at a small liberal
arts college, and then use the results from this study to argue for
an increased awareness of FSD and education regarding sexuality on
campus. My hypothesis is that there will be fewer college-aged women
struggling with FSD than in the general population, but enough to
warrant further consideration of the topic.
students at a private, religiously affiliated liberal arts college
in the Midwest. The college strives to maintain a ratio of 60 % women
to 40 % men. One hundred and fifty students ranging in age between
18 and 26 participated in this study. Two hundred and fifty women
were randomly selected from among the entire female population at
the college, and research was concluded after 150 surveys were administered.
No one declined participation, although one woman returned the survey
blank and another participant only answered two survey questions and
partially filled out the demographic page.
utilized in this study was the Female Sexual Function Index (FSFI),
which was developed for use by Rosen et al. (2000). There are 19 items,
each measured on a 5-point Likert scale, and most questions also have
a response box for “no sexual activity.” Rosen et al. used factor
analysis to determine six sub-domains measured by the FSFI, including
desire, arousal, lubrication, orgasm, satisfaction, and pain. The
discriminant validity, the ability of the scale to differentiate between
clinical and nonclinical populations, was assessed by comparing the
means of patients clinically diagnosed with FSAD (female sexual arousal
disorder, n=128) with the means of normally functioning controls (n=131).
There were statistically significant differences measured for each
of the six sub-domains. The questionnaire has a high level of internal
consistency (Cronbach’s α = .81-.97) and is also highly reliable
(test-retest of .61 < r < .92) (Daker-White, 2002).
A brief demographic
page was developed and administered in addition to the questionnaire.
Information requested on the demographic page included age, the number
of different sexual partners (for any sexual activities, as operationally
defined at the beginning of the FSFI, and also specifically for sexual
intercourse), whether or not the participants masturbate or have a
history of abuse, and the medications the participants were currently
taking. These data were used in conjunction with the results from
the survey to answer some basic questions about trends in sexual functioning.
Design and Procedure
Students were approached
in their dorm or phoned ahead and invited to stop by the psychology
department office to fill out the questionnaire. The purpose of the
study was briefly explained, both verbally and in the written consent
form. Participants were informed that involvement was voluntary and
that they could turn in a blank survey if they decided not to complete
it. They were then asked to fill out the questionnaire and demographic
page, being as honest as possible. To preserve anonymity, participants
placed completed (or blank) forms in an envelope along with other
forms previously collected. A debriefing handout with information
pertaining to female sexual dysfunction and references to counseling,
websites, and books were provided at completion of the survey.
No cut-off numbers
were provided with the FSFI, only the normative data were available.
The mean scores of the clinical and nonclinical populations were used
as a guide to determine cut-off values for the sub-domains, as well
as the scoring guide provided with another very similar questionnaire
(Quirk et al., 2002). The questionnaire by Quirk et al. had slightly
different questions to measure the same sub-domains. Quirk et al.
were contacted with a request to use their questionnaire, but they
did not respond to the request. When a discrepancy existed between
the means of the FSFI and the cut-off scores of the other questionnaire,
the more conservative number was used. This was the case in all sub-domains
except the pain category, where it was more meaningful to use a slightly
less conservative cut-off score of 10, keeping in mind that the average
score of the clinical population was even higher than 10. Scores of
the following magnitudes and lower were considered to have a high
probability of having sexual functioning difficulties: Desire: 4,
Arousal: 10, Lubrication: 10, Orgasm: 8, Satisfaction: 8, Pain: 10.
percent of women with at least one of the measured difficulties in
sexual functioning was 47% when the sub-domain of satisfaction was
not included. Including the sub-domain of satisfaction (which is not
a specific sexual dysfunction as recognized by the DSM-IV, but is
an important criteria for receiving a diagnosis of dysfunction), the
percentage climbs to 67.8% of the surveyed women.
of women who have engaged in some form of sexual activity and who
are struggling with some form of sexual dysfunction is 41.3%. The
questionnaire provides the opportunity to indicate that no sexual
activity has occurred for questions regarding arousal, lubrication,
orgasmic and pain disorders. It is important not to discount the
validity of a desire disorder; however, participants could answer
the desire questions whether they had engaged in any sexual activity
As indicated by the
response to the question on the demographic page regarding abuse,
90% of those struggling with some form of FSD (again not including
the sub-domain of satisfaction) had no history of abuse. As measured
by the FSFI, 58% of the women in this study with a history of abuse
were likely to have at least one form of FSD as measured by the DSM-IV.
For the category
of desire, 22.8% of the surveyed population reported sexual functioning
difficulties as defined by our cut-off scores (see Figure 1). That
is, 34 of the 149 valid surveys indicated problems in the desire domain
of sexual functioning.
Percent of women with desire functioning difficulties
2 shows the results of the arousal category, where only 6.1% of the
148 who answered the question reported arousal problems. Thirty-six
percent of the surveyed population reported no relevant sexual activity,
and 58.1% reported normal functioning. Thus, for those reporting some
sexual activity, actually 9.5% have a high probability of having a
sexual arousal disorder.
Percent of women with arousal functioning difficulties
trend was noticeable in the lubrication category: 4.7% of those surveyed
reported lubrication difficulties. Again, 37.2% of the population
reported having no sexual activity in the past 4 weeks, and 58.1%
reported normal functioning (see Figure 3). Here, the percent of sexually
active participants with lubrication difficulties jumps to 7.5%.
Percent of women with lubrication functioning difficulties
larger 26.4% of the surveyed population expressed orgasm problems
as shown in Figure 4; again, 38.5% reported no sexual activity, and
only 35.1% had a high probability of functioning normally. When only
those who have engaged in sexual activity in the past 4 weeks are
accounted for, actually 42.9% of sexually active women may have had
an orgasmic disorder. As Figure 5 depicts, a high 42.6% claimed dissatisfaction,
and 54.7% reported being satisfied with the level and amount of sexual
Percent of women with orgasm functioning difficulties
Percent of women who are unsatisfied
women surveyed, 8.1% reported pain difficulties with intercourse.
Figure 6 shows that 59.5% of the women surveyed had not attempted
intercourse in the past 4 weeks, and the remaining 32.4% claimed normal
functioning. So, actually, 20% of those engaging in sexual intercourse
in the previous 4 weeks have a high probability of having a sexual
Percent of women with sexual pain
reveal that the percentage of college-aged women struggling with FSD
is very similar to the widely cited 43% of the general female population
(Laumann, Paik, & Rosen, 1999; as cited in Rosen et al., 2000).
Similar liberal arts colleges may have similar percentages of women
struggling with sexual functioning problems. Although the specific
demographics may be different at this college than at a state school,
it is a high percentage of women regardless of the unique composition
of the school. Thus, one could tentatively conclude that the percentage
of college-aged women struggling with FSD is very similar to the general
for orgasmic difficulties represent a higher percentage than for any
of the other categories relating specifically to sexual activity in
the past four weeks, (percent for the satisfaction domain were higher,
but that includes more than the past four weeks).Another troubling
finding is that 20% of women who attempted sexual intercourse in the
previous four weeks experienced a high degree of pain, which suggests
that they may have been struggling with a sexual pain disorder.
The questions regarding
satisfaction were applicable even to those who have never engaged
in any sexual activity, because women were able to comment on their
satisfaction with the amount of sexual activity they personally experienced.
Also, in this category, 2 women answered these questions incorrectly,
failing to answer the question with regards to their level of satisfaction,
instead hand writing “no sexual activity”. These considerations should
cause one to use caution when generalizing the results of the satisfaction
The results indicate
that a history of abuse is not a necessary qualification to have sexual
functioning difficulties, nor does it make sexual functioning difficulties
more likely. When this research was initially proposed, it was suggested
that the only reason women of a college age would have any sexual
functioning difficulties is due to a past history of abuse. The validity
of that claim is not supported by the results of this study.
Referring back to
Williams and Leiblum (2002), it is interesting to note that the treatments
they suggest are very simple. Sex education and permission to explore
one’s body and one’s sexuality seem to be superfluous or unnecessary,
yet the prevalence of FSD in society indicates that these steps are
way to get started would be to form some supportive women’s groups
as a forum to discuss sexuality. These small groups could be a good
setting to discuss permission to explore one’s body as well as directed
masturbation training. A forum could be held, or a lecture on general
or specific sex education could take place.
good place to start would be in counseling centers on campus. Perhaps
some up-to-date training in the treatment of FSD or sex education
would be appropriate. Counseling centers might create an informative
pamphlet on FSD, including the importance of a greater self-awareness.
among the subtypes of FSD leads me to believe that addressing issues
central to one specific subtype will have an effect on other subtypes
as well. Treatments have been shown to be efficacious for orgasmic
disorder and for pain disorders and since arousal is strongly linked
to previous pain or orgasmic experience (Heiman, 2002), using treatments
known to be efficacious for one subtype of FSD may have an indirect
effect on other subtypes.
In future research
it would be incredibly useful to investigate any correlation between
the taking of birth control pills and sexual dysfunction. Two possible
arguments could be made: one suggests that without the threat of pregnancy,
women would have a lower prevalence of FSD. The opposing view takes
into account the effect many birth control pills have on ease of lubrication
and arousal functioning; the hypothesis being that the rate of FSD
would be higher in those taking birth control pills. The correlation
between masturbation and FSD would be interesting to investigate as
well. One of the suggested treatments for FSD is directed masturbation
training and permission to explore one’s body. Thus, if one regularly
masturbates, the likelihood of sexual functioning difficulties should
arguably be lower.
be concerned that a heightened awareness of FSD on campus and greater
access to healthy sex education would lead to a “sex crazed” campus.
In a meta-analysis by Grunseit, Kippax, Aggleton, Baldo and Slutkin
(1997), 53.2% of studies showed no effect of HIV/AIDS and sexual health
education on promiscuity, while 36.2% of them actually decreased age
of onset of sexual activity, reduced the number of sexual partners,
or reduced unplanned pregnancy. Only 6.4% of the articles showed an
increase in sexual behavior due to sexual education; although, it
is arguable that it might have been healthier and safer sexual activity.
Other articles show very similar results of education, including the
ineffectiveness of abstinence-only education (Sather & Zinn, 2002;
Starkman & Rajani, 2002). Education is an empowering step aimed
at giving women permission to have control over their bodies. It is
not enough to say that the environment at a college does not openly
endorse traditional gender roles; the campus needs to step up and
actively dispute the traditional societal messages and pressures.
of this research was two-fold: to investigate the prevalence of FSD
on a college campus and to investigate possible solutions to the problem
if it was found. It is now evident that perceptions can be misleading
and have caused us to ignore a major issue: many college-aged women
do struggle with sexual functioning difficulties, and past abuse has
little to do with that. As this research demonstrates, there is much
that is not understood about FSD, and there is a large gap between
the amount and quality of research on FSD and that on Male Sexual
Dysfunction. I would like to issue a challenge to my fellow researchers:
continue to stretch the boundaries of what is known about FSD, and
continue to raise awareness about this important issue.
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