Most pharmacological treatments that are currently being developed for women with sexual arousal disorder are aimed at remedying a vasculogenic deficit. In a study we did in the late 1990s we compared pre- and postmenopausal women with and without sexual arousal disorder, diagnosed according to strict DSM-IV criteria (1). Women with any somatic or mental comorbidity were excluded. This study investigated whether pre- and postmenopausal women with sexual arousal disorder were less genitally responsive to visual sexual stimuli than pre- and postmenopausal women without sexual problems. From the findings of this study we concluded that in such women, sexual arousal disorder is unrelated to organic etiology. In other words, we are convinced, from this and other studies to be reviewed, that in women without any somatic or mental comorbidity, impaired genital responsiveness is not a valid diagnostic criterion. The sexual problems of women with sexual arousal disorder are not related to their potential to become genitally aroused. We propose that in healthy women with sexual arousal disorder, lack of adequate sexual stimulation, with or without concurrent negative effect, underlies sexual arousal problems. This view is at odds with the dominant view on male sexual arousal problems.
In the history of sexological science, the study of women's sexuality has been neglected, or has been obscured by comparisons with sexuality of men. In textbooks, descriptions of women and men's sexuality were often aimed at increasing awareness of similarities in physiological and psychological mechanisms (2). Even today, as will be shown later in this chapter, clear conceptualizations of women's sexual problems and dysfunctions seem hindered by dominance of the "male model."
For a long time, the general idea in western culture has been that although women may have a disposition for sexual feelings, in decent and healthy women these feelings will only be aroused by a loving husband. "In women ... , especially in those who live a natural and healthy life, sexual excitement also tends to occur spontaneously, but by no means so frequently as in men. (...) In a very large number of women the sexual impulse remains latent until aroused by a lover's caresses. The youth spontaneously becomes a man; but the maiden—as it has been said—'must be kissed into a woman'" (3, p. 241). Stekel believed that it was a man's task to awaken sexual feelings in a woman, a responsibility that should not be taken lightly. "As a matter of fact it is the duty of every man whose wife is unfortunately anaesthetic to investigate for himself his marital partner's erogenous zones, adroitly, carefully until he discovers the areas or positions which are capable of rousing his wife's libido and of bringing on her orgasm during intercourse" (4, p. 133). He disapprovingly remarked: "There are men so brutally blunt and so selfish that they take no trouble to study their wives so as to become acquainted with their erogenous zones and learn to meet their particular desires" (p. 130). About half a century earlier, a book entitled The Functions and Disorder of the Reproductive Organs by W. Acton, a surgeon (5), passed through many editions and was popularly regarded as a standard authority on the subjects with which it dealt. The book was almost solely concerned with men; the author evidently regarded the function of reproduction as exclusively appertaining to men. He claimed that women, if "well brought up," are, and should be, absolutely ignorant of all matters concerning it. "I should say," this author remarked, "that the majority of women (happily for society) are not very much troubled with sexual feeling of any kind." The supposition that women do possess sexual feelings he considered "a vile aspersion."
It was not until the late 18th century, however, that the above view had become the dominant one. For thousands of years prior to this, scholars had assumed that conception could not take place without the woman becoming sexually aroused and having an orgasm (6, pp. 2-3). Thus, sexual pleasure for women was not only accepted, but also essential. Yet, although sexual feelings in women were acknowledged, they were not always considered to be unproblematic. Shorter summarized the prevalent view of women's sexuality in the Middle Ages as follows: "Women are furnaces of carnality, who time and again will lead men to perdition, if given a chance. (...) Because the flame of female sexuality could snuff out a man's spirit, women had sexually to be broken and controlled" (7, pp. 12-13).
Ellis had distinctive opinions about differences between women and men concerning the physiological mechanisms involved in sexuality (3). In men, the process of tumescence and detumescence was considered to be simple. In women "we have in the clitoris a corresponding apparatus on a small scale, but behind this has developed a much more extensive mechanism, which also demands satisfaction, and requires for that satisfaction the presence of various conditions that are almost antagonistic____It is the difference, roughly speaking, between a lock and a key We have to imagine a lock that not only requires a key to fit it, but should only be entered at the right moment, and, under the best conditions, may only become adjusted to the key by considerable use" (p. 235). It seems that phrases such as "an extensive mechanism behind the clitoris" served to conceal ignorance about physiological facts. Even today, scholars acknowledge that "it is glaringly obvious that we know so little about sexual arousal that we cannot answer some of the most elementary questions about the ... human genital function" (8, p. 3).
In his excellent book on the role of the body in female sexuality, Laqueur (6) demonstrated that conceptions about human sexuality were not the result of scientific progress. Instead, he argued, they were part of social and political changes, "explicable only within the context of battles over gender and power" (p. 11). Feminists have long criticized the notion that the behavior and abilities of women are uniquely determined by their biology. This criticism led to an almost total rejection of the role of biology in the construction of gender (9). It also contributed to an image of female sexuality devoid of the body. Masters and Johnson (10) were the first to carefully study and describe the genital and extragenital changes that occurred in sexually aroused women. Tiefer critiqued the suggestion of the human sexual response cycle as a universal model for sexual response, not in the least because the concept of sexual desire was not included in the model, therewith eliminating "an element which is notoriously variable within populations" (11, p. 4). She argued that the human sexual response cycle, with its genital focus, neglects women's sexual priorities and experiences. Indeed, Masters and Johnson did not assess the subjective sexual experience of the 694 men and women who were studied. Their emphasis on peripheral physiology, particularly the genital vasocongestive processes associated with sexual response, may reflect the influence of primarily male-dominated theorizing and research in sexology, with its inevitable emphasis on penile -vaginal sexual contact. Tiefer wondered why problems such as "too little tenderness" or "partner has no sense of romance" were excluded (11). These problems have been frequently reported by women (12). The sexual response cycle model assumes men and women have and like the same kind of sexuality. Yet, various studies show that women care more about affection and intimacy, and men care more about sexual gratification in sexual relationships (13). There seems to be support for the cliche "Men give love to get sex, and women give sex to get love." Men and women are raised with different sets of sexual values. Tiefer concludes that focusing on the physical aspects of sexuality and ignoring other aspects of the sexual response cycle favors men's value training over women's.
Recently, there has been a growing awareness of the limitations of the "male model" for understanding women's sexuality (14-16). In this chapter, we will review the current definitions of female sexual arousal disorder (FSAD) and the prevailing difficulties in pinpointing the etiology of the problems clients present. We will then present our view on the activation and regulation of women's sexual responses, which is derived from modern emotion and motivation theories, underlining differences with men's sexual responses. We will briefly discuss treatment options, and we will end with a few recommendations for clinical practice that follow from our analysis.
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