Differences between men and women in the sexual response system: the clinical consequences for management of arousal disorders

Rik HW van Lunsen and Ellen TM Laan

Dept Sexology & Psychosomatic Ob/Gyn, Academic Medical Centre, University of Amsterdam, The Netherlands

In the last decades research in the field of male sexual dysfunctions has been dominated by studies that use the genital sexual response, the erection, as the major endpoint The main reason for this is that men tend to use their erection as indicator for their arousal state. In men without sexual problems, correlations between penile circumference change and subjective report are usually fairly high. Men with psychogenic erectile dysfunction, however, tend to underestimate their sexual responses. The introduction of 5PDE inhibitors as enhancer of the genital response and the physiological similarities between the male and the female sexual system have led to the presumption that female sexual arousal disorders (FSAD) should be approached in the same way as erectile dysfunction and could be seen as a predominantly vasculogenic disease. In line with this genital approach to sexual arousal problems of women the current classification system of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines female sexual arousal entirely in terms of genital indices of a sexual response, namely, the lubrication-swelling response. The definition of female sexual arousal disorder (FSAD) is consistent with this definition. In clinical practice, however, more often it is the lack of subjective sexual arousal that leads women to seek treatment. Women are, in contrast to men, relatively unaware of their genital sexual responses and tend to define sexual arousal in terms of their subjective feeling state. Only a severe inhibition or complete absence of a physical sexual response indirectly leads to complaints by the discomfort and pain that is the result. Diminished physical responsivity is rarely described in terms of perceived incomplete, or absence of, lubrication and/or swelling.

In women experiencing arousal problems, the lack of a systematic relation between awareness of genital responses and feelings of arousal is even more apparent in comparison with women without sexual problems. Their subjective experience of sexual arousal is determined less by feedback from their genitals than by the intensity and appraisal of the sexual stimulus and other contextual factors. In the laboratory pre- and postmenopausal women with FSAD and without known organic disease have similar genital responses as women without arousal problems and moreover on a subjective level do not benefit of enhancement of genital reponses by means of 5PDE inhibitors. Men come from Mars and women from Venus; their bodies show similarities but in the way subjective appraisal of sexual arousal is processed their brains and their genitals interact in a completely different way. Treatment modalities and medications suitable for men have no clinical relevance whatsoever for women. FSAD does not exist. Women need approaches that increase central arousal and take into account context related variables and quality of sexual stimuli. While men often have to learn to focus less on their genitals, women should often be more aware of their personal prerequisites for being able to respond to sexual stimuli and should learn not to engage in sexual intercourse when not sufficiently aroused.

Literature

Lunsen HW van, Laan E. Genital vascular responsiveness and sexual feelings in midlife women: psychophysiologic, brain, and genital imaging studies. Menopause 2004;11(6):741-8. 

Nappi R. Salonia A. Traish AM. van Lunsen RHW. Vardi Y. Kodiglu A. Goldstein I. Clinical biologic pathophysiologies of women's sexual dysfunction. Journal of Sexual Medicine  2005;2(1):4-25.