How do I know when it’s time to seek help for female sexual problems?

A sexual dysfunction is a distressing disturbance in a person’s ability to respond sexually or experience sexual pleasure, though definitions of specific sexual dysfunctions vary depending on the organization doing the defining. The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD) are the two internationally accepted classification systems, but the DSM’s focus is psychiatric while the ICD’s focus is medical. The DSM’s psychiatric focus limits is relevance to female sexual dysfunction (FSD), and it has also been criticized for failing to adequately reflect the diversity of women’s actual experiences of sexual dysfunction, and the most recent edition (the DSM-5) has been criticized further for combining different disorders together because some healthcare providers struggled to differentiate between them. Because many healthcare providers will only be familiar with the definitions from the DSM, I will mention these definitions briefly, but I will be using the most up-to-date and evidence-based FSD definitions from experts in female sexual medicine—the International Society for the Study of Women’s Sexual Health (ISSWSH), the International Society for Sexual Medicine (ISSM), International Society for the Study of Vulvovaginal Disease (ISSVD), and the International Pelvic Pain Society (IPPS).

If you don’t want to read everything below, you can just skip to the information under the headings that seem relevant to you.

I have a sexual desire problem

If you experience low or absent desire even after paying attention to sexual cues (e.g., sexual images or erotica) or experiencing adequate sexual stimulation (e.g., cunnilingus, masturbation), you may want to seek help. However, if you do experience responsive sexual desire but want to experience more spontaneous sexual desire, you can still seek help to enhance your sexuality—just know that there is nothing wrong with you!

Hypoactive sexual desire disorder (HSDD) is defined as any of the following for a minimum of six months:

• Lack of motivation for sexual activity as manifested by:
  • Decreased or absent spontaneous desire (sexual thoughts or fantasies); or
  • Decreased or absent responsive desire to erotic cues and physical stimulation or inability to maintain desire or interest through sexual activity;
• Loss of desire to initiate or participate in sexual activity, including behavioural responses such as avoidance of situations that could lead to sexual activity, that is not secondary to sexual pain disorders;
• And is combined with clinically significant personal distress that includes frustration, grief, guilt, incompetence, loss, sadness, sorrow, or worry.

HSDD symptoms should be rated as mild, moderate, or severe, and can be classified as acquired (e.g., first occurring after an event, such as surgery) versus lifelong (i.e., the woman has always had the condition). HSDD symptoms should also be classified as generalized (i.e., occurring in all sexual situations) versus situational (e.g., only with a partner, a specific partner, or a certain activity).

You’ll notice that this definition requires symptoms for a minimum of six months. This does not mean you cannot seek help before then, but it does mean that you may end up waiting six months before your healthcare provider is willing or able to diagnose you. (This is usually only important for getting healthcare plans to cover the treatment.) You’ll also notice that significant distress is a requirement—if you have low desire and are not bothered by it, there is no problem. If your partner is bothered by your low desire, then that may require a different response—you may wish to seek treatment alone, you may go to couples therapy, or you may pursue another route.

Note: Your healthcare provider may only be familiar with the DSM-5, in which HSDD is combined with arousal disorders under “female sexual interest/arousal disorder.” You can still use the HSDD definition above to explain your symptoms more specifically.

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I have a sexual arousal problem

There are two types of female sexual arousal disorders (FSADs): female genital arousal disorder (FGAD) and female cognitive arousal disorder (FCAD). I have included persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) in this section, though it could also fit under pain disorders or orgasm disorders, depending on the individual’s specific symptoms.

My genitals aren’t responding

While you should feel free to supplement your own lubrication with synthetic lubricants, you can seek help if you are concerned about producing too little lubrication. You should consider seeking help if you notice that your genitals are not swelling and darkening with sexual stimulation.

Female genital arousal disorder (FGAD) is defined as the difficulty or inability to achieve or sustain sufficient genital response (e.g., lubrication, engorgement) and sensitivity of the genitalia while engaged in sexual activity. Like the desire disorders, diagnosis requires that the symptoms cause significant distress and last for at least six months. FGAD is usually acquired (women are not born with it) and generalized (occurring in all situations).

FGAD is diagnosed mainly by history and physical examination and should not be diagnosed in those whose lack of genital arousal is due to inadequate stimulation. It is tough to define what “inadequate” stimulation is, but note that vaginal intercourse without additional clitoral stimulation is inadequate for most. Adequate stimulation usually includes direct or indirect clitoral stimulation, such as masturbation by touching the clitoris directly or indirectly, putting a vibrator on or near the clitoris, or receiving cunnilingus (oral sex on a vulva) with attention to the clitoris.

Note that your healthcare provider should rule out other conditions (e.g., vulvovaginal atrophy, vulvovaginal infection or inflammation, inflammatory disorders of the vulva or vagina, vestibulodynia, and clitorodynia) before making a diagnosis of FGAD.

Note: Your healthcare provider may only be familiar with the DSM-5, which combines the two female sexual arousal disorders (FGAD and FCAD) with desire disorders (HSDD) under “female sexual interest/arousal disorder.” You can still use this FGAD definition to explain your symptoms more specifically.

My brain can’t get/stay interested in sex

You may want to seek help if you find that you’re having problems with mental arousal or staying present with sexual activity. This could mean that you can’t get mentally aroused at all, or that you struggle to stay mentally aroused.

Female cognitive arousal disorder (FCAD) is the mental version of FGAD. It is defined as difficulty or inability to achieve or sustain adequate mental arousal or engagement with sexual activity. These symptoms must cause distress and last for at least six months. The symptoms should be rated as mild, moderate, or severe, and can be classified as acquired versus lifelong and generalized versus situational. While FGAD and FCAD are distinct sexual dysfunctions, women can also experience both.

As with the previous sexual dysfunctions, diagnosis requires that symptoms cause distress and last for at least six months.

Note: Your healthcare provider may only be familiar with the DSM-5, which combines the two female sexual arousal disorders (FGAD and FCAD) with desire disorders (HSDD) under “female sexual interest/arousal disorder.” You can still use this FCAD definition to explain your symptoms more specifically.

I have abnormal genital sensations

You should seek help if you experience unwanted arousal or abnormal genital sensations, particularly if these sensations occur without any sexual interest.

Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD) is completely different from the other two sexual arousal disorders. PGAD/GPD is defined as unwanted or intrusive, distressing, and recurring or persistent sensations of genital arousal or abnormal genital sensations, without any sexual interest or thoughts, for a minimum of six months. It can be characterized as lifelong versus acquired and generalized versus situational. Sexual activity and/or orgasm help symptoms only a little or not at all, or may even increase symptoms. Orgasm quality, frequency, intensity, timing, and pleasure may all be impaired. Those with PGAD/GPD may experience mental distress, such as despair or suicidality. Certain circumstances (e.g., sitting, stress, nervousness) may increase genital sensations. However, genital sensations do not necessarily correspond to physical signs of genital arousal (e.g., lubrication, swelling).

Note: Your healthcare provider may only be familiar with the DSM-5, which does not include PGAD/GPD or anything like it, but some healthcare providers will have heard of it. Healthcare providers may be able to diagnose these symptoms under DSM-5 Code 302.79: “Other specified sexual dysfunction.”

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I have an orgasm problem

There are two female orgasm disorders: female orgasm disorder (FOD) and female orgasmic illness syndrome (FOIS).

My orgasm is too weak/delayed/difficult

If you struggle to orgasm from masturbation and you’ve spent considerable time practicing, then you may want to seek help. If you struggle to orgasm with a partner but not by yourself, you may want to seek help from a sex therapist or a self-help resource. You may also want to seek help if you experience little to no pleasure with/from orgasm.

Female orgasm disorder (FOD) describes several problems with female orgasm. Orgasm may occur less frequently, not at all (anorgasmia), less intensely, later or earlier than you desire, or with absent or decreased pleasure (pleasure dissociative orgasm disorder [PDOD]). Female orgasm disorder is classified as either lifelong versus acquired and generalized versus situational. A woman who can achieve orgasm with clitoral stimulation but not through vaginal penetration alone should not be diagnosed with female orgasm disorder.

Note: Your healthcare provider may only be familiar with the DSM-5, which includes only one orgasm disorder (female orgasm disorder) and does not account for other orgasm problems such as decreased or absent pleasure (PDOD), unwanted orgasms (PGAD/GPD), or unpleasant symptoms around orgasm (FOIS).

I feel physically terrible before/during/after orgasm

If you experience unpleasant symptoms (e.g., pain, headache) during or after orgasm, you should seek help from a pelvic floor physiotherapist and/or a sexual medicine specialist.

Female orgasmic illness syndrome (FOIS) is defined as negative symptoms that occur before, during, or after orgasm. These symptoms are not necessarily related to altered quality of orgasm. These negative symptoms could include disorientation, seizures (orgasmic epilepsy), chills, genital pain, or other symptoms. Symptoms may vary between people, and these symptoms may last for minutes, hours, or days after orgasm.

Note: Your healthcare provider may only be familiar with the DSM-5, which does not include FOIS or anything like it, and you may have trouble finding healthcare providers who have heard of it unless you seek out a sexual medicine specialist.

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I experience pain with sexual activity

Female sexual pain disorders can be divided into vulvar pain caused by a specific disorder, vulvodynia, painful orgasm, and female genital-pelvic pain dysfunction. If you have pain, it may be a bit confusing to figure out which definition fits you best.

I have pain on the outside of my genitals

You should seek some sort of help if you experience pain on the external genitals—with or without any stimulation. If you cannot pull back the hood of your clitoris to reveal your glans but you do not have any pain, you do not necessarily need to seek help, but I personally would recommend it.

Vulvar pain caused by a specific disorder is a bit of a mouthful to say, but it describes one of the sexual pain classifications well. Disorders that can cause vulvar pain include infections (e.g., herpes), inflammation (e.g., lichen sclerosis), neurologic factors (e.g., nerve compression), trauma (e.g., female genital cutting), treatments for other conditions (e.g., chemotherapy), and hormonal deficiencies (e.g., menopause). (It’s also possible to have these conditions and experience no vulvar pain.)

Vulvodynia is defined as vulvar pain that lasts more than three months and has no apparent cause.

For both conditions (vulvar pain with a specific cause or with no apparent cause), you should note the following:

• Location of the pain: localized to one area (e.g., the clitoris, the vestibule) or generalized to the whole vulva, or both,
• Whether the pain only happens the vulva is touched or if it happens spontaneously,
• Whether you’ve had the pain your whole life, if it began at some point, and
• Whether the symptoms are intermittent, persistent, constant, immediate (e.g., upon touching), or delayed (e.g., after touching).

Note: Your healthcare provider may only be familiar with the DSM-5, which only includes the broad definition of “genito-pelvic pain/penetration disorder” (GPPPD), which does not have room for vulvodynia in its definition. You can still use this these two definitions of vulvar pain to explain your symptoms more specifically.

I have pain during/after orgasm

If you have genital pain during or shortly after orgasm, you should seek help.

Painful orgasm is simply defined as genital and/or pelvic pain during or shortly after orgasm. Diagnosis of painful orgasm should note whether the symptoms are lifelong or acquired, have occurred for at least three months, cause distress, and occur in 75% to 100% of sexual experiences.

You may look at that definition and say, “I need to have painful orgasms 75% to 100% of the time in order to get a diagnosis? That seems ridiculous.” I agree. If you are having painful orgasms more than occasionally, I would seek help.

Note: Your healthcare provider may only be familiar with the DSM-5, which does not include painful orgasm, and the sexual pain disorder in the DSM-5 (genito-pelvic penetration/pain disorder) does not have room for painful orgasm in its definition.

Genital touching and penetration scare me or cause me pain

If you are experiencing difficulties (e.g., fear, anxiety, pain) before, during, or after genital touching (internal or external), you should seek help. You should also seek help if you have noticed that your pelvic floor muscles seem very tight or crampy, if you experience pain when inserting a tampon or your own finger into your vagina, or if you experience pain when touching your vagina or anywhere on your vulva

There are some self-help options that you may want to try first, such as using a personal lubricant (and trying out different lubricants in case one is irritating) and receiving gentle and shallow vaginal penetration after you are very aroused. However, if you have tried those options and you are still experiencing pain, you should seek help.

Female genital-pelvic pain dysfunction (FGPPD) is defined as persistent or recurrent difficulties with at least one of the following:

• vaginal penetration during intercourse;
• marked vulvovaginal or pelvic pain during genital contact;
• marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of, genital contact;
• marked hypertonicity (tightness) or overactivity (spasms) of pelvic floor muscles with or without genital contact.

Diagnosis of painful orgasm or FGPPD should note whether the dysfunction is lifelong or acquired, has been in place for at least three months, leads to individual distress, and occurs in 75% to 100% of sexual experiences.

You’ll notice that this definition is quite broad and encompasses a lot of possibilities. You could have difficulty with penetration, pain with genital contact, anxiety about pain before/during/after genital contact, or pelvic floor muscle tightness or spasms. This definition covers a lot of different conditions. While there is some overlap between FGPPD and vulvar pain with/without cause, only the definition of FGPPD includes fear of pain.

Note: Your healthcare provider may only be familiar with the DSM-5, which includes one female sexual pain disorder: genito-pelvic pain/penetration disorder (GPPPD). It is quite similar to FGPPD.

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I’m not experiencing enough pleasure

Your partner’s sexual knowledge and sexual skills are an important factor in your experience of pleasure, as are the sexual activities you participate in. For example, if you are not experiencing pleasure but you’re only engaging in vaginal intercourse, you probably don’t need to seek help—you need to try out some other ideas, such as cunnilingus, touching yourself during intercourse, masturbating, or using a vibrator (alone or with a partner). You should give your partner feedback about what you like and what you don’t like. If you can experience pleasure by yourself but struggle to experience it with another person even though your clitoris is definitely getting stimulated, you may wish to seek help from an AASECT-certified sex therapist or another therapist with competency in sex therapy.

I already mentioned pleasure dissociative orgasm disorder (PDOD) under orgasm disorders, though it could also fit here under pleasure disorders. People with PDOD experience pleasure leading up to orgasm but not during orgasm. However, there is another sexual dysfunction that refers to decreased or absent sexual pleasure during the whole sexual response cycle.

My genitals feel numb

If you do not experience pleasure through any sexual activity (partnered or solo), you should seek help, especially if you’ve already tried using erotica, pornography, and/or a vibrator (especially any vibrator that provides clitoral suction).

As research on post-SSRI sexual dysfunction (PSSD) is new, we only have a working definition: distressing issues with sexual function/pleasure that emerge with SSRI initiation/termination and persist after termination (not due to depression or other contributors). There are many possible symptoms of PSSD, including low desire, decreased vaginal lubrication, decreased orgasm frequency and intensity, loss of pleasure with orgasm, and genital/nipple numbness. Other drugs may also cause lasting sexual dysfunctions, including SNRIs, finasteride (“Propecia”), and isotretinoin (“Accutane”). Starting or stopping these drugs may lead to symptoms similar to those of PSSD. These conditions are known as post-finasteride syndrome (PFS), post-retinoid sexual dysfunction (PRSD), and post-Accutane syndrome (PAS).

Note that other causes must be ruled out in order to be diagnosed with PSSD. This is because other conditions, such as depression, can cause some sexual dysfunctions, such as low desire or orgasm difficulties. However, if you did not have any sexual dysfunction until you started or stopped a drug, and the sexual dysfunction continued after stopping the drug, then it strongly suggests that the drug is the cause of your sexual dysfunction. Further, some symptoms (e.g., lack of sexual pleasure) are not a symptom of depression (or acne or hair loss) and therefore can’t be blamed on depression (or acne or hair loss). Note: Your healthcare provider may only be familiar with the definitions from the DSM-5, which include substance/medication-induced sexual dysfunction. However, some people have had a hard time getting their healthcare providers to believe that their persisting sexual dysfunctions are caused by medication, even though this definition exists.

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