Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Love and passion

Elaine Hatfield, Richard L Rapson


Scholars from a variety of academic disciplines (e.g., cross-cultural studies, history, psychology, sociology, neurophysiology, endocrinology) have started to explore the relationships of passionate love with sexual desire, sexual motivation, and sexual behavior. In this chapter, we will review historical and cultural forces that have shaped women’s sexual attitudes, sexual feelings, and sexual behavior. We will then discuss the impact of passionate love and other sexual motives on women’s sexual desire and pleasure.

Defining passionate and companionate love

Ahdat Soueif, an Arab novelist, described the multitude of meanings that the word love possesses in Arabic:

“Hubb” is love, “ishq” is love that entwines two people together, “shaghaf” is love that nests in the chambers of the heart, “hayam” is love that wanders the earth, “teeh” is love in which you lose yourself, “walah” is love that carries sorrow within it, “sababah” is love that exudes from your pores, “hawa” is love that shares its name with “air” and with “falling”, “gharm” is love that is willing to pay the price.1

Scholars and laypersons alike have distinguished between two kinds of love: passionate love (i.e., being in love) and companionate love (i.e., loving).2 Passionate love is a powerful emotional state. It has been defined as “a state of intense longing for union with another”.3 A union with another (i.e., reciprocated love) is associated with fulfillment and ecstasy, while separation (i.e., unrequited love) is associated with feelings of emptiness, anxiety, and despair.3 Companionate love is a far less intense emotion. It comprises feelings of deep attachment, commitment, and intimacy, and has been defined as “the affection and tenderness we feel for those with whom our lives are deeply entwined”.3 The Passionate Love Scale has long been used to tap the cognitive, emotional, and behavioral incidents of such longing for union.4

Historical and cultural factors influencing women’s sexual attitudes and behavior

Historical factors

It has been suggested by several social commentators that today women’s personal attitudes can lead to problems with sexual desire, sexual arousal, and sexual pleasure. Yet, the idea that throughout history (and today in many cultures) women have been taught that sex is evil, and have been warned not to allow their own passionate and sexual feelings to get out of control,3,5 suggests that historical factors are probably connected to sexual problems. Historically, in the West, women’s sexual attitudes were influenced by an ideology that viewed sexual pleasure as unimportant at best and as shameful at worst. (See the reviews of the historical factors that have influenced women’s sexual attitudes and behaviors in non-Western countries.8) Such notions have likely had strong negative impacts on sexual attitudes, sexual behaviors, and sexual function, both in the past and today.

Western literature abounds in tragic tales of lovers caught up in a sea of passion and violence (Orpheus and Eurydice, Daphnis and Chloe, Dido and Aeneas, Tristan and Isolde, Paolo and Francesca, Romeo and Juliet). While such stories are popular and widely enjoyed today, in the medieval world, religious, medical, and scientific authorities almost uniformly condemned such passion.3 The early Catholic Church, for example, decreed that all passionate love and sexual pleasure was sinful, whether or not couples were married. The Church urged Christians to be celibate. As Tannahill observed:

It was Augustine who epitomized a general feeling among the Church Fathers that the act of intercourse was fundamentally disgusting. Arnobius called it filthy and degrading, Methodius unseemly, Jerome unclean, Tertullian shameful, Ambrose a defilement. In fact there was an unstated consensus that God ought to have invented a better way of dealing with the problem of procreation.9

Until the eighteenth century, physicians generally assumed that masturbation and so-called excessive sexual activity are unhealthy. A pamphlet by Daniel Defoe, for example, warned about the pitfalls of sexual excess: “Whence come Palsies and Epilepsies, Falling-Sickness, trembling of the Joints, pale dejected Aspects, Leanness, and at last Rottenness, and other filthy and loathsome Distempers, but from the criminal Excesses of their younger times?”10

In addition to being suppressed for the aforementioned reasons, sexuality was probably also contained as there was less temptation to indulge in sexual acts in those days than there is today. Twelfth-century troubadours’ tales of courtly love defined love affairs as “pure” and “holy” relationships, never to be “tainted” by “crass” physical consummation.11 By contrast, the lives of commoners were, as Thomas Hobbes notes, “nasty, brutish, and short”. Stone5 points out that at the beginning of the Early Modern Period (1500-1700), most young men and women rarely encountered potential romantic partners who were very sexually appealing. People rarely washed, and had lice, bad breath, rotting teeth, and skin diseases. Women suffered from gynecologic problems (e.g., vaginal infections, ulcers, tumors, and bleeding), which made sexual intercourse uncomfortable, painful, or impossible. Men and women who engaged in sexual relations were likely to catch any number of venereal diseases. Furthermore, it is unlikely that men and women, plagued with malnutrition and exhaustion, often possessed the energy required to indulge in sexual “excess”.

Cultural factors

Cultural factors also make it difficult for many women to celebrate passionate love or to experience satisfying romantic and sexual relationships. Cross-cultural researchers argue that romantic love and women’s sexual pleasure are more valued in affluent, modern, egalitarian cultures than in traditional, patriarchal societies with strong, extended family ties.12-14 In modern, urban, egalitarian societies, it is often assumed that the healthy woman is one who experiences pleasurable sex. In more patriarchal cultures, this is not necessarily so. For the So woman of Uganda, for example, penetration is expected to be nonlubricated and painful; it is not surprising that the So have no word for female orgasm (although they do have a word for male ejaculation).15 In many African cultures, the customs of dry sex, salt cuts, and female genital mutilation further render the issue of female sexual pleasure irrelevant. In a culture in which women prepare themselves to pleasure their husbands by drying their vaginas with powdered stem and leaf mixed with water, wrapped in a nylon stocking and inserted into the vagina for 15 minutes before intercourse, the concept of “female sexual dysfunction” takes on a very different meaning than it holds in other parts of the world.15 In some African cultures, such as the Hausa of Nigeria, itching vulva, amenorrhea, dyspareunia (i.e., painful intercourse), infertility, and obstructed labor are all considered to be sexual dysfunctions that can be cured by making a “salt cut” on the anterior vaginal wall.15

In any multicultural society, women’s sexual attitudes are shaped by a variety of inconsistent cultural messages about sexuality.6,16 In recent years, globalization and the “women’s revolution” have had a profound impact on women’s sexual attitudes, desires, and demands.6 When passionate love is increasingly cherished, when women are no longer entirely dependent on the power of men, and when the ideal relationship is considered to be a committed, stable, and equitable one, more women come to seek sexual pleasure in their love relationships, to have a voice in how and when sexual relations occur, to admit to sexual dissatisfaction, and to seek solutions.

Social psychological perspectives

Passionate love, sexual desire, and sexual satisfaction

Recent research has shed some light onto the impact of passionate love on women’s sexual attraction and desire, sexual arousal, and sexual satisfaction. Social psychologists, neuroscientists, and physiologists have started to explore the links between love, sexual desire, and sexual function in both men and women. The first neuroscientists to study passionate love by functional Magnetic Resonance Imaging (fMRI) were Birbaumer and his colleagues,17 who, as a result of their research, concluded that passionate love is “mental chaos”. The neural bases of passionate love were recently studied by Bartels and Zeki.18,19 They interviewed young men and women from 11 countries and several ethnic groups who claimed to be “truly, deeply, and madly” in love and who scored high on the Passionate Love Scale.4 Bartels and Zeki 18 concluded that passionate love leads to a suppression of activity in the areas of the brain controlling critical thought. They argued that once an individual gets close to someone, there is less need to assess their character and personality, and thus there is less need to use the frontal lobe critical thinking. Passion also produced increased activity in the brain areas associated with euphoria and reward, and decreased levels of activity in the areas associated with distress and depression. Activity appeared to be restricted to foci in the medial insula and the anterior cingu- lated cortex, and, subcortically, to the caudate nucleus and the putamen, all bilaterally. Deactivations were observed in the posterior cingulated gyrus and in the amygdala, and were right- lateralized in the prefrontal, parietal, and middle temporal cortices. The authors concluded that the deactivation of networks used for critical social assessment allows individuals to become closer to their loved ones. They argued that this bonding is reinforced by the deactivation of negative emotions and the activation of the reward circuit. This hypothesis fits the observation that love motivates and exhilarates individuals.

Scientific investigations have also validated the link between passionate love and sexuality. Passionate love was found to be closely associated with sexual arousal,18 sexual desire,20,21 and sexual motivation.20,21

In parallel with this research, social psychologists, neurobiologists, and physiologists have started to explore the neural and chemical substrates of passionate love, sexual desire, and sexual mating.20,22-25 Questions that remain to be conclusively addressed include whether romantic and passionate love are emotions,26,27 and how passionate love, sexual desire, and sexual motivation are related as constructs.3,26,2 30

Companionate love, relationship quality and stability, and sexual satisfaction

There is considerable evidence that companionate love, in combination with a variety of factors traditionally thought to contribute to relationship quality and relationship stability, is an important determinant of dating and marital sexual satisfaction. This includes constructs such as affection, intimacy, commitment, the ability to communicate, and the fairness or equity of the relationship.3,31-34

Women are more likely than men to view romantic love, emotional intimacy, and commitment as prerequisites for sexual activity and are less likely to be receptive to casual sex.35,36 Men and women’s perceptions of the fairness and equity of their relationships have been found, for example, to be an important determinant of whom they choose for a sexual encounter, how sexual and satisfying their sexual relationships are, and how likely those relationships are to endure.37 Specifically, researchers have found that:

(1) The more socially desirable people are (i.e., the more physically attractive, personable, famous, rich, or considerate they are), the more socially desirable they will expect an “appropriate” mate to be.

(2) Dating couples are more likely to fall in love if they perceive their relationships to be equitable - that is, if they feel that they and their partners are receiving approximately what they deserve - neither appreciably more nor less than they deserve. They seem to care about fairness and equity in the personal, emotional, and day-to-day rewards involved in a relationship, as well as about the rewards one reaps from simply being in a relationship.

(3) Couples are likely to be romantically matched on the basis of self-esteem, looks, intelligence, education, and mental and physical health or disability.

(4) Couples who perceive their relationships to be fair and equitable are more likely to get involved sexually. When asked about the sexual intimacy of their relationships (e.g., necking, petting, engaging in genital play, intercourse, cunnilingus, and fellatio), couples in equitable romantic relationships tend to report more sexual involvement. In one study, it was found that couples in equitable relationships were generally having sexual relations; couples in inequitable relationships tended to stop before “going all the way”.

Partners have also been asked why they make love. Those in equitable affairs were most likely to say that both partners wanted to have sex. Couples in inequitable relationships were less likely to claim that sex had been a mutual decision; many partners felt pressured into having sexual relations in order to keep the relationship alive.

Perhaps it is not surprising, then, to discover that dating and married couples had more satisfying sexual lives if they were in equitable relationships than if they were not. (See a summary of this research.37,38 For a critique of this research, see Mills and Clark39).

Other motives for sex

Thus far, we have focused on one primary motive for sexuality - love. But love is not the only motive women have for engaging in sexual activities. As Levin40 observed in discussing men’s sexuality:

Coitus is undertaken not only for pleasure and procreation but also to degrade, control and dominate, to punish and hurt, to overcome loneliness or boredom, to rebel against authority, to establish one’s sexuality, or one’s achieving sexual competence (adulthood), or to show that sexual access was possible (to “score”), for duty, for adventure, to obtain favours such as a better position or role in life, or even for livelihood.

Recently, scientists have begun to investigate the impact of a variety of possible sexual motives on the sexual desire and behavior of women and men.3,41,42

In our own cross-cultural work, for example, we found that throughout the world, women assign a wide variety of meanings to passionate love and sexuality, and engage in sexual activities for a wide variety of reasons.43,44 The three reasons for having sex that are typically reported by women and studied by researchers are passionate love, procreation, and eroticism (i.e., the attainment of physical pleasure; recreational sex; “sport” sex).41 However, a multitude of other sexual motivations have also been cited, including the desire for spiritual transcendence, duty, conformity, fostering self-esteem and status, kindness, a desire to conquer/possess power over another, submission to others, vengeance, curiosity, money, fostering jealousy, the attainment of health and long life, stress reduction, a desire to save the world, and political revolt.43,45 Scientists are only beginning to study the wide variety of motives that may spark sexual desire and behavior. Nonetheless, the sparse research suggests that these rarely studied motivations may add appreciably to our understanding of women’s sexuality. For example, a series of studies showed that men’s and women’s desire for power may strongly affect their sexual behavior in that relationship. The desire to dominate or submit to a partner may motivate some sexual behaviors. These behaviors vary from the typical (e.g., kissing and sexual intercourse) to the more unusual (e.g., cross-dressing, sadomasochism, exhibitionism).45,46

Critical review of existing literature

The literature has shown a remarkable increase in studies on passionate love in the past four decades. Researchers from a variety of disciplines, such as social psychology, anthropology, evolutionary psychology, and neuroendrocinology, have directed their attention to questions concerning passionate love, sexual desire, and sexual behavior. Some strengths of recent studies on passionate love include the variety of methodologies employed (e.g., primate behavior and fMRI studies), the focus on the majority of women rather than only a few women from elite social classes, and the inclusion of demographic variables as potential mediators or moderators.

Research has yet to answer a number of questions concerning the origins of love and its relationship to sexuality. The evolutionary basis of passionate love is unclear, and it is still debatable whether passionate love is a culturally universal phenomenon. Passionate love and sexual desire have yet to be clearly defined in cognitive, emotional, or behavioral terms, and the distinction between passionate love and sexual desire is ambiguous. More work is also needed to understand the emotional and cognitive consequences of passionate love. Finally, understanding sex differences in the experience of passionate love and sexual desire may enlighten opinion on sexual relationships.


Throughout the world, globalization, the woman’s movement, increasing modernization, urbanization, and affluence have combined to produce more positive views of gender and sexual equality, of passionate love and sexual desire, and of love matches (as opposed to arranged marriages), and an increased acceptance of the notion that both men and women are entitled to satisfying sexual lives (see Hatfield and Rapson3 for a discussion of these issues). Increasingly, societies worldwide are rejecting the notion that passionate love and sexual desire, especially in women, are evil and ought to be punished.3 The increasing awareness of women’s rights to social power, equality, pleasure, and sexual satisfaction may well lead the women of this century to define female sexual satisfaction and sexual function in new ways. We are likely to see a growing emphasis on the importance of female sexual delight and satisfaction, thus suggesting that sexual problems and dysfunctions are something to be cured, not patiently borne.


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