Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Prevalence data in Europe

Axel R Fugl-Meyer, Kerstin S Fugl-Meyer

This chapter is intended to provide an up-to-date, evidence- based overview of the European epidemiology of female sexual dysfunction since the mid-1980s. Descriptive and analytic female sexual dysfunction literature was identified through searching conventional databases, books, literature surveys1-3 and references. The literature was evaluated for validity with the 15-item (scores: yes - 1; no - 0; maximum 15) checklist suggested by Prins et al.4 Our criterion for inclusion in this chapter was a score of at least 8. In the text, Prins (P) scores are given in parentheses. Table 2.2.1 should give the reader pertinent characteristics of the majority of the selected descriptive epidemiologic studies. Four are from the UK,5-11 four from the Nordic countries,12-18 one from France,19,20 one from Germany,21 and one a recent multicountry investigation.22

One must first ask an ontologic question: are there female sexual dysfunctions? In Europe, it has been suggested that female sexual dysfunction is an invention which, through med- icalization, paves the road for drug companies.23,24 We think that this suggestion is a caricature. However, several indices for classifying female and male sexual dysfunctions appear rather tailor-made for certain clinical trials. Quite clearly, adherence solely to a biologic model of women’s sexual response imposes physiologic restrictions on definitions. It has been suggested that female sexual dysfunction may best be conceptualized as a global inhibition of sexual response due to intrapersonal factors,25 because many cases of female sexual dysfunction can be regarded as adaptations to sexual relationship problems.26 In other words, female sexual dysfunction must be seen in a multifaceted socio-psycho-biologic context.

Widely different definitions, mostly following the very medicalized International Classification of Impairments, Disabilities, and Handicaps (ICIDH)27 or the Diagnostic and Statistical Manual of Mental Disorders, third and fourth editions (DSM-III or -IV),28 make valid comparisons of different investigations difficult. In fact, Dunn et al.3 found that meta-analyses are currently meaningless to perform. Another problem is the scaling of the severity of sexual dysfunctions. While some investigators use the dichotomy of dysfunction versus no dysfunction, others use scales with 3-6 gradations, which then may be reduced to 2-4 classes of function/dysfunction. A further problem is the different age strata studied, and even the time-frames for the dysfunctions vary from lifetime, through parts or periods of 1 year to the current situation. It is hardly surprising, therefore, that an international committee29 recently recommended international consensus on definitions and classification of sexual dysfunction.

Table 2.2.1. Some methodological details of reasonably valid European descriptive epidemiologic investigations of female sexual dysfunction

Country and ref

Method I/T/Q R/N Scale steps

Performed/

published

Time frame

Age (years)

Respondent (response rate)

Validity (Prins score)

UK5

I, R, 5

NG/1988

1 year

35-59

436 (72%)

12

UK6

I, R, 2

1993/1997

2 years

>55

2011 (61%)

10

UK 7-9

Q, NG, 2

1996/1998-2000

Current

18-75

657 (33%)

10

UK10,11

T, N, 2

1999-2001/2003

1 or 6 months last year

16-44

NG (65%)

12

France1920

T, N, 4

1991-2/1998

Lifelong

18-69

1137 (70%)

11

Germany21

I, R, 2

2002/2004

1 year

30, 45, 60

278/(?)

9

Iceland13

I, N, 2

1987-8/1993

Lifelong

55, 57

417 (75%)

14

Denmark14

Q, N

NG/1998

Current

18-88

686 (55%)

8

Sweden12,15-17

I, N, 6

1996/9-2004

1 year

18-74

1335 (59%)

14

Finland18

I, N, 6

1992/1995

1 year

18-74

1146 (78%)

13

Northern Europe22

T, N, 4

NG/2004

At least 2 months last year

40-80

1741 (?)

9

Southern Europe22

T, N, 4

NG/2004

At least 2 months last year

40-80

1753 (?)

9

I: person-to-person interview; N: nationally representative; NG: representativity not given; Q: mailed questionnaire; R: regionally representative; T: telephone interview.

Prevalence

The prevalence of female sexual dysfunction in Europe, as reported in reasonably valid descriptive investigations, can be seen in Table 2.2.2, where, as far as possible, the definitions of Basson et al.30 are followed. For some (total) populations, it has been possible to classify different female sexual dysfunctions as manifest (occurring at least quite often) or mild (occurring sporadically) as suggested elsewhere.17,29 The authors are, however, aware of the three-grade (mild, moderate, or severe) classification developed in the USA.

Sexual interest/desire

It must first be emphasized that sexual desire cannot readily be distinguished as an entity, as desire and the psychologic aspects of sexual arousal are confluent. Table 2.2.2 shows that a manifestly low level of sexual interest prevails in 10-51% of subjects. The use of different age strata is problematic in comparing the data on low sexual interest. In several countries, there is a clear decline in sexual interest at or above the age of 60. One example of the impact of different time frames was found by Mercer et al.,11 who, when studying relatively younger women, found that a 6-month prevalence of 10% increased to 41% when the question covered a 1-month period during the past year.

The German21 prevalence of low sexual interest appears exceedingly high, increasing from about 40-50% in 30- and 45- year-old women to 86% by the age of 60. On the other hand, in Sweden17 (1-year time frame), 54% reported mild dysfunction in sexual interest in addition to the 33% with manifest dysfunction.

The reader can also find large variation in dysfunction of sexual desire, sometimes, unfortunately, labeled “libido”, ranging from a maximum, age-dependent 35% (1 year) prevalence in Finland to 8% (lifetime) in France, where 55% reported mild desire dysfunction. In a Nordic country, the ratio desire/interest (Table 2.2.2) was about 0.3-0.4 for the age span 18-49, increasing to 0.8-0.9 for those age 50 and above. This indicates that at least up to a relatively advanced age, the dysfunctions of sexual interest and desire are, to some extent, separate entities.

Arousal/lubrication

We have found no study that distinctly separates genital from psychologic arousal or explicitly combines these. In Icelandic women in their mid-50s, low level of (lifetime) sexual excitation was reported by as little as 6%, as defined by DSM-III, while Dunn et al.7 found that 17% of their 18-75-year-old British women currently had arousal dysfunction.

Insufficient lubrication generally appears to occur in about 10-15% of adult European women, peaking around levels of 25-35% after the age of 50. Additionally, nearly half of Swedish women aged 18-74 years have mild lubrication dysfunction. In a regional Nordic questionnaire study, however, investigating the prevalence of genitourinary and other climacteric symptoms in 61-year-old women (P:10), Stenberg et al.31 found that 43% had “trouble with” vaginal dryness.

Orgasm

Even the prevalence of manifest orgasmic dysfunction varies quite considerably within and between different geographic areas, and may or may not be age dependent. While the overall prevalence of orgasmic dysfunction occurring frequently or periodically in an area labeled “northern Europe” (i.e., Austria, Belgium, Germany, Sweden, and the UK) has been found to be 10%, it has been reported in “southern Europe” (i.e., France, Italy, and Spain as well as Israel) to be 17%.22 In one regional British investigation,5 16% of 35-59-year-old women had orgasmic dysfunction, ranging from 5% in those aged 35-39 to 35% in 55-59-year-olds. In another report from that investigation32 covering the same 3-month period, however, clearly higher age- dependent results emerged, the overall prevalence being 38% (range 19-68%). In addition, 45% of the total sample achieved orgasm in half or less of their sexual intercourse encounters, classified here as mild dysfunction. The percentages of mild dysfunction in France (lifetime) and Sweden (12 months) were 44% and 60%, respectively, yielding totals of orgasmic dysfunction of 82% in the Swedish and 55% in the French women. The prevalence of manifest orgasmic dysfunction reported by Hawton et al.32 is overshadowed only by that in the German21 regional investigation.

While the (lifetime) prevalence of manifest dysfunction in France and the UK is approximately the same rate as that found in the pan-European investigation,22 higher 1-year prevalence has been ascertained (age independent) in 17-29% of Swedish and British women.7 Anorgasmia, one category of orgasmic dysfunction, was found to have a prevalence of less than 10% in Iceland and Denmark. Hence, the prevalence of orgasmic dysfunction appears to vary so widely that at the moment there is no conclusive evidence. In a small but extremely well-defined (P:14), regionally representative investigation of women in Denmark, Eplov33 found that 33% of women at the age of 40 had a relatively low level of desire. Twenty years later at age 60, this was the case for 37%. At this time, 50% reported no change in desire, while more frequent or less frequent desire was reported by 25%, respectively. At age 40 and again 20 years later, 16% rarely or never experienced orgasm. Even mild orgasmic dysfunction was similar at ages 40 and 60 (65% and 69%, respectively).

Table 2.2.2. Prevalence of manifest female sexual dysfunction as reported in valid descriptive epidemiologic European investigations. When possible, prevalence of mild (sporadically occurring) dysfunctions for total samples are given (in parentheses)

Country

Age cohorts

Interest (I) Desire (D) MaD (MiD)

Lubrication MaD (MiD)

Orgasm MaD (MiD)

Dysparuenia MaD (MiD)

Sexually

satisfied

UK5

35-59

I. 17%

17%

16%

8%

-

 

35-39

4%

8%

5%

0%

-

 

40-44

8%

12%

8%

1%

-

 

45-49

16%

16%

1 4%

9%

-

 

50-54

29%

26%

22%

17%

-

 

55-59

28%

22%

35%

17%

-

UK6

55-84

-

8%

-

2%

-

 

55-64

-

11%

-

3%

-

 

65-74

-

7%

-

1%

-

 

75-84

-

7%

-

< 0.5%

-

UK7-9

18-75

-

28%

27%

18%

75%

UK1071

16-44

I: 10%(a)

3%

4%*

-

-

   

41%(b)

9%

14%*

   

France1920

18-69

D: 8% (55%)

-

11% (44%)

5% (43%)

48%

Germany21

30, 45, 60

I: 51%

-

38%

14%

32%

 

30

50%

-

38%

16%

-

 

45

42%

-

33%

8%

-

 

60

86%

-

61%

26%

-

Iceland13

55, 57

D: 16%

-

4%*

3%

-

Denmark14

18-88

D: 11%

-

7%*

3%

67%

 

18, 23

6%

-

11%

3%

65%

 

28, 33

13%

-

9%

4%

55%

 

38, 43

17%

-

7%

4%

68%

 

48, 53

14%

-

6%

5%

67%

 

58-88

10%

-

3%

1%

63%

Sweden1913-17

18-74

I: 33% (54%)

13% (49%)

22% (60%)

6% (33%)

56%

   

D: 14%

       
 

18-24

I: 21% D: 8%

11%

27%

6%

59%

 

25-34

I: 37% D: 11%

10%

24%

6%

60%

 

35-49

I: 29% D: 8%

6%

17%

4%

57%

 

50-65

I: 41% D: 32%

24%

22%

8%

52%

 

66-74

I: 47% D: 44%

26%

19%

12%

47%

Finland18

18-74

D: 35%

15%

-

7%

83%

 

18-24

15%

8%

-

9%

-

 

25-34

26%

10%

-

5%

-

 

35-44

21%

9%

-

1%

-

 

45-54

29%

16%

-

4%

-

 

55-64

51%

35%

-

1 9%

-

 

65-74

55%

34%

-

27%

-

Northern Europe22

40-80

I: 17%

13%

10%

6%

-

Southern Europe22

40-80

I: 21%

12%

17%

9%

 

MaD: manifest dysfunction; MiD: mild dysfunction. (a) denotes 6-month and (b) 1-month prevalence; * denotes anorgasmia

Dyspareunia

Manifest genital pain at intercourse is also reported by a large range of women. In the UK (Table 2.2.2), two investigations have found the overall prevalence to be less than 10%. This is reasonably consistent with most European epidemiologic studies. In a well-defined, subarctic sample (P:12) of 3024 women aged 20-60, Danielsson et al.34 found the prevalence of manifest dyspareunia to be 13% in those aged 20-29, with a nearly linear decrease over age cohorts down to 7% of those aged 50-60 years. In contrast, the Finnish study showed an increase in prevalence of dyspareunia at about the age of 55.

Overall, high prevalence of about 14-18% has been found in Germany,21 in the UK,7 and in yet another Swedish investigation.31 Again, methods and definitions may play a role here, as mild dyspareunia has been found to prevail in 43% of French (lifetime) and in 33% of Swedish (1-year) nationally representative women.

Vaginismus is a rare condition. According to the only European epidemiologic study of which we are aware,17 the prevalences of mild (occurring sporadically) and manifest (occurring at least quite often) vaginismus are 5% and 1%, respectively. This seems to agree with the only other truly epidemiologically anchored investigation of vaginismus, in which Kadri et al.35 found the prevalence in Morocco to be 6%.

In conclusion, it appears that there is a clear lack of investigation on female sexual dysfunction by common methods of sampling, definition, classification of severity, and time-frame. Moreover, while there are a series of reports from western and northern European countries, there is a paucity from the southern and eastern parts.

Different sexual dysfunctions quite often occur together. For example, manifest orgasmic dysfunction in 18-74-year-old women is accompanied by manifestly low levels of sexual interest in 53% of Swedish women and 28% have insufficient lubrication. Indeed, in univariate analyses, all female sexual dysfunctions are significantly (p <0.001) associated.16 In addition, at least in Sweden, all female sexual dysfunctions are significantly associated with partner’s erectile and ejaculatory dysfunctions.

The incidence of female sexual dysfunction in Europe is very sparsely studied. In the Finnish18 and Swedish16 studies, women aged 18-74 reported a 5-year incidence rate of decreased desire in the order of 40-45%. In both countries, as might be expected from the increasing prevalence of low level of desire, this incidence increased with age. The incidence rate of prolonged and severe dyspareunia in Sweden in 199834 (P:12) was inversely related to age, being 4.3 per 100 women-years for 20-29-year- olds and then successively decreasing to 2.3 and about 1.0 for age cohorts 30-39 and 40-49, respectively, down to 0.5 for those aged 50-60 years.

How distressed?

There are only a few valid epidemiologic studies on the prevalence of distress accompanying female sexual dysfunction. In the mid-1990s, a pan-European (Denmark, France, Germany, Italy, the Netherlands, and the UK) investigation36 (P:10) found that 3.4% of women aged 55-64, compared with 0.9% of those aged 65-75, felt that dyspareunia was “an irritating problem”. It appears that only one other epidemiologic investigation17 has discussed the prevalence of distress caused by female sexual dysfunctions per se. Manifest dyspareunia was, as shown in Table 2.2.3, accompanied by manifest personal distress for the vast majority of sexually active 18-65-year-old women. Much the same was the case for lubrication insufficiency. Manifest dysfunctions of sexual interest and orgasm were clearly less frequently (about 45%) followed by manifest distress. Moreover, Table 2.2.3 shows that about 90% of all manifest female sexual dysfunctions lead to some degree of distress. Slightly more than half of those with mild female sexual dysfunction experienced distress, although this was nearly exclusively mild.

Table 2.2.3. Prevalence of manifest and mild sexual dysfunctions (per se) and distress caused by them

 

Dysfunction (per se)

Dysfunction is distressful Manifestly/mildly

Sexual interest

Manifest (29%)

47%/40%

 

Mild (60%)

2%/54%

Lubrication

Manifest (12%)

61%/28%

 

Mild (50%)

1%/57%

Orgasm

Manifest (22%)

44%/40%

 

Mild (60%)

1%/60%

Dyspareunia

Manifest (5%)

72%/20%

 

Mild (34%)

2%/60%

How satisfied?

The level of sexual satisfaction varies widely across and within European countries. Thus, in the UK, one study found that, independent of age, 75% of women aged 18-75 years were satisfied with their current sex life. In clear contrast, an investigation of 16-44-year-old British women found that less than half were satisfied (Table 2.2.2). Two Scandinavian studies have revealed that about half (Sweden) and up to two-thirds (Denmark) of sexually active women are satisfied or very satisfied with their sex life. Although some female sexual dysfunctions increase at age 50 and higher, the proportion of sexually satisfied women apparently does not decrease appreciably as a function of (higher) age.

As previously pointed out, all female sexual dysfunctions per se are closely associated with each other and with the women’s perception of the partner’s sexual dysfunctions. Relating overall sexual satisfaction univariately to any particular dysfunction therefore appears to be quite a strongly contaminated measure. Logistic regression17 found that the likelihood (odds ratio: OR) of distressful lubrication insufficiency being associated with overall sexual dissatisfaction (as opposed to satisfaction) was 1.3. Distressing orgasmic dysfunction and dys- pareunia lead to four- and fivefold greater likelihood of being sexually dissatisfied. In Sweden,16 the (adjusted) risk of not being overall sexually satisfied is about five- to sixfold greater if the woman has distressingly low levels of sexual interest or orgasmic dysfunction and threefold greater with lubrication insufficiency, while distressful dyspareunia and vaginismus (i.e., pain syndromes) did not contribute significantly to this logistic regression model.

And the risks?

We shall address first the somatic risks of female sexual dysfunction, then partner relationship factors, and finally other psycho- socio-demographic risk factors. Generally speaking, less than good health - as experienced by the woman - has been shown by some, although not all, authors to have a negative significant effect on different parameters of female sexual function.

Urogenital conditions

In an Austrian investigation (P:11) of 159 gynecologic or urog- ynecologic patients,37 the prevalence of female sexual dysfunction was about 50%, and no age dependency was found. The only remarkable discrepancy from most descriptive epidemiologic investigations was a quite high prevalence of dyspareunia (24% in the gynecologic and 18% in the urogynecologic groups). In women treated for early cervical carcinoma (stages IB-IIA), Bergmark et al.,38 covering the total Swedish population (P:13), reported that after treatment (different modalities), 25% had manifestly increased level of distress with low sexual interest, while 20% became distressfully dyspareunic and about 30% reported distress due to lubrication insufficiency and orgasmic dysfunction, respectively. In this context, it appears relevant to mention that Mannaerts et al.,39 in a small Dutch series (P:10) of patients treated with high-dose, external radiotherapy plus surgery with intraoperative radiotherapy found that in 50% of the women treated the preoperative ability to reach orgasm had disappeared at follow-up.

We have not been able to locate any conclusive European evidence on the effect of hysterectomy on sexual life. Other than a beneficial effect on dyspareunia (from 50% preoperatively to 10% at follow-up), it appears that the quality of postoperative sexual life is primarily determined by preoperative sexual factors.40

Recently, an (P:14) Italian investigation41 of women with lower urinary tract symptoms (LUTS) and/or incontinence found that they had significantly more dysfunctions of desire and lubrication and more dyspareunia than controls. In Denmark42 (P:12), lower urinary tract symptoms have been found to be an independent risk factor for “sexual dysfunction” in 40-65-year-old women. The impact of urinary incontinence on the prevalence of female sexual dysfunction has been surveyed internationally by Shaw,43 who found impairment in sexual function to range from as low as under 1% to 64%. However, in the UK,5 stress urinary incontinence has been identified as a risk factor for sexual interest, desire, “arousal”, lubrication, orgasm, dyspareunia, and even vaginismus. In a small-scale, retrospective Swedish study of 44 women aged 34-62 years,44 stress incontinence appeared to lead to reduction in lubrication (55%), orgasmic dysfunction (39%), and dyspareunia (33%), while 64% of women were sexually satisfied. One year after surgery, hardly any changes were detectable.

Cardiovascular conditions

In France, in a prospective study of 142 women treated with antihypertensive drugs (response rate: 74%; P:9), Hanon et al.45 found that 41% had a decreased level of interest. Compared with male peers, however, women had less sexual dysfunction. In the UK,7 use of antihypertensive medication was likely to be accompanied to a significant degree (OR: 0.3) by orgasmic dysfunction.

In Belgian women with type I diabetes mellitus, Enzlin et al.46 (P:10) concluded that insufficient lubrication, orgasmic dysfunction, and dyspareunia were almost twice as prevalent in women with diabetic complications than in those without.

Neurologic conditions

Although there is a group of publications on the impact of neurologic conditions on the sexual function of European women, none seem to be adequately epidemiologically anchored for citation under evidence-based circumstances.

Partner relationship

Single women are more likely to have female sexual dysfunction (manifest low level of sexual interest, insufficient lubrication, orgasmic dysfunction, and dyspareunia) than women who have a steady partner. On the other hand, in 18-24-year-old women, the relationship duration has been demonstrated to influence sexual interest negatively.12 In a heterosexual student population of German women aged 19-32, Klussmann47 (P:11) found a significant decline in sexual interest if the duration was over 3 years.

The quality of the relationship is a major predictor of several sexual dysfunctions. A poor quality is more likely (logistic regression) to occur with women who have manifestly distressing dysfunctions of sexual interest (OR: 5.6), lubrication (OR: 4.0), and orgasm (OR: 4.5), and twice as likely to prevail in women with mildly distressing dysfunction of sexual interest (OR: 2.2).48 In the UK, marital difficulties are very likely to be accompanied by arousal problems (OR: 6.8) and orgasmic dysfunction (OR: 5.1).8 Moreover, “northern European” women who worry about the future of their partner relationship are nearly three times more likely than those who are optimistic to have lubrication dysfunction, while “southern European” women have a higher likelihood of having dyspareunia.22

Probably the greatest risk factors for distressful female sexual dysfunction within a stable heterosexual relationship are the male partner’s sexual dysfunctions. Thus, if the partner has erectile dysfunction, there is a more than a 30-fold greater risk of the women having a mildly or manifestly distressing low level of sexual interest. If the partner has delayed ejaculation, the risk of the woman’s having manifest or mild lubrication dysfunction is high (OR: 18.2 and 7.7, respectively). Erectile dysfunction and early ejaculation are also very sizeable predictors for women’s capacity to reach orgasm. ORs for erectile dysfunction and early ejaculation being associated with manifestly distressing orgasmic dysfunctions are about 14 and 4, respectively; while ORs for these two male dysfunctions as predictors of mildly distressing orgasmic dysfunctions are about 3.5.48 In the Czech Republic, Raboch and Raboch49 (P:8) found in 21-40- year-old women significant (univariate) associations between distressful orgasmic dysfunction (as opposed to nondistressful) and husbands’ “weak sexual desire” or “weak sexual potency”.

Psychiatric/psychologic conditions

There is clear evidence that mood disorders influence sexual functions negatively. In the UK,8 significant ORs (1.8-4.5) linked depression and anxiety to dysfunctions of arousal, lubrication, orgasm, and dyspareunia. In both northern (OR: 2.2) and southern Europe (OR: 1.7), depression was significantly linked to lack of sexual interest, and in “southern Europe” to lubrication (OR: 1.8) and orgasm (OR: 1.6) dysfunctions as well.22 In a prospective investigation of Spanish women and men treated with selective serotonin reuptake inhibitors (SSRI), Arias et al.50 clearly identified increased risks of “sexual dysfunctions” for both genders, but significantly more so for men than for women.

Lifetime sexual abuse is a sizeable negative predictor for current sexual dysfunctions. Thus, Swedish women51 who have ever been sexually abused have a significantly higher number of sexual dysfunctions than the nonabused, and sexual abuse is a strong predictor of later manifestly distressing orgasmic dysfunction (OR: 4.3).

It has been reported from the Czech Republic49 that women who lost a parent early in life, who had three or more siblings, or who had an unhappy childhood to a significant degree (p <0.01) had a high frequency of distressful orgasmic dysfunction. Among a wealth of sociodemographic variables studied in northern and southern Europe22 and Sweden,50 relatively few have emerged as significant predictors of female sexual dysfunction. In northern Europe, “belief in religion guiding sex” is positive for orgasmic function (OR: 2.3), while such a belief is negative for southern European women’s lubrication function (OR: 0.6).22 As might be expected, having young offspring living at home is associated with distressful dysfunction of sexual interest.50 In northern Europe, relatively low educational level appears22 to constitute a risk factor for lubrication and orgasmic dysfunctions, and to some extent for having dyspareu- nia. This has not been found in Sweden.50 In contrast to erectile dysfunction,29 smoking has not been found to influence women’s sexual function negatively.

Treatment seeking

Do women with female sexual dysfunction seek professional help? Across European investigations, the proportion of women who have at least one manifest female sexual dysfunction is 3555%. It must be remembered, though, that female sexual dysfunctions, in particular, low interest and distress caused by female sexual dysfunctions, are far from congruent categories.

For example, while 47% of all women aged 18-74 in a Nordic country have at least one manifest female sexual dysfunction, 24% feel that this is accompanied by manifest personal distress (the corresponding proportions for men are 23% and 13%) - still impressive numbers at the population level. However, only a small fraction of the manifestly distressed women (16%) had sought professional help during the last year; most frequently from gynecologists/midwives.52 In the UK,8 39% of women from a regionally representative sample aged 18-75 wished to receive help for “sexual problems”, but only 8% of these had sought help, most commonly from general practitioners (GPs). In another recent British nationally representative investigation of 16-44-year-old women, 21% with female sexual dysfunction had sought help, usually from their GP.11 The big question is, to what extent is society prepared to meet the demands for sexual medicine/sexology consultation even if just half of those with manifestly distressing female sexual dysfunction would actually seek any kind of professional help?

The problem of the ontology of female sexual dysfunction may, therefore, simply be a semantic one. As pointed out by Bancroft et al.,53 the term “dysfunction” is defined by the dictionary as “malfunctioning, as of a structure of the body”. Consequently, several years ago, we12 argued in favor of substituting “dysfunction” for “disability”, denoting incapacity to reach (sexual) goals. This definition was discussed by the definitions committee of the World Health Organization,29 but was discarded, as it might confuse existing concepts.

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