Female Sexual Arousal Disorder (FSAD), now called Female Sexual Interest/Arousal Disorder (FSIAD), is characterized by a lack of motivation to engage in sexual activity and absent or significantly reduced sexual thoughts and fantasies.1 Studies show that over 40% of all females will experience some form of sexual dysfunction over their lifetime.2
Female sexual disorders can apply to people assigned female at birth or individuals who are taking estrogen therapy and recognized as females, nonbinary, or other genders.
What Is Female Sexual Arousal Disorder?
Those with FSIAD do not have interest in sex and are not sexually stimulated. This lack of interest can impact females at any age and despite their relationship status. A lack of interest in sex and sexual behaviors alone is not considered FSIAD—it would only be diagnosed when a females is unaroused during sexual activity or if there are feelings of stress or distress associated with the sexual activity.
FSIAD vs. Asexuality
Signs of Female Sexual Arousal Disorder
Little or no interest in engaging in partnered sex or masturbation may be a sign of FSAD if other issues aren’t the primary cause. A woman who has previously enjoyed sex and now finds that she is less likely to think about sex, initiate sex, be receptive to a partner initiating sex, or engage in solo sex may feel distress at these changes. This change in behavior may be due to other changes in life that are causing added stress.
People with FSAD may also experience significantly reduced pleasure when engaging in sexual activity, or arousal non-concordance (when their body physically responds but they are not feeling aroused). This can foment a cycle of sexual avoidance and stress around sexual interactions. If a woman anticipates that she will have difficulty enjoying sexual activity, she will be less likely to engage in sex. If she does engage in sexual activity, she is more likely to experience lack of arousal simply from the distraction and stress of anticipating that she will not be able to enjoy herself. This creates a self-fulfilling cycle of sexual dysfunction.
FSAD vs. Normal Shifts in Desire
Libido discrepancy between partners is common and female sexual arousal disorder differs from “not being in the mood.” Normative desire for females, in terms of engaging in or wanting sexual interactions, ranges from monthly to daily. Simply because one partner has more desire and is frustrated by the frequency of sexual interactions does not indicate that the partner with lower levels of desire has a problem.
However, when a woman has previously felt a higher level of desire, or experiences significant distress because she does not crave sex more frequently or intensely, then a lack of desire/arousal becomes problematic.
Symptoms of Female Sexual Arousal Disorder
FSAD is defined by a complete lack of or significant reduction in sexual interest/arousal. Medical conditions should first be ruled out prior to diagnosis.
The symptoms for FSAD include:1
- Absent or reduced interest in sexual activity
- Absent or reduced sexual thoughts or fantasies
- Absent or reduced initiation of sexual activity and lack of receptivity to a partner’s attempts to initiate
- Absent or reduced sexual excitement or pleasure in all (or almost all) sexual encounters
- Absent or reduced sexual interest or arousal in response to any internal or external cues
- Absent or reduced genital or non-genital sensations during sexual activity
When to See a Doctor
It may be time to see a doctor if you are concerned about your sexual arousal and it is impacting your life, lifestyle, or relationships. If you are having issues for longer than 1 to 2 months and have considered or tried psychotherapy and continue to have issues, it may be time to speak with a doctor. If you are feeling concerned about the health of your relationship, speaking with your doctor and working with a sex therapist who has experience with arousal disorders is a good next step.
Types of Female Sexual Arousal Disorder
There are three types of FSIAD:1
- Subjective: Not aroused by sexual genital or nongenital stimulation, such as kissing, watching an erotic video, or physical stimulation. They are physically aroused, but not mentally or emotionally aroused.
- Genital: Arousal occurs in response to nongenital stimulation, such as viewing an erotic video, but not in response to genital stimulation. This disorder typically affects postmenopausal people. Vaginal lubrication and/or genital sexual sensitivity is reduced.
- Combined: Arousal in response to any type of sexual stimulation is absent or low, and they report low or no physical genital arousal. They may have a need for external lubricants and may state they know that swelling of the clitoris no longer occurs.
What Causes FSAD?
Female sexual arousal is complex and not very well understood scientifically, as are the reasons for when desire/arousal dissipates. Typically there are multiple contributing factors to a reduction in desire which can be biological, medical, physical, or psychological.
Medical factors that can cause low arousal or desire in females include:
- Side effects of medications, including antidepressants such as SSRIs and oral contraceptives
- Hormonal fluctuations, including perimenopause and menopause
- Vascular and neurological problems, such as multiple sclerosis
- Recent surgeries
- Co-occurring medical conditions causing pain, tension, or significant physiological issues
Psychological factors that contribute to low arousal/desire in females include:
- Stress
- Abuse or trauma history, sexual or otherwise
- History of negative sexual experiences
- Sexual shame or cultural messages of sex negativity
- Body image issues
- Relationship longevity
- Relationship conflict or anxiety
- Lack of communication, affection, or emotional bonding with a partner
When Is Female Sexual Arousal Disorder Diagnosed?
Typically a short period of less than six months of reduced desire is not an indication to seek a diagnosis, as life stressors can occur that cause natural fluctuations in arousal. When symptoms persist for longer durations, this signifies that a sexual disconnect has become entrenched. Your primary care provider or OBGYN is a good place to start in exploring treatment options and for ruling out medical issues.
Treatments for FSAD
If you or your female partner is experiencing other symptoms and has significant distress at a lack of desire/arousal, seek help first through your primary care physician or OBGYN. They can help you to rule out physiological issues and refer you to other medical providers if necessary.
Medical Treatments
Common medical approaches for treating female sexual arousal disorder include:
- Hormone therapies, such as testosterone or estrogen patches, pills, or topical creams. These can be prescribed for both physiological arousal and psychological desire issues. These are most likely to be prescribed by a general practitioner, OBGYN, hormone specialist, or endocrinologist.
- Buproprion (Wellbutrin) is an antidepressant that can be prescribed as a substitute for or supplement to other antidepressants (SSRIs) believed to cause a decrease in sexual desire/arousal. This is most likely to be prescribed by a psychiatrist, psychiatric RN, or general practitioner.
- Flibanserin (Addyi), also called “female Viagra,” can be prescribed to increase female desire/arousal with limited effectiveness. This is most likely to be prescribed by a general practitioner, endocrinologist, or OBGYN.
Sex Therapy
Once physiological factors such as hormone levels and medical conditions have been assessed by a doctor, psychological issues are best addressed with a certified sex therapist (CST). Females with sexual dysfunction should be offered sex therapy in addition to any medical intervention they receive in order to achieve the most positive outcome for treatment.3
Common therapeutic approaches in sex therapy for treating low sexual desire/arousal include:
- Psycho-education about factors which lead to decreased desire/arousal
- Prioritizing time for sex/intimacy in a couple (or masturbation for an individual)
- Shift in the context for when/how sexual activity occurs
- Increasing agency/control in the sexual experience for low-arousal partner
- Conflict resolution and communication strategies for couples
- Reduction in goal oriented/orgasm focused sexual activities
- Increase in sensation/pleasure-focused sensual activities
- Sensation-focused exercises to cultivate awareness and improve communication for couples
- Mindfulness exercises to increase somatic awareness for individuals
Sex therapy can be sought as an individual who is experiencing sexual symptoms or as a couple impacted by lower desire/arousal in a female partner. A sex therapist will take a detailed sexual and psychosocial history to assess for psychological factors contributing to reduced sexual arousal.
The therapist will explore the onset and context of the symptoms being experienced, especially any changes in the situations or cues that have stimulated desire/arousal in the past. Co-occurring psychological conditions, such as mood disorders, will also be assessed and treated.
How to Get Help for FSAD
If you or your female partner is experiencing issues in arousal, you should first seek treatment through your primary care provider or OBGYN. They will be able to assess whether further medical treatment is indicated or referrals to other medical providers should be made. It is important to make sure that there are no underlying medical conditions, hormone imbalances, or side effects to current medications before treating the psychological components of low sexual arousal/desire.
Once medical factors have been addressed, seeking further treatment with a mental health practitioner is the next step. Even if the initial cause of Female Sexual Arousal Disorder (FSAD) is physiological, psychological factors are likely to develop as a result of desire disruption.
Finding the Right Sex Therapist
When a sexual dynamic has been disrupted, regardless of the underlying cause, avoidance of sexual interactions or anxiety about sexual intimacy often occurs. In order to adequately treat avoidance or anxiety cycles around sex, an AASECT certified sex therapist should be consulted. You can use an online therapist directory to search for a qualified sex therapist in your area.
“Sex therapist” and “sex therapy” are not protected terms, meaning that anyone can call themselves a sex therapist in their marketing. Additionally, most mental health licensure requirements contain little or no instruction in human sexuality. AASECT certified providers receive an additional 18-24 months of training and a minimum of 300 additional hours of supervision in sex specific psychological issues.4
How Much Does Sex Therapy Cost?
Typical rates for an AASECT certified sex therapist are on the upper end of private pay therapy rates in your area. Most sex therapists see individual clients for 45-60 minute sessions at rates between $120-$180 and couples for 75-90 minute sessions at rates between $190-$310. These rates may vary widely based on the availability of certified sex therapists in your area and on general mental health costs in your state.
What to Try at Home
Unlike many diagnoses, FSIAD is typically not a disorder based on medical factors that a woman has little or no control over. Once medical factors have been ruled out, treatment through sex therapy can be highly effective, and a sex therapist could give you many changes to try for yourself at home.
Use Lubricant
If the primary symptom you or your female partner experiences with FSIAD is insufficient lubrication, utilizing a personal lubricant that works well for you and/or your partner is an easy solution. Contrary to popular thinking, the amount of vaginal lubrication the female body produces may have nothing to do with a subjective experience of arousal. While adding lube to a sexual repertoire might not be ideal, there are many reasons why a woman may have vaginal dryness and still be able to experience subjective arousal.
Be Patient
An important outlook in approaching treatment for any sexual dysfunction is patience. Unhealthy dynamics around sex and sexuality develop over months or years and usually take significant time to explore and dismantle. Allow for six months to a year of proactive treatment before expecting to see major changes in a sexual dynamic.
Change Up Your Sex Habits
Also crucial in treating sexual dysfunction is letting go of an ideal sexual rhythm that you or your partner would like to “get back to.” You are more likely to find satisfaction and connection in your sexual experiences by evolving into a new pattern of interactions than by trying to return to a sexual dynamic that no longer exists.
New interactions may include engaging in sensual touch before sexual arousal is experienced in order to cultivate the context for pleasure and sexuality. Reducing the emphasis on genital focused play and eliminating the goal of orgasm can also help expand what sex and pleasure look like for a couple or individual.
Women are more likely to have context-dependant, or “responsive,” desire, meaning that arousal does not happen without foreplay, toys, dirty talk, erotic literature, visual cues such as pornography, or anything else that helps get into a sexual mindset and body awareness.
Create a Relaxing Environment
Distractions such as work deadlines, kids in the other room, dishes in the sink, bills to pay or anything else that feels stressful are important to alleviate or set aside before expecting that arousal can be cultivated. Consider what you and/or your partner can do to create a relaxing and pleasurable context for sexual interactions before jumping into old routines and expecting more satisfying results.
Female Sexual Arousal Disorder vs. Other Sexual Disorders
FSAD is one of many female sexual disorders that may appear alongside or separate from other sexual issues. Symptoms for Female Sexual Arousal Disorder do not include any pain related to sex, although those problems may also occur. It is important to differentiate these diagnoses in order to seek out appropriate treatment.9
FSAD vs. Hypoactive Sexual Desire Disorder (HSDD)
Prior to 2013, Female Sexual Arousal Disorder (FSAD) was listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This diagnosis was differentiated from Hypoactive Sexual Desire Disorder (HSDD) by whether the issue was disinterest in sex or in physiological arousal. Female Sexual Arousal Disorder (FSAD) was diagnosed based on an inability to maintain sufficient lubrication during sexual activity whereas Hypoactive Sexual Desire Disorder (HSDD) was characterized by a lack of interest in sex and an absence in sexual thoughts and fantasies.
FSAD vs. Female Sexual Interest/Arousal Disorder (FSIAD)
In 2013 when the DSM-5 was released, FSAD and HSDD were merged into Female Sexual Interest/Arousal Disorder (FSIAD). Researchers had found that the separation between diagnosing desire and arousal issues among women may be based on artificial criteria. Since there was also a high comorbidity between desire and arousal issues, criteria was merged for purposes of both clarity and accuracy, with the hope that more women could be diagnosed and treated effectively.
Female Sexual Interest/Arousal Disorder (FSIAD) vs. Female Orgasmic Disorder (FOD)
The cluster of symptoms included in FSIAD do not address whether orgasm is easy or difficult to achieve once sexual interactions begin. Female Orgasmic Disorder (FOD) is a commonly co-occurring disorder with FSIAD, wherein a woman will rarely or never be able to reach orgasm, even if she is sexually aroused.
Female Sexual Interest/Arousal Disorder (FSIAD) vs. Genito-Pelvic Pain/Penetration Disorder (GPPPD)
The symptoms of FSIAD do not address whether any pain is experienced during sex. Genito-Pelvic Pain/Penetration Disorder (GPPPD) is a commonly co-occurring disorder with FSIAD. GPPPD is a diagnostic umbrella for conditions which may also be diagnosed as Dyspareunia (pain during sexual penetration), Vestibulodynia (a more specific diagnosis denoting superficial sexual pain experienced at the “vestibule”), or Vaginismus (vaginal muscle spasm). The decision in the DSM-5 to merge these diagnoses was based on the conclusion that they could not be reliably differentiated.
Female Sexual Interest/Arousal Disorder (FSIAD) vs. Female Sexual Dysfunction (FSD)
Female Sexual Dysfunction (FSD) is an overarching term inclusive of Female Sexual Arousal Disorder (FSAD), Female Sexual Interest/Arousal Disorder (FSIAD), Hypoactive Sexual Desire Disorder (HSDD), Female Orgasmic Disorder (FOD) and Genito-Pelvic Pain/Penetration Disorder (GPPPD).
Common Co-Occurring Disorders
Other commonly co-occurring psychological conditions which can cause or interact with sexual dysfunction include:
- Major Depressive Disorder
- Persistent Depressive Disorder (Dysthymia)
- Cyclothymic Disorder
- Premenstrual Dysphoric Disorder
- Generalized Anxiety Disorder
- Panic Disorder
- Social Phobia
- Obsessive Compulsive Disorder
- Post-traumatic Stress Disorder
Statistics About Female Sexual Arousal Disorder
Female Sexual Arousal Disorder has typically been studied alongside other commonly co-occurring female sexual issues and overlapping diagnoses, such as Hypoactive Sexual Desire Disorder (HSDD), Female Sexual Interest/Arousal Disorder (FSIAD), Female Orgasmic Disorder (FOD) and Genito-Pelvic Pain/Penetration Disorder (GPPPD). The umbrella term for studying these conditions is Female Sexual Dysfunction (FSD).
A 2016 review and meta-analysis of 95 observational studies on Female Sexual Dysfunction (FSD) revealed substantial heterogeneity among the studies reviewed. Results showed that 41% of premenopausal women around the globe experienced some FSD. This included a 20.6% prevalence rate for Female Sexual Arousal Disorder (FSAD) as defined by lubrication difficulties and 28.2% prevalence rate for Hypoactive Sexual Desire Disorder (HSDD).2
An older and often cited analysis of data in 1999 from the National Health and Social Life Survey revealed that sexual dysfunction among U.S. women was reported at 43%, results similar to the global meta-analysis from 2016.5
While the high numbers of women who may be experiencing sexual dysfunction are disheartening, statistics regarding the efficacy of psychological interventions for sexual dysfunction are hopeful. A 2013 meta-analysis of all available studies from 1980 to 2009 revealed that psychological interventions were shown to especially improve symptom severity for women with Hypoactive Sexual Desire Disorder (HSDD) and Female Orgasmic Disorder (FOD).6
Less hopeful, perhaps, is a 2018 meta-analysis of pharmacological treatment for Female Sexual Dysfunction (FSD), including neuromodulators, hormonal agents and onabotulinum toxin A, which revealed that 67.7% of the treatment effect could be accounted for by placebo. This emphasizes the ongoing need for more efficacious medical treatment for Female Sexual Dysfunction (FSD) and indicates that psychological interventions are a relevant adjunct to any medical care for these conditions.7
Studies show that mindfulness-based sex therapy has particularly positive outcomes for Female Sexual Dysfunction (FSD). In a study conducted in 2017, participants in mindfulness-based sex therapy reported significant improvements in sexual desire, sexual function, and sex-related distress. A meta-analysis of the study found evidence that mindfulness-based sex therapy was effective for treating female sexual dysfunction.8
