The Female
Sexual Response
Rosemary Basson, MB, BS, MRCP
Clinical Associate Professor
UBC Departments of Psychiatry and
Obstetrics & Gynaecology.
Sexual Medicine Consultant at
VHHSC Centre for Sexuality.
Gender Identity & Reproductive Health.
Vancouver. BC
KeyWords
Female sexual response. intimaey. stimuli
Received on September 9th. 1999.
Revised and accepted on March 6th. 2000.
Revisited
Abstract: indieators of healthy sexual desire in women and men have traditionally been the
presenee of sexual thoughts and sexual fantasies. and an urge from within the person to
self stimulate or be sexually aetive with a partner. This has led to an apparent prevalenee
of low sexual desire in so me 33% of women in eommunity sampies. The need for a dif-
ferent understanding of women's sexual desire is evident. Similarly, a widespread but rather
limited view of women's sexual arousal as being equivalent to vaginal lubrication has pre-
eluded effeetive understanding and management of women's arousal diffieulties. The major
foeus on genital reflexes in our definitions of dysfunetion has stemmed from viewing the
human sexual response eyele (with a range of orgasmic release possible for women) depiet-
ed by Masters and Johnson and later expanded by Kaplan as the only sex response eyele.
Alternative eyeles likely exist, and one more relevant to women, especially those in long-
term relationships, is presented.
Resurne : traditionnellement, les indieateurs d'un desir sexuel sain ehez les femmes et ehez
les hommes sont la presenee de pensees sexuelles. les fantasmes sexuels et le besoin
ressenti de se livrer a I'auto-stimulation ou a une aetivite sexuelle avee un partenaire. Ceci
a produit une prevalenee apparente d'un desir sexuel reduit ehez 33 % des femmes dans
les groupes etudies. 11 est evident qu'une eomprehension differente du desir sexuel de la
femme s'impose. Dans la meme veine, la pereeption repandue, mais plutöt limitative, selon
laquelle la stimulation sexuelle feminine est synonyme de lubrifieation vaginale, a fait obsta-
ele a une eomprehension et a un traitement effieaees des diffieultes de stimulation eprou-
vees par eertaines femmes. Masters et Johnson, et plus tard Kaplan, ont influenee les
definitions du dysfonetionnement sexuel qui mettaient surtout I'aeeent sur les reflexes geni-
taux eomme si ce eyele de reponse sexuelle humaine--et tout le repertoire d'orgasmes
possibles ehez la femme---etait le seul eyele de reponse sexuelle. 11 est probable qu'il existe
d'autres eycles. Cet article en presente un qui s'applique partieulierement aux femmes,
surtout a eelles qui so nt engagees dans une relation stable.
J Soe Obstet Gynaeeol Can 2000;22(5):383-87
INTRODUCTION
üf the manyaspects of a woman's sexuality, those that most directly concern the gynaecol-
ogist indude her fertility: its enhancement and prevention, ability to have painless inter-
course, and freedom from conditions that can interfere with sexual activity such as infection,
dysfunctional uterine bleeding, and endometriosis. However, given that sexuality is perhaps
the prime example of a mandatory blending of mind and body, the sexual concerns presented
to the gynaecologist may weIl stern from the woman's own psyche, her interpersonal rela-
tionship in its emotional and sexual aspects, as weIl as from more medical matters. The enti-
ties oflow sexual desire and sexual dissatisfaction are patticularly common.1. 2 The definitions
of women's sexual dysfunction in the American Psychiatrie Diagnostic and Statistical Man-
ual ofMental Disorders (DSM-IV) based on the traditional model of the human sex response
cyde ofMasters and Johnson,3later expanded by Helen Singer Kaplan,4 are ofren of very lit-
tle assistance as we try to help women with low sexual desire and sexual dissatisfaction.
JOURNAL SOGe MAY 2000
OBJECTIVES
This manuscript offers an alternative model of women's sexual
response cyde, perhaps more relevant on a consistent basis for
women in longer term relationships regardless of whether or
not they have sexual concerns. This alternative model also sup-
ports the need to consider the multiple components of sexual
arousal and that orgasmic release may be partial, repeated, pro-
longed, or unnecessary.
THE TRADITIONAL SEX RESPONSE CYCLE
FIGURE I
TRADITIONAL HUMAN SEX RESPONSE CYCLE
- No inclusion of intimacy or stimuli
t
Sexual
Excitement
Desire
-----.. Time
Often referred to as "the sexual mountain," the traditional sex
response cyde originating from Masters and Johnson's depic-
tion of male sexual arousal3 can be simply depicted as
Sexual desire ---t arousal ---t orgasm ---t resolution
Masters and Johnson also suggested that women have a
variety of patterns of orgasmic release. 3 This genital focus of
the "normal human sex response cyde" is dear in the DSM-
IV definitions of female sexual dysfunction. Problems with
these definitions indude:
1. The focus is very much on genital reflexes of engorgement
(particularly that of vaginallubrication) and orgasm, where-
as dinically we see far more women with problems con-
cerning their sexual des ire and sexual satisfaction, often
associated with lack of tenderness, emotional connected-
ness, mutuality, caring, and sexual attraction. 5
2. Dysfunctions are conceptualized as discreet entities, where-
as in practice we see large numbers of women with at least
two areas of dysfunction (e.g., concerns with sexual desire
and sexual arousal, or women complaining of not experi-
encing orgasm who also appear to be only modestly sexual-
ly aroused and often consider their desire to be low also).
Masters and Johnson's aim in describing four phases was
to darifY anatomy and physiology, focused on (but not lim-
ited to) the genitalia. It is unfortunate that we have not inte-
grated this knowledge into an expanded model of sexual
response which addresses emotions, especially motivation
and intimacy, but instead have kept genital function as the
JOURNAL SOGC
major focus defining sexual function and dysfunction.
3. An innate sense of sexual hunger, or "sexual desire," with its
markers of sexual thoughts, sexual fantasies, sexual dreams,
self-stimulation for sexual reasons (as opposed to a need to
be relaxed), is conceptualized as initiating the sexual response.
Many, perhaps the majority of women in longer term rela-
tionships, themselves free of any sexual complaints, would
argue that reasons other than their own sense of sexual hunger
motivate them on a consistent basis. They are far more fam-
iliar with a receptivity to sexual cues and stimuli than with an
ongoing innate drive. This receptivity appears to be very
much influenced by the degree of emotional intimacy.
4. The DSM-IV definitions imply a rather mythica1 division
of dysfunctions into those of psychologica1 or medical eti-
ology whereas more often both physiologica1 and psycho-
logical etiologies are inseparably mixed, while on other
occasions, etiologies are unknown.
Note the entities of intimacy (as a driving force) and sex-
ual stimuli do not feature in the traditional cyde. However,
that cyde, with the variable orgasmic peaks described by Mas-
ters and Johnson, can be true for many women on so me occa-
sions. It is perhaps typical early on in a new relationship or
after physical or emotional distancing and perhaps in the few
days post ovulation for women premenopausally, who are sen-
sitive to the increase in testosterone that occurs with ovulation.
At these times women may sense sexual neediness that is not
obviously triggered by external factors. After a number of years
in the same relationship, however, women may weH describe a
rather different cyde. 6
ALTERNATIVE FEMALE SEX RESPONSE CYCLE
Starting from astate of sexual neutrality, a woman senses an
opportunity to be sexual. She may be motivated to find and
respond to sexual stimuli that lead to her sexual arousal, primarily
because her intimacy with her partner will be thereby enhanced.
This motivation mayaiso be aided by the expectation that
although she has no sexual hunger currently, the experience is
FIGURE 2
ALTERNATIVE MODEL OF
FEMALE SEX RESPONSE CYCLE
,,"p,,,,,o
~ek~~ out. and being
TO ~
CONTINUE
MAY 2000
likely to become physica11y as weil as emotionaHy pleasurable.7
Coincident with the woman's continuing to fee! somewhat
sexuallyaroused is a sense of sexual desire to continue the expe-
rience now for "sexual reasons" which had been begun for "inti-
macy reasons." If the physical and emotional outcome is
positive, the couple's intimacy is enhanced: there is an increased
sense of commitment, bonding, tolerance of each other's
imperfections, caring, and affection.
Using this alternative model, various sites of potential inter-
ruption of the cyde, involving both psychological and physi-
ological factors, become apparent, demonstrating that the cyde
is indeed somewhat vulnerable. Since the drive stems from the
wish to enhance intimacy, dearly the multitude of potential
factors which lessen intimacy can reduce this force. Ir becomes
very important that the outcome is both emotionally and phys-
ically rewarding; otherwise intimacy will not be enhanced.
Therefore, lack of tenderness, mutuality, respect, communica-
tion, or pleasure from sexual touching, perhaps undue focus
on the act of intercourse itself, or any cause of physical dis-
comfort or emotional discomfort, will predude achievement
of the woman's overall goal of enhanced intimacy. The cyde
is very dependent on external sexual stimuli. The effectiveness
of these stimuli likely depends not only on details of the
stimulation itselfbut on the overall context of atmosphere, safe-
ty, privacy, caring, and consideration, as well as sufficient estro-
gen and testosterone and neurological integrity.
A number of psychological factors can influence the pro-
cessing of sexual stimuli. A woman may feel generally "sub-
standard," a self-view often stemming from childhood
experiences. This self-view may interfere and preclude aware-
ness of sexual cues and triggers around her. Other women may
experience some arousal in response to stimuli but in keeping
with a more generalized tendency to be perfecrionists, they self-
monitor their "performance," causing the response to fade. Still
others describe "dysphoric arousal," often stemming from past
abuse as a child or within a relationship, or from a re!ationship
now deemed to be quite inappropriate. Non-sexual distrac-
tions are very commonly acknowledged to reduce the effec-
tiveness of sexual stimuli.
Depression is by far the most common biological factor
interfering with registering of stimuli and the unfolding of an
arousal response. Around perimenopause, it is not uneommon
for changes in sexual wanting and ability to respond to for-
merly effective cues to be the predominant symptoms of
depression. Only in retrospect, once on antidepressant med-
ication, does the woman acknowledge the former "grayness"
of her moods and lack of desire for aspects of life other than
sexual. Debilitating illness, some medications (induding anti-
depressants themselves), or decrease of ovarian androgen pro-
duetion (espeeially the complete loss after surgery or
chemotherapy), mayalso interfere with processing of stimuli. 8 ,9
Despite her aecessing arousal and sexual desire, a physical-
JOURNAL SOGe
ly or emotionally negative ollteome may still occur and reduee
rather than enhance the woman's motivation to repeat the
cyde. Chronic dysparunia is dearly a common cause of neg-
ative outcome, but other causes indude any partner dysfunc-
tion or the woman's inability to reach the intensity of sexual
pleasure she is needing, e.g. due to medication (typically SSRI)
or to lack of estrogen or testosterone.
Discussing this alternative model with women complain-
ing oflow sexual des ire usually leads to identifying at least two
or three different sites of interruption. For example, the
woman presenting after her menopause with ahistory of
"somewhat low desire" for many years tells us "she has now
totally lost it." Discussing the model with her, we find a pauci-
ty or complete absence of sexual stimuli, emotional distancing
for both non-sexual and sexual reasons, and now an addition-
al factor of less ovarian androgen. I find women, rather than
being overwhelmed by the number of likely factors involved
in the lowering of their sexual desire, to be hopeful that a num-
ber of sites exist for potential therapeutic intervention. If the
woman can accept (he need to enhance her intimacy with her
partner as a legitirnate driving force for her sexual experiences,
she sees reasons to give priority to nurturing that intimacy.
ALTERNATIVE MODEL OF FEMALE SEXUAL
AROUSAL
Often equated in the medicalliterature simply with vaginal
lubrication, a woman's sense of sexual arousal is difficult to
define. Ir appears to be predominantly her experience of sub-
jective mental excitement, which itself is largely dependent on
her appreciation of the stimulus. lO ,l1 How conscious she is of
feedback from somatic manifestations of arousa! is undear.
Women with and without female sexual arousal disorder
(FSAD), studied in the laboratory by means of a vaginal plethys-
mograph to record increases in vaginal blood flow, all charac-
teristically show a very early ("within seconds") increase in blood
flow in response to an erotic video. This is tme whether or not
the subject finds the stimulus arousing, or even whether she
finds it not only unarousing but quite negative in any sense. 11
Women with chronic dyspareunia have similar blood flow
response to control warnen when shown erotic videos of non-
penetrative sex, but, unlike the control women, do not have a
further inerease in blood flow when penetrative sex is added to
the erotic video. However, both groups ofwomen report com-
parable subjective sexual arousal to both types of video. 12 Thus
objective and subjective measurements of sexual arousal appear
to correlate quite poorly.13
Nevertheless, since for many women its gentle massaging
can be a very useful sexual stimulus, I would suggest that the
engorgement of the erectile tissue around the urethra,14 extend-
ing into the vestibular bulbar areal 5 and constituting the rami,
shaft, and head of the ditoris, is very important for the woman's
sexual arousal. Not only can the erectile tissue engorge in
MAl' ZOOO
 FIGURE 3
ERECTILE TISSUE IN THE WOMAN
response to subjective mental arousal but if it is skilfully and gen-
tly massaged, it can be the stimulus the woman needs to move
her from neutrality to astate of mild arousal, and thus on to a
state of further arousal and then sexual desire to continue the
experience. So then adefinition of women' s arousal might be: 6
Sexual = excitement + pleasure from
arousal (stimulus appreciation physical stimulation
- distractions )
Vaginallubrication, resulting from increased capillary pres-
sure as the submucosal vaginal plexus dilates in response to
vasointestinal polypeptide (VIP) and perhaps also to nitric
oxide (NO) released from the autonomic nerves, is thus seen
as a rather peripheral component of sexual arousal. Indeed,
women with large arnounts of lubrication find this non-sexu-
al and quite distressing. However, iflubrication is insufficient
(along with insufficient expansion and tenting of the vagina),
the act of intercourse will be associated with discomfort, if not
pain. Thus, it is the lack of lubrication that is problematic,
rather than that its presence is particularly relevant to the
woman's experience of pleasure.
The importance of induding the item "pleasure from phys-
ical stimulation (of the genital area)" in the definition of sex-
ual arousal is twofold. Firstly, the necessary stimulation sadly
is sometimes lacking, since it is not uncommon for the focus
to be on the act of intercourse itself which, due to anatomical
considerations, is a very poor stimulus of the erectile structures,
which are not only largely hidden from view, but often from
knowledge. Such lack of necessary stimulation is a major cause
ofFSAD.
Secondly, in cases of estrogen lack, the vasocongestion of
the erectile tissue is reduced due to the relative unavailability of
NO. 16 Suggesting to the woman that she use an externallubri-
cant is dearly not helpful in this regard. The future use of
vasoactive drugs that may enhance the action of nitric oxide,
possibly despite low levels of estrogen, is an exciting possibility.
THE MANY PATTERNS OF ORGASMIC RELEASE
Masters and Johnson depicted many patterns of orgasmic release
during a plateau ofhigh sexual arousal. Similarly, when women
are given a chance to depict their own experiences, various pat-
terns are drawn. 3
I would like to stress pattern No. 1, described by very many
women who do not report any sexual problem. It shows arous-
ability to a high level which is highly enjoyable (without defi-
nite peak and release). When the experience is over, there is
emotional and physical wellbeing. These women may or may
not experience peak tensions and releases on other occasions.
In pattern No. 5, described by women after some years of
sexual experience, the women have learned to maintain orgas-

FIGURE 4
COMMON CURVES DEPICTING WOMEN'S SEXUAL AROUSAL ± ORGASMIC RELEASE

2 3

~
Sexual
Tension
Sexual
Tension t Sexual
Tension t
... ;
~ /
;
;~
..... Time " ..... Time ..... Time

4 5

Sexual t Sexual t
Tension Tension

..... Time ..... Time

JOURNAL SOGC MAY 2000

mic intensity of their sexual tension for many seconds, and to
enhance it to even higher levels by further tensing of their
pelvic muscles, holding their breath, focusing their mind, such
that the whole experience of intense pleasure and tension can
last weil over aminute. This is not simply the well-known lack
of arefractory period in women, but a single experience of peak
sexual tension that does not return to baseline for an extend-
ed period. Masters and Johnson termed this experience status
orgasmus. 3
DEFINITIONS OF DYSFUNCTION
Acceptance of these alternative models of female sexual response
will lead not only to asking women different questions when
they have a sexual complaint, but to different definitions of sex-
ual dysfunction. Progress in the latter began at the 1998 Con-
sensus Conference in Boston, during which new definitions were
proposed,17 including non-separation ofbiological and psycho-
logical etiologies and the acceptability of stating that the etiolo-
gy is unknown. Despite the fact that most women' s complaints
show an overlap of the previously defined dysfunctions, those
terms are still kept in view of the large body ofliterature to date.
Also, a dysfunction is only so defined if the reported changes
cause personal distress to the woman (as opposed to the couple).
The pertinent change in the definition ofhypoactive desire
is that the woman's condition is only considered potentially dys-
functional if, in addition to absence of sexual thoughts and fan-
tasies, she also lacks receptivity. The important change in the
definition ofFSAD is that rather than focusing on vaginallubri-
cation, arousal is now conceptualized as including mental excite-
ment, genitallubrication, and other somatic responses. Adding
"sexual pleasure from genital stimulation" as a component of
arousal is strongly advocated by this author. The change in the
definition of orgasmic disorder is simply that there is only dys-
function if the lack of orgasm is causing personal distress to the
woman.
CONCLUSION
A different model of women's sexual response emphasizes a
receptive or responsive desire that often coincides with some
early sexual arousal and is triggered by sexual cues and stimuli.
It is motivated by a wish to enhance intimacy, rather than by a
conscious sexual neediness or hunger. The model allows expla-
nation for the multiple causation of problematic sexual desire:
in that issues to do with intimacy, to do with processing of the
sexual stimuli allowing arousal, to do with the stimuli them-
selves, to do with the biological aspects of the genital response,
mayall interrelate and compound. Sexual arousal in women is
often more amental excitement, very much to do with the
appreciation of the sexual stimulus and less to do with aware-
ness of genital changes. Nevertheless, those changes are impor-
tant for her ability to respond to a very common stimulus,
JOURNAL SOGC
namely, genital stimulation. Orgasmic release is extremely vari-
able and not essential for sexual satisfaction for many women.
Acceptance of a model of sexual response that allows the
roles of intimacy and sexual stimuli and reconsidering what
might be termed dysfunctional may help us assist women who
find their sexuality problematic. The interplay of psychologi-
cal and biological factors is emphasized rather than an attempt
made to "rule out" one or the other. A clearer understanding
of women's sexual response is also necessary before meaningful
clinical trials of vasoactive drugs that might enhance sexual
response can be undertaken.
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