Sexual function and depression
It is difficult to determine which begins first -- depression or sexual dysfunction. Some studies suggest there are high rates of sexual dysfunction in those who have mood disorders. Types of dysfunction associated with depression include low desire and orgasmic disorder. The use of anti-depressants make the situation more complicated because of their sexual side effects. Some studies show that the incidence of sexual function side effects is as high as 50% while other studies show no difference in sexual function between those who are taking anti-depressants and those who are not.

Sexual function and marriage
Again, some studies say there is no connection between sexual function and the state of the marriage; others say they are inextricably intertwined. Researchers Sager (1976) and Hayden (1999) found marital discord and sexual dysfunction to be so connected that it was impossible to analyze them separately.

Couples seeking therapy were different as well. Those in general couple's therapy were more antagonistic and less affectionate than those who sought therapy specifically for their sexual problems (Frank et al., 1977). Couple's therapy is a form of talk therapy, with the goal of resolving conflict in a relationship. Sex therapy is also talk therapy, but is directed at solving sexual difficulties or sometimes a very specific sexual problem such as lack of libido, lack of arousal or early ejaculation. Rust (1988) found that the relationship between marital discord and sexual function was much closer in men with impotence or erectile dysfunction than in women with orgasmic disorder or vaginismus.

Sexual function and stress
There are relatively few studies that show the impact of stress on a woman's sexual function although the complicated relationship between sexual function and stress has been seen in mice. Dominant mice that were placed under stress showed impaired sexual function (D'Amato, 2001) yet, male mice that were stressed showed enhanced sexual performance at puberty (Alameida et al., 2000). However, it seems likely that stress must impact negatively on the female sexual experience. In a recent survey of 1000 adults, stress was ranked as the number one detractor from sexual enjoyment (26%) above other potential detractors such as children, work and boredom.

There may be a connection between stress, testosterone levels and female sexual function. This connection is becoming increasingly clear.

We studied 31 women who had a variety of overlapping sexual function complaints including hypoactive sexual desire disorder, problems with orgasm, arousal and lubrication issues, low sexual satisfaction and pain. They each completed five questionnaires regarding overall sexual function, sexual distress, perceived general stress, relationship health, and depression. A high score indicated positive functioning, for example, a 6 on the arousal scale would indicate that arousal was not a problem and a 6 on the pain scale would indicate no pain at all associated with sex. Generally, the lower the score, the higher the incidence of a sexual function problem. Overall, scores were low for all measures and on overall function. This particular group of women seemed to have a high incidence of orgasmic dysfunction.

Our evaluation of the surveys found that while this group experienced high sexual distress, they had low general stress, moderately healthy marital relationships and low levels of depression. So we see a difference between sexual distress and other quality of life measures.

Depression was associated with all the measures of sexual function, sexual distress, general stress and relationship health. In addition, sexual distress not only increased with depression, but also with problems in sexual function. Those who experienced good relationship health had fewer sexual function problems, but those who had negative relationship had greater depression and general stress.

General stress did not correlate with any of the Female Sexual Function Index sub-scores. This may be further evidence that women may experience general stress differently than sexual stress. Orgasm also proved to be an interesting case, correlating only with depression. As well, it was the only category unaffected the state of the relationship -evidence that it may be a somewhat unique aspect of female sexual function. Women did not appear to be experiencing as much distress over orgasm complaints, suggesting that perhaps this aspect of the sexual experience is seen as less central than others.

Women who reported low levels of desire did not seem to be distressed by this - it is the classic picture of the patient whose low libido is not a problem for her, but is a problem for her partner. Arousal, an aspect of sexual function that incorporates both physical and emotional factors, correlated with all quality of life measures except for general stress.

Conclusion
The small number of patients in this study certainly had an impact. There may have been other correlations that we simply couldn't detect. Our sample represented women seeking treatment for sexual function complaints and therefore, cannot necessarily be generalized to women as a whole. The variables we addressed are all quite related and difficult to consider in isolation.

In future research, it will be beneficial to study the causal relationships among the variables using control groups or controlled interventions. Using a larger population of women in order to separate out those who are taking antidepressants will give us different results. We could also subdivide women into groups based on primary sexual complaint (e.g. hypoactive sexual desire disorder vs. pain) and see if quality of life measures differ among the groups.