That sex is a taboo in Indian culture is no news. But, what we perhaps underestimate, is how intricately layered that taboo is, especially for women. Female sexuality is not yet fully understood, but what understanding we do have is complicated by the way society treats it: as a reflection of character more than the biological and psychological need that it is.

The effect of this almost willful misunderstanding, then, is difficulty in defining what is normal, versus what is abnormal, what is societal, versus what is biological, when it comes to women’s sexuality. Nowhere is this clearer than in the diagnosis of Female Sexual Dysfunction.

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Most women experience some form of sexual difficulty during their lives, just as most men experience erectile dysfunction at some point. But female sexual dysfunction (FSD), is an umbrella term for continued and recurrent difficulty in experiencing pleasure, desire, arousal, or orgasm. A woman experiencing FSD may have trouble with any one or several of these aspects of sexuality. The most common version of sexual dysfunction among women is thought to be hypoactive sexual desire disorder (HSDD), that is, lack of desire or interest in sex. FSD may also be characterized by female climax issues, or by dyspareunia, that is, pain during intercourse, and more.

One of the key factors of FSD, regardless of how it manifests, is persistence. That is, if a woman persistently does not desire or enjoy sex, over an extended period of time, then it may indicate more than a passing, natural lack of interest, or dissatisfactory sex.

Read more: We Need More Research Into Women’s Sexual Experiences

Although its symptoms manifest physically, female sexual dysfunction is not a solely biological disorder. Rather, it is a biological-psychological-social problem, and must be evaluated through all these lenses. Protocol dictates that a diagnosis be given only after a thorough examination of the woman’s medical and psychological history, socio-economic status, educational background, and relationship status and satisfaction.

Some biological conditions such as diabetes, prolonged use of certain prescription drugs, fibroids, pelvic inflammatory disease, and hormonal changes can contribute to lowered sex drive or pain during sex. Some of the psychological influences of FSD can include depression, anxiety, history of abuse, and relationship issues, which in turn can lead to distress and lack of interest in sex. Socio-culturally, perceptions around sex and sexuality impact a woman’s desire and pleasure; for instance, if sex is viewed as a sin, it may impede an individual’s capacity to enjoy it fully.

Often, these three factors overlap. For instance, the cultural – yet biologically inaccurate – belief that women who have reached menopause don’t feel sexual desire can lead to psychological dissonance, for some women, about whether they should feel sexual desire. Further, this could be compounded by the fact that hormonal changes associated with menopause may make it difficult for some women to become adequately lubricated for intercourse to be comfortable. The result, for some women, could be female sexual dysfunction.

Ultimately, FSD seems to be about defining normal function – as satisfaction; another, perhaps most critical, factor in diagnosis is whether the difficulty distresses the woman, and/or causes strain on her relationship.

There’s just one problem: In many cultures, including India’s, it is assumed that it is “normal” for a woman not to feel desire at all, much less satisfaction.

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“Some women feel they are not good enough. They don’t feel it is their right to enjoy sex, because they are inferior to men, and that it’s only the man’s right,” says Dr Arpita Gangwani, a consultant gynecologist at Apollo Cradle, New Delhi. Others, she says, are never taught that they can enjoy sex. Sex is sold to them as a chore, an obligation, a duty – a baby-making tool.

This stigma attached to women’s sexuality – especially sexual pleasure and taking charge of the same – has created a lack of awareness about sexual health in general, Gangwani says, and creates an environment ripe for FSD.

While population-wide data for female sexual dysfunction does not exist in India, one small-scale study in Ahmedabad in 2016 found 56% of its pre-menopausal participants identified as having FSD per the Female Sexual Function Index, a 19-question diagnostic tool. The same study also showed a positive correlation between the length of a relationship and FSD, specifically, that cases of FSD were higher among those who had been monogamous for more than 16 years. This could be partially a function of aging; the older a woman is, the more opportunity there is for biological factors that could contribute to female sexual dysfunction to accrue. But there is more opportunity for social factors, like relationship satisfaction, to accrue, too.

According to Dr. Arpita Gangwani, the state of the relationship a woman is in plays a huge role in the development of FSD. That is, if a woman is happy with her partner, she is more likely to desire and enjoy sex. She says many of her FSD patients report that it’s not that they don’t desire sex at all. Rather, the problem exists with the kind of sex that their partners demand. In these cases, FSD is more a disorder of the relationship, and as such, requires professional intervention in the form of counseling or couples therapy, she says.

For other patients, sexual dysfunction is rooted in keeping up with cultural expectations around motherhood.

“If you look at the average 40-something Indian woman, she would not take care of herself,” Gangwani says. “Indian women … are burdened by child-rearing responsibilities. The cases of postpartum depression are also very high in India. But, because of the culture of silence around any sort of emotional difficulties a woman may face, many don’t open up about it, or try to fix it. They sort of give up.”

These expectations, combined with the lack of awareness around sexual health, also keep many women from spotting physical and mental postpartum complications, like pelvic floor prolapse, or depression, that can make sex less pleasurable and contribute to sexual dysfunction, Gangwani says.

“Many women do not know that something can be done about it, both pre-, and post-pregnancy. Thorough check-ups and exercises before and during pregnancy can prevent this,” she stresses.

Prevention is always difficult. But what frustrates Gangwani is that FSD, despite the complexity of its causes, is very treatable – but only when a lack of interest or enjoyment in sex isn’t considered the norm. For instance, in the case of a menopausal woman with sexual dysfunction as described above, a course of treatment might include counselling, to dispel the myth that menopausal women don’t feel desire, and/or hormonal replacement therapy to aid vaginal lubrication.

Related: ‘Lust Stories’ Captures Some Realities of Indian Women’s Sexuality

“After delivery, there are treatments available [too],” Gangwani says, almost exasperated. “The problem with this also is that nobody is willing to go to a doctor and find out if there are treatments available, because in many cases, there are. In many cases, you only need some counselling. Couples counselling can help most women, or couples, facing FSD. But, people don’t want to go for it. That’s the bigger problem here.”

Psychologist Carl Rogers famously said, “What’s most personal is most universal.” What he meant by this is that the raw, hurtful, embarrassing experiences we go through that we believe nobody else will understand, and thus, keep to ourselves, are the very experiences many people go through, and remain silent about. This perpetuates the culture of silence around issues that can be resolved, at least partially, if only we spoke about them. Female sexual dysfunction fits the bill. In speaking about female sexuality, we make female pleasure the norm, the function. Only then can we spot – and treat – what’s truly dysfunctional: dissatisfaction.