Sexual Health and Sexual Problems
Sexual health refers to the ability to enjoy sex. It also includes birth control, abortion, and the avoidance and treatment of sexually transmitted disease.
Sexuality is an important part of health, quality of life, and general wellbeing. As a consequence of the impact of Viagra on male sexual dysfunction, considerable attention is now being paid to sexual dysfunctions in women, which might respond to pharmacological treatment.
In 1918, Marie Stopes published some letters from women who expressed their anxieties about their ?unnatural? sexual desire or lack of pleasure in sexual intercourse. Stopes stated that enjoyment of sex could be brought about through information, education and good contraception.
Sexual dysfunction is more prevalent for women (43%) than men (31%). Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being. Sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems.
Normal sexual response in women
Female sexual arousal is strongly modulated by thoughts and emotions triggered by the state of sexual excitement. An emotional relationship with the partner and emotional wellbeing are the strongest predictors of absence of sexual distress.
Spontaneous sexual desire is common among younger women and those in new relationships. It can be cyclical in younger women and can be disrupted by medical intervention. However, in some women innate desire can endure for decades.
A Model Of Female Sexual Response – After Taylor and Francis
Stage One – Excitement
This stage can last anywhere from a few minutes to several hours. Sexual activity during this stage is often called foreplay. Extending foreplay can sometimes make the other stages more intense. During this stage:
- the blood flow to the genitalia increases
- the clitoris swells
- the vagina begins to lubricate (becomes wet and slippery)
- blood flow to a woman’s breasts increases and her nipples may get hard
- heart rate and blood pressure increase
- breathing may speed up
Stage Two – Plateau
During this stage:
- due to increased blood flow, the outer third of the vagina swells and the genitalia appear darker
- the clitoris is very sensitive and retracts beneath its hood
- heart rate, blood pressure and breathing continue to increase
- muscle tension increases and spasms may occur in the feet, face and hands
Stage Three – Orgasm
This stage is also called climax. During this stage:
- muscles in the outer third of the vagina contract in a rapid series of pulses
- the first contractions are the most intense and the closest together
- the muscles in the uterus also contract
- heart rate, blood pressure and breathing are at their highest rate
- the skin may appear red or flushed (this may begin in earlier stages)
Orgasm is the shortest of the four stages, usually measured in seconds.
Just before or during orgasm, some women release a clear fluid from their urethra. This is now commonly called female ejaculation. Most researchers believe that this is not urine, but instead a clear fluid similar to the fluid containing a man’s sperm. Ejaculation is most likely to occur when a woman is being penetrated vaginally and pressure is being applied to the top wall of the vagina. This is where the back of the clitoris meets the wall of the vagina and is sometimes called the G-spot.
Stage Four – Resolution
During this stage:
- a woman’s clitoris and nipples become softer
- the vagina and genitalia return to their normal size and colour
- breathing, heart rate and blood pressure decreases
This process typically takes longer for women than men, although some women may be able to return to the plateau stage at this point.
Female Sexual Problems
Low sexual desire is more likely to occur in women in relationships for 20-29 years (odds ratio 3.7) and less likely in women reporting greater satisfaction with their partner as a lover or who placed greater importance on sex. Low genital arousal is more likely among women who are perimenopausal (4.4), postmenopausal (5.3,), or depressed (2.5), and is less likely in women taking hormone therapy (0.2), more educated (0.5), in their 30s (0.2) or 40s (0.2), or placed greater importance on sex (0.2). Low orgasmic function is less likely in women who are in their 30s (0.3) or who placed greater importance on sex (0.3). Sexual distress is positively associated with depression (3.1) and is inversely associated with better communication of sexual needs (0.2). Relationship factors are more important to low desire than age or menopause, whereas physiological and psychological factors are more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress is associated with both psychological and relationship factors.
Studies indicate that less than half of patients’ sexual concerns are known by their physicians, and physicians are unaware of how common these sexual concerns are in their practices. Nussbaum et al mailed their survey in waves. Of 1480 women seeking routine gynecological care 964 responded. The main outcome measures were self-reported sexual concerns and their experiences with discussing these concerns with a physician. A total of 98.8% of the women we surveyed reported one or more sexual concerns. The most frequently reported concerns were
- lack of interest (87.2%)
- difficulty with orgasm (83.3%)
- inadequate lubrication (74.7%)
- dyspareunia (71.7%)
- body image concerns (68.5%)
- unmet sexual needs (67.2%)
- need for information about sexual issues (63.4%)
More than half reported concerns about physical or sexual abuse, and more than 40% reported sexual coercion at some point in their lives. It was concluded that sexual health inquiry should be a regular and important part of health care maintenance.
DSM-IV classification of female sexual dysfunction: 1999
- Sexual Desire Disorders
- Hypoactive sexual desire disorder
- Sexual aversion disorder
- Sexual Arousal Disorder
- Orgasmic Disorder
- Sexual Pain Disorders
- Other sexual pain disorders
Basson et al evaluated and revised existing definitions and classifications of female sexual dysfunction. An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. Classifications were expanded to include
- psychogenic and organic causes of desire
- arousal, orgasm and sexual pain disorders.
An essential element of the new diagnostic system is the “personal distress” criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.
Sexual problems can be primary or secondary and generalised or situational.
Physical illness and medication should be considered, but psychological factors are often more important. In some cases there is more than one dysfunction; for example, the woman who experiences sex as painful can develop vaginismus and then have problems becoming aroused. Avoidance of sex can follow and this can lead to loss of intimacy and relationship problems.
Sexual desire disorder
Desire disorders become more common as women age. Desire is affected to some extent by hormones; loss of desire can be experienced at the menopause, regardless of age, and is often reported after a surgically-induced menopause. From early to late menopausal transition, the percentage of women with scores indicating sexual dysfunction rose from 42% to 88%. Decreasing scores correlated with decreasing oestradiol but not with androgens. By the postmenopausal phase there was a significant decline in sexual arousal and interest, Frequency of sexual activities, and the Total Score. There was a significant increase in vaginal dryness and dyspareunia and women’s reports of their partner’s problems in sexual performance. Women with low scores of sexual functioning were more likely to be distressed on the Female Sexual Distress Scale. There is a dramatic decline in female sexual functioning with the natural menopausal transition.
If a woman expects sexual activity to be rewarding she may well embark on it and enjoy it, whatever her hormonal status. There can be negative psychological factors such as distraction, prediction of a negative outcome because of previous experience of pain, guilt, low sexual esteem, shame, embarrassment and awkwardness. These factors can be the result of earlier negative experiences triggered by culture, loss, trauma or past relationships. Women may learn to keep a tight rein on their emotions generally to avoid conflict and, in particular, to suppress anger.
There may be problems in the current relationship or with a partner?s sexual dysfunction or there may be inadequate stimulation. Depression is a common cause of loss of desire and selective serotoninreuptake inhibitors (SSRIs) affect the sexual response and orgasm in men and women. The existing literature confirms sexual dysfunction as a possible adverse event of all antidepressants, but it is not sufficiently robust to support claims for differences in the incidence of drug-induced sexual dysfunctions between existing antidepressant therapies.
It may help women with hypoactive desire disorder to know that many women do not have spontaneous sexual desire. Thus, treatment can be centred away from why a woman does not have such thoughts and focused on how she can access sexual satisfaction.
Certain types of oestrogen (HRT) therapy are associated with increased Frequency of sexual activity, enjoyment, desire, arousal, fantasies, satisfaction, vaginal lubrication, and feeling physically attractive, and reduced dyspareunia, vaginal dryness, and sexual problems. Certain types of testosterone therapy (combined with oestrogen) are associated with higher Frequency of sexual activity, satisfaction with that Frequency of sexual activity, interest, enjoyment, desire, thoughts and fantasies, arousal, responsiveness, and pleasure. Whether specific serum hormone levels are related to sexual functioning and how these group effects apply to individual women are unclear. Other unknowns include long-term safety, optimal types, doses and routes of therapy, which women will be more likely to benefit from (or be put at risk), and the precise interplay between the two sex hormones.
In surgically menopausal women (both ovaries have been removed, usually during hysterectomy) with hypoactive sexual desire disorder, a 300 mug/d testosterone patch significantly increases satisfying sexual activity and sexual desire, while decreasing personal distress, and is well tolerated through up to 24 weeks of use. Tibolone is licensed for the treatment of loss of desire among postmenopausal women.
Sexual arousal disorder
A woman with sexual arousal disorder cannot access excitement when she wishes to be sexual. Studies show that she may experience the swelling and lubrication of physical arousal but have little subjective experience of pleasure. In women, peripheral feedback from consciously detected genital arousal seems to be a relatively unimportant determinant of subjective sexual arousal.
A woman may prevent herself from accessing pleasure for a variety of reasons or she may be mentally disengaged and unaware of any sensations of arousal. There is a small group of women who report subjective feelings of arousal but who do not become physically aroused. Peripheral neuropathy secondary to diabetes, spinal cord injury and surgery may be implicated.
Pharmacological and physical treatments include the use of estrogen, lubricants and vibrators. There may be a place for drugs that increase vasocongestion and vasodilation. One study examined the effect of a single oral dose of sildenafil citrate (, Pfizer, Inc., New York, NY) on vaginal vasocongestion and subjective sexual arousal in healthy premenopausal women. Twelve women without sexual dysfunction were randomly assigned to receive either a single oral 50 mg dose of sildenafil or matching placebo in a first session and the alternate medication in a second session. Subjective measures of sexual arousal were assessed after participants had been exposed to erotic stimulus conditions. Vaginal vasocongestion was recorded continuously during baseline, neutral, and erotic stimulus conditions. At the end of each session, subjects were also asked to specify which treatment they suspected they had received. Significant increases in vaginal vasocongestion were found with sildenafil treatment compared with placebo. There were no differences between treatments on subjective sexual arousal experience. Analyses by suspected treatment received found that significantly stronger sexual arousal and vaginal wetness were reported for the treatment that was believed to be sildenafil vs. the treatment that was believed to be placebo. The suspected treatment se quence was incorrect for half of the women. Sildenafil was well tolerated, with no evidence of significant adverse events. Sildenafil was found to be effective in enhancing vaginal engorgement during erotic stimulus conditions in healthy women without sexual dysfunction but was not associated with an effect on subjective sexual arousal.
However, the evidence does not show sildenafil to be an effective treatment for women with sexual dysfunction. In a review the pathophysiology of female sexual dysfunction (FSD) and the literature regarding the use of sildenafil in its treatment, search terms included female sexual dysfunction; sexual dysfunction, psychological; phosphodiesterase inhibitors; and sildenafil. The lack of a clear understanding of FSD contributes to the limited treatment options available. Studies regarding the safety and efficacy of the phosphodiesterase 5 inhibitor sildenafil in the management of FSD were evaluated. Many trials have been of poor quality, making clinical application of their results difficult. The current literature does not show sildenafil to be an effective treatment option for FSD.
Persistent sexual arousal
Persistent sexual arousal is an uncommon condition that was first reported in 2000. The disorder is characterised by sensations of spontaneous and persistent genital arousal that occur without any conscious awareness of sexual desire; orgasm offers only temporary relief. Women are very distressed by this condition, the causes of which are as yet unknown; no definitive treatment can be recommended.
An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia (muscle relaxation) that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.
Anorgasmia (inability to experience orgasm) is more common among younger women, demonstrating that sexual response is a learned response. The problem of anorgasmia may be constant, or may occur only with a partner or with penetration.
Women’s orgasms can be induced by erotic stimulation of a variety of genital and nongenital sites. As of yet, no definitive explanations for what triggers orgasm have emerged. Studies of brain imaging indicate increased activation at orgasm, compared to pre-orgasm, in the paraventricular nucleus of the hypothalamus, periaqueductal gray of the midbrain, hippocampus, and the cerebellum. Psychosocial factors commonly discussed in relation to female orgasmic ability include age, education, social class, religion, personality, and relationship issues. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.
Sex education, communication skills training and Kegel exercises are often included in cognitive behavioural treatment programmes for anorgasmia. To date there are no trials showing that any pharmacological agent is more efficacious than placebo in enhancing orgasmic function among these women.
Sexual pain disorders
Historically, these conditions are categorised as or vaginismus, but they often overlap. Each case should be considered as a pain syndrome and managed as such.
Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.
This is discussed at vaginismus.
Menopause and sexuality: key issues in premature menopause and beyond.
Woman’s sexuality encompasses sexual identity, sexual function, and sexual relationships.
It is modulated throughout life by life and reproduction-related events, health, relationships, and sociocultural variables.
The aging process and menopause are two potent contributors to female sexual dysfunction.
The earlier the menopause, the more severe and complex the impact on sexuality is.
The younger the woman, the less she realizes the different key goals of her life cycle (falling in love, having a satisfying sexual life, forming a stable couple, getting married, having a family) and the more pervasive the consequences on her sexual identity, sexual function, and sexual relationship can be.
Premature menopause is an amplified paradigm of the complex impact menopause can have on women’s and couple’s sexuality.
Almost every disease to which the sexual organs are liable can cause dyspareunia; they can be classified by anatomical location.
Chronic vulval pain
If there is chronic vulval pain, dermatological conditions, such as the dermatoses, lichen sclerosis and psoriasis, should be excluded by genital examination.
Vulvar vestibulitis is characterised by pain at the vaginal introitus on attempted penetration, tenderness in the vestibule and erythema. This is a common presentation among young women that is poorly recognised by primary care doctors and some gynaecologists and frequently misdiagnosed as recurrent thrush.
Women may repeatedly seek a correct diagnosis from a variety of clinicians over a long period. Recent work has demonstrated that women with vestibulitis have lower pain thresholds in the vestibule and lower tactile pain thresholds compared with controls. Some authors suggestthat vestibulitis represents one end of a continuum of common vulval signs and symptoms. Relevant studies reporting more depressive symptoms and somatic complaints have found no link between vestibulitis and sexual or physical abuse.
Pelvic pain is a common complaint and many women present because they want an explanation. Consultations that elicit the woman?s own ideas about the origin of the pain will result in a better doctor?patient relationship and improved cooperation with investigation and treatment. In one study a history of physical or sexual abuse in childhood was significantly more common among women with chronic pelvic pain than among those with chronic pain in other locations or among controls. The history of physical and sexual abuse in childhood and adulthood was assessed in 31 women with chronic pelvic pain, 142 women with chronic pain in other locations, and 32 controls. Thirty-nine percent of patients with chronic pelvic pain had been physically abused in childhood. This percentage was significantly greater than that observed in other chronic-pain patients (18.4%) or controls (9.4%), though the prevalence of childhood sexual abuse did not differ among the groups (19.4, 16.3, and 12.5%, respectively). Abuse in adulthood was less common and was not significantly more likely to have occurred in patients with chronic pelvic pain than in other chronic-pain patients or controls.
General principles of management of Sexual Problems
Management requires an understanding of psychosexual function and an ability to communicate about sexual matters. The clinician should be alert to non-verbal communications that indicate anxiety. For example, a relationship problem or a history of abuse may be suspected, but the woman may not want to talk about it and will experience direct questioning as intrusive.
Management needs to be multidimensional, addressing biological, cognitive, affective, behavioural and interpersonal aspects.
Treatment should be individualised for each woman and her partner.
The management of some sexual problems may require more time and expertise than are available in a general clinic. However, listening to the woman in an active way and understanding the exact nature of the problem and its impact on her and her relationship, if she has one, can in themselves be therapeutic.
Some women need permission to enjoy their body and relaxation techniques can be of benefit. Specific self-examination or the use of vaginal trainers may be indicated for vaginismus. Education can be helpful, but there is a wealth of readily available information in women?s magazines and on the internet; it might be interesting to explore why a woman has not been able to access it herself.
Pain syndromes may respond to local anaesthetic creams, tricyclic antidepressants or other interventions such as biofeedback or cognitive behavioural therapy. Relationship issues that are identified may be the cause of or secondary to the problem.
The importance of sexual difficulties in gynaecology and obstetrics
Gynaecological conditions and procedures can distress women and cause sexual problems. Sexual pleasure improves after vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. Regardless of the surgical technique used, some women miss the uterine contractions associated with orgasm; removal of the cervix can change the experience of deep penetrative intercourse. Patients who are disease free after RT for locally advanced, recurrent, or persistent cervical cancer are at high risk of experiencing persistent sexual and vaginal problems compromising their sexual activity and satisfaction.
In obstetrics, a re quest for a caesarean section without an obstetric problem might indicate an underlying sexual problem. Sexual difficulties can appear after birth trauma. There is a significant decrease in sexual satisfaction scores in women who undergo vaginal delivery in comparison with those who have elective caesarean section at 2 years follow-up.
Some women present with a direct appeal for help with a sexual difficulty.Women expect their doctors to be able to discuss sexual problems, but some doctors feel uncomfortable talking about sex and may not see it as part of their clinical role. Routinely asking about sexual function lets the woman know that sexuality is an important aspect of health.
Covert presentation of a sexual difficulty can take the form of
- complaints about pelvic pain
- distress about menses
- general dissatisfaction with a contraceptive precaution
- expression of distaste for the genital area or dissociation at the time of genital examination.
A sympathetic doctor will be alert to these clues and will ask open-ended questions to explore these issues. New thoughts on the classification of sexual problems.
Should women’s sexual problems be conceptualized in the same way as men’s? A telephone survey of women used Computer Assisted Telephone Interviewing and Telephone-Audio-Computer-Assisted Self-Interviewing methodology to investigate respondents’ sexual experiences in the previous month. A national probability sample was used of 987 White or Black/African American women aged 20-65 years, with English as first language, living for at least 6 months in a heterosexual relationship. The participation rate was 53.1%. Weighting was applied to increase the representativeness of the sample. A total of 24.4% of women reported marked distress about their sexual relationship and/or their own sexuality. Physical aspects of sexual response in women, including arousal, vaginal lubrication, and orgasm, were poor predictors. In general, the predictors of distress about sex did not fit well with the DSM-IV criteria for the diagnosis of sexual dysfunction in women.
The new definitions recognise the importance of the context of the sexual relationship and the fact that sexual response phases overlap. There is an acknowledgement of the importance of responsive desire triggered by physical and mental arousal rather than spontaneous desire. Seventy percent of women in long-term relationships report no spontaneous sexual desire but they are able to access sexual and emotional pleasure from sexual activity (responsive desire). This starts from a willingness to be sexual and, with the appropriate stimulation in context, they are able to access arousal, leading to sexual pleasure and a willingness to be sexual on the next occasion. The willingness to be sexual derives from a wish for intimacy, to stabilise her own and her partner?s mood and to satisfy her own sexual needs as well as a wish for non-sexual gains.
Medical Training For Sexual Dysfunction Management
A postal questionnaire was sent to the 218 GPs on the Camden and Islington Health Authority List. A total of 133 GPs responded to the questionnaire. Although only eight had a special interest in sexual health, 41 and 50 reported a special interest in mental and women’s health, respectively. Forty-six had received postgraduate training in taking a sexual history, 45 in the diagnosis of a sexual problem, 49 in the management of sexual dysfunction, 39 in psychosexual counselling and 24 had training in all four areas. Most GPs (87) categorized sexual dysfunction as medium priority, 25 as high priority and 18 as low priority.
Doctors find it difficult to address the sexual problems of patients because of
- Lack of training
- Lack of practice
- Fear of ?opening the flood gates?
- Covert presentation of the problem
- Lack of time
- Lack of effective treatments
- Associated stigma
- Embarrassment of doctor, patient or both
- Sensitive subject
- Difficult subject
Training in psychosexual problems should be considered by all obstetricians and gynaecologists. The Institute of Psychosexual Medicine offers a brief, focused course for medical practitioners on psychosomatic therapy for sexual and related difficulties. The initial aim of training is to increase the skills of doctors who encounter women with psychosexual and related problems in their practice. The British Society of Sexual and Relationship Therapists offers training for practitioners of differing backgrounds in psychosexual couple counselling, using a cognitive behavioural approach.