Linda Vignozzi
Female sexuality encompasses a broad range of behaviors and processes, including female sexual identity and sexual behavior and the physiological, psychological, social, cultural, political, and spiritual or religious aspects of sexual activity.
Sexuality varies across the cultures and regions of the world, and has continually changed throughout history, and this also applies to female sexuality. Aspects of female sexuality include issues pertaining to biological sex, body image, selfesteem, personality, sexual orientation, values and attitudes, gender roles, relationships, activity options, and communication.
In particular, three major dimensions seem to interact on women’s sexual health: female sexual identity, sexual function, and sexual relationship [23, 24, 26].
Healthy sexual function and sexual dysfunction were studied for the first time by Masters and Johnson [39] and later elaborated on by Kaplan [32]. In the 1960s, they described four phases of the human sexual response cycle: excitement, plateau, orgasm, and resolution.
Sexual excitement refers to a subjective feeling of sexual pleasure and accompanying physiological changes. This phase includes vaginal lubrication in females. Plateau phase is a heightened state of excitement attained with continued stimulation. There is marked sexual tension in this phase, which sets the stage for the orgasm. The third stage, orgasm or climax, is defined as the peak of sexual pleasure. The final phase is resolution, during which a general sense of relaxation and well-being is experienced [39].
Today it is known that this linear model more accurately depicts the male than the female sexual cycle [31].
Recently, a more female-specific intimacy-based model of sexual response has been proposed. [4, 6]. This model describes a circular relationship between sexuality and satisfaction. In 2002, Basson described a “sexual response cycle” that incorporates psychological and social aspects into female sexual function, such as emotional intimacy and emotional satisfaction as well as sexual desire and physical satisfaction [4, 6].
This model definitively recognizes that sexual function and response are different in men and women. For example, in contrast to men, women’s desire does not always precede sexual arousal, with many women participating in sexual activity out of love and affection for their partners. Once engaged in sexual activity, women may then become aroused and then experience desire. For women, the sexual response cycle is intimately intertwined with the overall relationship that they are in and incorporates the societal and psychological milieu.
For men, sexual function and response centers on the ability to achieve and maintain an erection. For women, however, sexual response is much more complex, involving social, psychological, neurologic, vascular, and hormonal processes and includes complex interaction of sexual stimulation, the central nervous system, the peripheral neurovascular system, and hormonal influences [7, 15, 48].
Therefore, it seems clear that women’s sexuality is multifactorial, rooted in biologic, psychosexual, and context-related factors [2, 3, 8, 16-19, 23, 24, 35, 36, 45, 49]. The latter include couple dynamics, family and sociocultural issues, and developmental factors, including sexual abuse [5, 13, 34].
Several recent studies analyzed the role of interpersonal and affective factors in the development and maintenance of sexual problems [9, 10, 21, 25, 46], because this is especially true for female sexuality [12]. In her revised model of female sexual response, Rosemary Basson, for example, highlights the importance of factors such as self-image, emotional intimacy, and relationship satisfaction [4]. The development of this model has led to a shift in research emphasis with a stronger focus on psycho-affective and interpersonal factors [9, 10, 27, 43].
One such psycho-affective aspect is emotional intelligence (EI). Mayer and colleagues describe EI as some sort of intelligence in the sense of a cognitive ability, representing individual differences in processing affective information [40].
In spite of the awareness of the importance of psycho-affective factors in the development of sexual problems and the remarkable number of studies investigating the role of EI in a vast number of human behaviors and disorders [28], so far, only one study has investigated the possible relationship between EI and sexual functioning [9]. In the study conducted by Burri and colleagues, the authors reported a link between EI and female orgasmic frequency, with women showing higher EI levels also reporting more frequent orgasms [9].
Several constructs closely related to EI have also been associated with sexual functioning, including personality, alexithymia, and differentiation of self [10, 27, 33, 41]. In a recent study, EI was significantly negatively correlated with female sexual desire [51].
A further important aspect to consider is the role of interpersonal factors in determining of sexual problems, even in the context of organic diseases [1, 42, 47]. The relational component is not easy to evaluate and quantify, since its relative weight may vary according to age, partnership dynamics such as length and stage of partnership, and reproductive status, and it can be significantly influenced by cultural gender schemes. It has been reported that, with aging, women emphasize the importance of sexual intercourse less and place a greater value on intimacy, companionship, and affection [29]. The quality of a relationship has been highlighted as a main determinant of sexual interest and behavior in older married Greek women [44]. In a sample of Portuguese women from general population (mean age 35 years), relationship length predicted lower sexual desire [11]. A survey in middle- aged women in Hong Kong found that divorce history is a risk factor for lack of sexual interest and inability to achieve orgasm [52]. A survey of more than 900 female hospital employees in Taiwan (mean age 36 years) found that a poor relationship with the partner and perception of partner’s sexual dysfunction were major risk factors for low desire, low arousal, low orgasmic function, and low satisfaction [30].
The recognition of the negative impact of male sexual dysfunctions on partner’s sexual life is well established. In particular, the adverse effects of erectile dysfunction (ED) on the partner’s sexual experience have been widely investigated [20]. It has been suggested that, in women, a satisfying penile-vaginal intercourse, for which an adequate erection is a prerequisite, can provide higher levels of sexual satisfaction, resulting in lower rates of depression as compared with other types of sexual activity [14]. Other authors suggested that orgasm during penile-vaginal intercourse and simultaneous orgasms in the couple are specifically associated with women’s satisfaction, whereas other elicitors of orgasm are not [50].
The impact of another common male sexual dysfunction, premature ejaculation (PE), on female partners has also been studied in detail [37]. It has been reported that PE can lead the partner to inadequate central and genital arousal, vaginal dryness, and inability to climax [22].
Finally, Maseroli and colleagues recently provided evidence that women’s sexuality seems to be mostly impaired by the perceived reduction of their partner’s sexual interest [38]. In a sample of 156 heterosexual women consulting for sexual problems, results showed that sexual functioning (as derived by Female Sexual Function Index, FSFI) decreased as a function of partner’s age, conflicts within the couple, a relationship without cohabitation, and the habit of engaging in intercourse to please the partner; FSFI total score increased as a function of frequency of intercourse, attempts to conceive, and fertility-focused intercourse. FSFI total score showed a negative, stepwise correlation with partner’s perceived hypoactive sexual desire (HSD), whereas no significant correlation was found between FSFI and ED, PE, or DE. In an age-adjusted model, partner’s HSD was negatively related to FSFI total score and arousal, lubrication, orgasm, satisfaction, and pain domains. Partner’s HSD was also significantly associated with somatized anxiety, low frequency of intercourse, low partner’s care for the patient’s sexual pleasure, and with a higher frequency of masturbation, even after adjusting for age. In patients not reporting any HSD, FSFI total score was significantly lower when their partner’s libido was low; the correlation disappeared if the patient also experienced HSD.
In conclusion, these findings highlight the relevance of psycho-affective and relational factors in the development of female sexual problems.
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