This chapter deals primarily with APGO Educational Topic Area:
TOPIC 56 SEXUALITY AND MODES OF SEXUAL EXPRESSION
Students should be able to describe normal female sexual physiology. They should identify the influence of physical, medical, psychological, and societal factors on the female sexual response. They should be able to outline an initial approach to evaluation of different forms of female sexual dysfunction.
Clinical Case
A 23-year-old G5P5 woman presents because she has lost interest in intercourse with her husband. A review of her past history finds that she was married at an early age, conceiving her first child soon after. She had “difficult pregnancies” with her last two pregnancies, and she was unable to get a planned tubal ligation after her last pregnancy. Her last pregnancy ended roughly 6 months ago. She reports trouble losing her pregnancy-related weight gain despite reporting little appetite.
An estimated 35% to 45% of women perceive they have some type of sexual problem—most commonly low sexual desire. Illness, medical and surgical treatment; lack of knowledge to manage this life experience; and emotional and physical stresses contribute to the frequency and severity of sexual problems. Physicians should be able to identify sexual disorders and know whether to offer treatment or refer such patients to a specialist.
Determinants of healthy sexuality are complex and multifactorial. Intrapersonal factors include the sense of one’s self as a sexual being, one’s overall health status, a general perception of well-being, and the quality of an individual’s previous sexual experiences. For partnered individuals, this same list applies to the partner. Interpersonal aspects include the duration and overall quality of the relationship, communication styles, and the number and type of ongoing life events and stressors. Examples of generally “positive” life events, which nevertheless can contribute to sexual dysfunction, include the birth of a child and retirement.
Sexuality involves a broad range of expressions of intimacy and is fundamental to self-identification, with strong cultural, biologic, and psychological components. The obstetrician–gynecologist has an important role in assessing sexual function, because many women view their sexuality as an important quality-of-life issue. Moreover, gynecologic disease processes and therapeutic interventions have the potential to affect sexual response. The clinician should not make assumptions or judgments about the woman’s behavior and, when counseling patients, should keep in mind the possibility of cultural and personal variation in sexual practices.
SEXUAL IDENTITY
At the most basic level, the experience of sexuality begins with an individual’s genotype and phenotype. From this basic biologic underpinning, children develop a gender identity during early childhood. Eventually, each individual develops a sense of self as a sexual being and a sexual orientation. Each of these latter components is fluid and can vary over time and with particular circumstances. For example, some individuals who consider themselves heterosexual periodically engage in sexual encounters with same-sex partners.
HUMAN SEXUAL RESPONSE
In evaluating sexual problems, it is useful to consider the mechanisms of sexual response in women. Sexual function and dysfunction are perhaps the supreme examples of a necessary blending of mind and body. This interaction is crucial to the understanding of the assessment and management of sexual problems. The dualistic approach common to more traditional models of sexual response limits the understanding of female sexuality insofar as it suggests that dysfunction is psychological and/or biologic. Newer approaches are more holistic in their representations of female sexual response.
Traditional Model
Intimacy-based sexual response models that take other factors into consideration are replacing the traditional Masters and Johnson and Kaplan models of the human sexual response cycle. The traditional cycle depicts a linear sequence of events: desire, arousal, plateau of constant high arousal, peak intensity arousal and release (orgasm), possible repeated orgasms, and then resolution (Fig. 35.1). However, the sexual response cycle in women is complex, and events do not always occur in a predictable sequence, as they usually do in men.
Neither the stimuli to which the response occurs nor the nature of the “cyclicity” is evident in the traditional model. The usefulness of this model for depicting women’s sexuality is limited by the following considerations:
• Women are sexual for many reasons—sexual desire, as in sexual thinking and fantasizing, may be absent initially.
• Sexual stimuli are integral to women’s sexual responses.
• The phases of women’s desire and arousal overlap.
• Nongenital sensations and a number of emotions frequently overshadow genital sensations in terms of importance.
• Arousal and orgasm are not separate phenomena.
• The intensity of arousal (even if orgasm occurs) is highly variable from one occasion to another.
• Orgasm may not be necessary for satisfaction.
• The outcome of the experience strongly influences the motivation to repeat it.
• Dysfunctions may overlap (e.g., desire and arousal disorders, and orgasm and arousal disorders).
Intimacy-Based model
An alternative sexual response model depicts an intimacy-based motivation, integral sexual stimuli, and the psychological and biologic factors that govern the processing of those stimuli (i.e., determining the woman’s arousability) (Fig. 35.2).
A woman’s primary motivation for sexual response often is to be closer to her partner. If sexual arousal is experienced, the stimuli continue, the woman remains focused, and the sexual arousal is enjoyed, she may then sense sexual desire to continue the experience for the sake of the sexual sensations. A psychological and physically positive outcome heightens emotional intimacy with her partner, thereby strengthening the motivation. Any spontaneous desire (i.e., sexual thinking, conscious sexual wanting, and fantasizing) may augment the intimacy-based cycle. Spontaneous desire is particularly common early in relationships or when partners have been apart, is sometimes related to the menstrual cycle, and is extremely variable among women.
FIGURE 35.1. Traditional sexual response cycle of Masters, Johnson, and Kaplan. (From Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol.2001;98(2):350–353.)
FIGURE 35.2. Negative and positive feedback loops of sexual function. (From Basson R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet Gynecol.2001;98(2):350–353.)
Physiology of Female Sexual Response
Systemically, the physiologic components of the female sexual response (Box 35.1) are mediated by increased activity of the autonomic nervous system and include tachycardia, skin flushing, and vaginal lubrication. Several neurotransmitters have been linked to the sexual response cycle. Norepinephrine, dopamine, oxytocin, and serotonin via 5-hydroxytryptamine (5-HT) 1A and 2C are thought to have positive sexual effects, and serotonin via most other receptors, prolactin, and γ-aminobutyric acid (GABA) are thought to affect the cycle negatively.
BOX 35.1 Components of Subjective Sexual Arousal in Women
• Mental sexual excitement—proportional to how exciting the woman finds the sexual stimulus and context
• Vulvar congestion—direct awareness (tingling and throbbing) is highly variable
• Pleasure from stimulating the engorging vulva
• Vaginal congestion—the woman’s direct awareness is highly variable
• Pleasure from stimulating congested anterior vaginal walls and Halban fascia
• Increased and modified lubrication—wetness is usually not directly arousing to the woman
• Vaginal nonvascular smooth muscle relaxation—the woman is usually not aware of this
• Pleasure from stimulating nongenital areas of the body
• Other somatic changes—blood pressure level, heart rate, muscle tone, respiratory rate, and temperature
Throbbing and tingling and feelings of urgency for more genital contact and vaginal entry are far less consistent for sexually healthy women than are the equivalent sensations in men. Sexually healthy women typically experience this confirmatory sexual stimuli indirectly by the enjoyment of manual or oral stimulation or genital stimulation with a vibrator, which are enhanced when there is vulvar engorgement.
The measurement most commonly used for vaginal congestion is the vaginal pulse amplitude. The upper portion of the vagina dilates via a mechanism that is poorly understood. Figure 35.3 demonstrates some of the physiologic changes seen in sexual response phases. The duration of each phase varies with each individual and for a given individual at different times in her life, and phases also can overlap. Moreover, the state of subjective arousal is itself cognitively appraised. Women consider the appropriateness of being sexual in a particular situation and evaluate their safety. This momentto-moment emotional and cognitive feedback modulates the experience of arousal. The value of the phases depicted, then, lies in their use in identifying the physiologic events that occur during intimate encounters leading to climax. Clinically, the provider can inquire, during the initial interview and in the course of ongoing therapy, about whether or not these responses exist.
FIGURE 35.3. Physiologic changes of sexual response phases: (A) excitement stage; (B) plateau stage; (c) orgasm stage; (D) resolution stage.
SEXUAL DYSFUNCTION
There is uncertainty as to what exactly constitutes a sexual disorder. The definition of “sexual disorder” is made more complex because what is considered “disordered” varies with time and culture. The World Health Organization’s International Statistical Classification of Diseases and Related Problems (ICD-10) suggests that sexual dysfunctions are “the various ways in which an individual is unable to participate in a sexual relationship the way he or she would wish.”Table 35.1 lists the categories of sexual dysfunction as recognized by both the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, which limits its definitions to mental disorders, and the 1998 consensus committee sponsored by the American Foundation of Urological Disease, which is also limited insofar as it conceptualizes sexual response in women as discrete linear experiences, as in the formerly accepted model of female sexual response already discussed. These definitions will continue to be revised and updated to address contextual and other factors.
FACTORS AFFECTING SEXUALITY
The relationship between an overall sense of personal well-being and sexual function is complex.
Depression
Approximately one third of women presenting with sexual dysfunction are clinically depressed. Among individuals in whom depression has already been diagnosed, the type and progress of ongoing therapy and prescribed medication should be noted.
Medications
The commonly prescribed selective serotonin-reuptake inhibitors, such as fluoxetine, paroxetine, sertraline, and escitalopram, can be associated with decreased sexual desire. The clinical observation that is helpful when evaluating the contribution of medications to female sexual dysfunction is that antidepressants that activate dopaminergic, (central) noradrenergic, and 5-HT1A and 5-HT2C receptors may augment sexual response, whereas those that activate other 5-HT receptors, prolactin, and GABA reduce sexual response. The medications least likely to interfere with sexual response are nefazodone, mirtazapine, bupropion, venlafaxine, and buspirone.
Further complicating this picture is that depression itself causes a decrease in sexual desire. Other medications that can be associated with female sexual dysfunction are included in Box 35.2.
BOX 35.2 Medications commonly Affecting Sexual Response
• Codeine-containing analgesics
• Alcohol (chronic abuse)
• Cyproterone acetate
• Medroxyprogesterone (high doses)
• Some β-blockers used for hypertension or migraine prevention
• Anticonvulsants taken for epilepsy (but not necessarily for other conditions)
• Oral contraceptives
• Selective estrogen receptor modulators (such as raloxifene, tamoxifen, and phytoestrogens)
Medical Conditions
Medical conditions that affect energy and well-being may indirectly affect sexual desire and response, particularly those that are associated with the loss of estrogen and/or androgen production (Box 35.3). Estrogen is thought to have both a direct effect (by supporting vulval and vaginal congestion) and an indirect effect (by influencing mood) on female sexual response. There is likewise a strong consensus that androgens are needed for sexual response in women, though the limitations of widely available laboratory assays have made it difficult to establish a direct correlation between specific androgen levels and women’s sexual desire.
Psychologic Factors
Psychologic factors commonly affect sexual response in women as well (Box 35.4). Psychologic factors continuously modulate any arousal experienced from sexual stimuli and influence the woman’s motivation to seek or respond to those sexual stimuli—compounding any negative effects from biologic factors.
BOX 35.3 Conditions Commonly Affecting Sexual Response
Conditions associated with loss of adrenal androgen production and/or loss of estrogen production
• Bilateral salpingo-oophorectomy
• Chemotherapy-induced menopause
• Gonadotropin-releasing hormone–induced menopausal symptoms
• Premature ovarian failure
• Oral estrogen therapy (may cause androgen insufficiency)
• Oral contraceptives (may cause androgen insufficiency)
• Addison disease
• Hypopituitary states
• Hypothalamic amenorrhea
Chronic renal failure
Chronic cardiac failure
Chronic neurologic conditions
Chronic renal disease
Arthritis
Hyperprolactinemia
Hypothyroid and hyperthyroid states
Conditions interfering with autonomic function and/or somatic genital nerve function
• Diabetes mellitus
• Multiple sclerosis
• Spinal cord injury
• Radical pelvic surgery
• Past Guillain-Barré syndrome
BOX 35.4 Psychologic Factors Commonly Affecting Sexual Response
• Past negative sexual experiences, including abuse
• Knowledge of a likely unsatisfactory or painful outcome (e.g., dyspareunia)
• Decreasing self-image (e.g., from chronic infertility)
• Potent nonsexual distractions
• Lack of physical privacy
• Feelings of shame, naiveté, or embarrassment
• Partner sexual dysfunction
• Lack of safety from pregnancy and sexually transmitted diseases
• Orientation concerns
• Fear of physical safety
MANAGEMENT
A woman’s sexuality is influenced by her health and emotional well-being; likewise, healthy sexual functioning promotes physical and emotional well-being. However, studies suggest that fewer than one half of patients’ sexual concerns are recognized by their physicians. The obstetrician–gynecologist has a paramount role in assessing sexual function and managing sexual dysfunction to ensure the well-being of his or her patients. Beginning with screening a patient for sexual dysfunction, taking her history, and assessing sexual dysfunction risk factors, the physician establishes a diagnosis if dysfunction is present and treats the patient or refers her for treatment, as appropriate.
Screening for Sexual Dysfunction
Discussions of sexuality are accomplished best in a confidential and supportive setting. Mutual trust and respect in the patient–clinician relationship will allow appropriate discussion of questions and concerns about sexuality. A nonjudgmental and respectful approach by the clinician, as well as awareness by the clinician of his or her own biases, is essential for effective care.
Patients are more likely to develop trusting relationships with their health care practitioners when the issue of confidentiality has been addressed directly. A confidential relationship, in turn, can facilitate the open disclosure of health histories and behaviors. The use of broad, open-ended questions in a routine history gathering can help disclose problems that require further exploration. Inquiry about the partner’s sexual function and level of satisfaction may elicit more specific information and give an indication of the couple’s level of communication.
Studies have suggested that screening for dysfunction can be as simple as three questions in the review of systems: “Are you sexually active (expressive, involved)?” “Do you have any sexual concerns (problems, troubles)?” and “Do you have any pain associated with sex?” If any of the responses suggest that a dysfunction may be present, further questions are in order. Questioning patients about their sexual desire, especially about responsive desire and the components of arousal, can point to management options about which patients and their partners can be counseled. Simply providing information, confirming that many women have the same concerns, and explaining how one aspect of dysfunction leads to another can be therapeutic.
The clinician should not make assumptions about the woman’s choice of partner. Although most women report that their sexual partners are men, some women only have sex with other women, and others may have partners of both sexes. The use of terms such as “partner” instead of “husband” and “sexual activity” instead of “intercourse” and an understanding of nonheterosexual sexuality—including that of lesbians, bisexual women, and transgendered individuals—will assist in open communication and assessment of the patient’s problem.
Additional History
The patient’s history is the crucial part of an assessment for sexual dysfunction. The duration of the dysfunction and whether it has evolved over months or years should be clarified. Long-term problems are particularly difficult to evaluate and manage, and a concomitant in-depth psychological assessment may be needed. The context of the patient’s life when the dysfunction began is needed, addressing psychological, biologic, and relationship factors. Her medical history and past sexual experiences are recorded, including medications and any substance abuse. The woman’s developmental history also may be needed, particularly if her dysfunction is lifelong.
Deliberate inquiries should be made to assess the quality of the interpersonal relationship between the patient and her partner, including mutual satisfaction with their sexual relationship. The perceived importance of physical intimacy for a given couple depends largely on whether or not they are satisfied with that aspect of their relationship. Among couples who are not experiencing sexual dysfunctions, each partner will estimate that the sexual component of their relationship accounts for approximately 10% of their overall happiness. In couples experiencing sexual difficulties, however, the sexual aspects are estimated as accounting for approximately 60% of the overall relationship quality. This dramatic shift in perception underscores the importance that physical intimacy holds within the context of the overall relationship.
Risk Factors
Women often disclose sexual disorders during visits for routine gynecologic care, whereas some patients present with a complaint involving a sexual issue or of a specific sexual dysfunction. Other patients neither express a sexually related complaint nor have a medical problem with a commonly associated sexual issue. Still other patients have a medical problem or have or have had a medical or surgical therapy that is known to be associated with sexual issues or problems (Box 35.5).
BOX 35.5 Medical Risk Factors for Sexual Disorders
• Depression, with or without antidepressants
• Breast cancer that required chemotherapy
• Radical hysterectomy for cancer of the cervix
• Multiple sclerosis
• Hypertension
• Diabetes
• Sexual abuse
In addition, sexual function may be affected by biologic and psychological aspects of reproduction and the life cycle (Box 35.6). The mechanisms governing the interplay between psychological responses to reproductive events and the biologic changes themselves are not well understood. However, women’s past sexual experiences, self-image, support from and attraction to their sexual partners, sufficiency of their knowledge of sexuality, and sense of control are all typically important factors.
BOX 35.6 Biologic and Psychologic Risk Factors for Sexual Disorders
• Healthy pregnancy
• Complicated pregnancy where intercourse and orgasm are precluded
• Postpartum considerations
• Recurrent miscarriage
• Therapeutic abortion
• Infertility
• Perimenopause
• Natural menopause
• Premature menopause (idiopathic and iatrogenic)
• Use of oral contraceptives
Establishing a Diagnosis
For each of the various dysfunctions, it is important to establish whether it is lifelong or acquired and to distinguish between dysfunctions that are situational and those that are global or generalized (Fig. 35.4). If the woman’s sexual response is healthy in some circumstances, physical organic factors are not involved in a dysfunction. It is, therefore, important to ask patients about their sexual response with masturbation, with viewing or reading erotica, and with being with individuals other than their regular partners—even if this activity does not involve physical sexual interaction.
FIGURE 35.4. Algorithm for establishing a diagnosis of female sexual dysfunction. (From Basson R. Clinical Updates in Women’s Health Care: Sexuality and Sexual Disorders. Vol. II, 2. Washington, DC: American College of Obstetricians and Gynecologists; 2003:36.)
Treatment
Some sexual problems can be managed by the primary physician, whereas others are best referred to a sex therapist. A detailed, sensitive, and respectful assessment will help establish a dialogue with the patient. It is difficult to distinguish between assessment and treatment, because the physician often provides information during the assessment that is therapeutic. Management may be within the scope of the obstetrician–gynecologic practice, or a referral may be appropriate, depending on the nature and the extent of the problem, and the physician’s comfort with addressing the issues. Box 35.7 shows interventions that commonly occur in gynecologic offices. Largely, the decision should be based on whether or not the physician has adequate resources to approach sexual dysfunction from an integrated perspective, rather than merely a biological one. Psychology, pharmacology, partner intimacy, and alternative therapies are some of the other factors that must be addressed in treating sexual dysfunction. Referrals to mental health practitioners, marriage or relationship counselors, or sex therapists may be appropriate. Box 35.8shows when and why to refer patients.
BOX 35.7 Primary care Treatments for Sexual Dysfunction
• Giving nonjudgmental and respectful information (e.g., of women’s sexual response cycles)
• Normalizing nonpenetrative sex to both partners
• Screening for depression and sexual side effects of antidepressants
• Screening for medication-associated female sexual dysfunction and advising alternative medications
• Replacing estrogen locally or systemically
• Replacing testosterone (formulations for women are currently being developed)
• Treating hyperprolactinemia, hypothyroidism, or hyperthyroidism
• Possibly using vasoactive drugs for genital arousal disorder in the future
• Applying the model of women’s responsive desire to the individual patient experiencing low desire, empowering her and her partner to make the necessary changes
BOX 35.8 When to Refer Patients with Sexual Dysfunction
The decision to refer a patient depends on a number of factors, including
• Expertise of the obstetrician–gynecologist
• Complexity of the sexual dysfunction
• Presence or absence of partner sexual dysfunction
• Availability of a psychologist, psychiatrist, or sex therapist
• Motivation of the patient (and partner) to undergo more detailed assessment before therapeutic interventions
More detailed assessments and management may be available from
• Physicians with extra training and expertise in sexuality—psychiatrists, family practitioners, gynecologists, and urologists
• Psychologists
• Sex therapists and abuse counselors
• Physiotherapists (regarding hypertonic pelvic muscle–associated dyspareunia)
• Relationship counselors
• Support groups (e.g., for women with past histories of breast cancer, women with vulvar vestibulitis syndrome–associated chronic dyspareunia, and women with interstitial cystitis–associated dyspareunia)
Clinical Follow-Up
The most common cause of reduced libido is depression. Social stresses, the demands of a household with multiple small children, and the possibility of fears about future pregnancy all suggest depression in this patient. A screening questionnaire confirms the suspicion, and with medication, social support, and counseling, her libido would be expected to resolve shortly.
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