William D. Petok1
(1)
Independent Practice, 479 Jumpers Hole Road, Suite 304 B, Severna Park, MD 21146, USA
William D. Petok
Email: bpetok@comcast.net
Keywords
AgingChildbirthChildrenMenopauseParenthoodPregnancyPostpartum
While the hope of most women is that sexual function will remain consistent throughout their life span, certain normal events can play a role in sexual function and dysfunction, most notably, pregnancy, children, and aging. Traversing these events without significant problem will be the course for most women. However, some will develop sexual problems that require intervention. Health-care providers who are prepared for these events in their patients’ lives will be able to assist them with these important transition experiences and help them to reduce the psychological impact these disorders can cause.
30.1 Pregnancy
Casey, a 25-year-old married to Robert for 2 years, was 2½ months pregnant with her first child when she sought therapy. She was anxious about the pregnancy, concerned that her desire was waning and equally worried that her husband was rapidly losing interest in her. He had declined to have intercourse with her several times over the past 2 weeks, saying he was tired. She certainly was tired but couldn’t understand why he would use fatigue as a reason to avoid something they had enjoyed so much for the past several years. A meeting with both of them revealed that he was worried about harming the baby growing inside her uterus. This, he said, was why he had avoided intercourse. He was embarrassed to tell her the truth and created the story.
For most women pregnancy is an expected consequence of their sexual lives. A number will experience the lack of pregnancy as a significant impediment to satisfying sex. The impact of infertility on sexual experience is discussed in Chap. 28.
One of the more common sexual problems during pregnancy is not a diagnostic entity at all. It involves a male’s reaction to the fact that his partner is carrying a child. A frequent comment notes his concern that intercourse will in some way harm the developing fetus. Treatment can be as simple as explaining that the fetus is well protected and he has nothing to worry about or more complicated and require significant education and assessment of potential anxiety issues that could underlie his concern.
It is significant to note that review articles conclude that female sexual function declines steadily during the course of pregnancy with the greatest decrements taking place during the third trimester [1]. These same authors highlight the complex interplay of psychological, cultural, ethical, and sexological factors along with organic and neurologic components that contribute to this end result.
Changes in desire are common during pregnancy. Depending on the incidence of morning sickness and fatigue, some women will find that desire declines during the first trimester and rebounds into the second and third [2]. One would hardly consider this decrement in desire a dysfunction, but it should be acknowledged as a normal occurrence. Similar symptoms at other times of the day will certainly create an impediment to desire that is understandable. Many health-care providers hear reports from pregnant women that they are unusually tired during the first trimester. Given that sex when tired is less desirable, some women will experience reduced sexual activity for this reason. Hormonal changes that can lead to decreased desire are also implicated in breast tenderness and anxiety that can further reduce desire and arousal [1]. Usually, reassurance that this will diminish with time is sufficient for the woman who is concerned about the situation.
As her abdomen increases in size and other physical effects of pregnancy are felt, desire may not be the issue. Rather, comfort during intercourse is the focal point. Women report difficulty with intercourse in the missionary position for a variety of reasons. Having a partner on top pushes the baby into her other organs and creates discomfort. A natural outgrowth of this situation can be a decline in desire. Experimentation with alternate positions for coitus as well as other forms of sexual stimulation can relieve the discomfort and maintain desire and sexual satisfaction. However, there is evidence that libido, clitoral sensitivity, and orgasm are all reduced during pregnancy [3, 4].
Women report fears that intercourse during pregnancy will cause abnormal bleeding, fetal damage, vaginal or urinary infections, and vaginal pain [3]. Research indicates that these events occur with relatively low frequency. More importantly, it appears that women are not very likely to discuss these concerns with their physician, suggesting that good practice anticipates questions about sexual function and associated problems early in pregnancy care to allay fears and prevent reduced sexual satisfaction during this time. Simply raising the issue by saying “Many people are concerned about sexual activity during pregnancy. Do you have concerns about this,” can open the door for a fruitful and prophylactic conversation. This approach is consistent with the observation that patients want to talk about sexual function and prefer their health-care providers to raise the issue because they may be embarrassed to do so themselves.
Most women are advised to refrain from intercourse for 6 weeks postpartum to allow for vaginal healing. This recess from sexual activity also takes into account the very real fatigue that women (and most likely their spouses) experience caring for a newborn. Problems with sexual function have been noted at 3 months postpartum that include coital pain, lack of vaginal lubrication, difficulty with orgasm, changes in vaginal “fit,” bleeding or irritation after sex, and loss of sexual desire [5]. Significant improvements in many of these symptoms were noted at 6 months postpartum. Several other studies have confirmed these findings. Elevated prolactin levels, which occur during lactation, suppress gonadotropin secretion and result in persistently reduced estrogen levels, thereby mimicking menopausal symptoms. Once again, preemptive counseling is recommended to help couples traverse what can be a sexually difficult period [1].
Clinical experience indicates that couples are often misinformed about how pregnancy will impact their sexual experience and are reluctant to bring the topic up with care providers. They may become anxious or depressed if they encounter problems. Having established that sexual function is part of overall health care can provide entry to this area [6], affording an opportunity to prevent the psychological impact if problems do arise.
30.2 Parenthood
Anna, 34, and Juan, 35, have 3 children who are 7, 4, and 2 years old. Anna works part time as a nurse, and Juan is a mechanical engineer. She entered therapy at the advice of her gynecologist after she reported a total loss of desire for sex. She was upset and worried that Juan would lose interest in her and even more so that she no longer wanted to engage in sex.
Raising children has its challenges and rewards. The opportunity to nurture new lives into productive people is something many women look forward to. While they may understand that the time invested in rearing children must come from somewhere, they may not appreciate how it can impact sexual activity and function. Popular culture complicates matters. Shoppers are inundated with sexual images and pronouncements from every grocery store checkout counter magazine section. Their overwhelming message is that phenomenal sexual experiences are what every woman wants and has. Reality is typically different. Such was the case with Anna and Juan.
Women’s intimate relationships necessarily change with parenthood. Some do report enhanced sexual intimacy, but a more frequent experience is dissatisfaction due to less time, energy, and opportunity for sexual activity with their partners. The physical and social demands of parenting are significant and include increased financial pressures as well as the tasks that raising children requires. Some find themselves “sandwiched” between children and aging parents that require attention of their own. For newer parents, the introduction of other members to a family can interrupt the rhythm that the couple has established prior to the arrival of children. A consequence is that couples must readjust their expectations of what is reasonable sexually. If one partner takes on a disproportionate responsibility for child-rearing, the other can feel abandoned or sexually undesirable. This can lead to discord about what is the optimal level of sexual closeness.
In some cases, a resolution is as simple as helping the couple define what the problem is and how they can set aside time for intimacy that is comfortable for both. In other cases, it will be more complex. Sexual dysfunctions can develop during child-rearing years that are more significant. The biological bases of these problems and their treatment are discussed in the preceding chapters in this section.
Declines in desire that are the result of unsatisfying sexual relations do take place. Changes in sexual patterns that worked well for the couple in the early stages of their relationship can suffer when fatigue prevents either the length of time available or the energy for similar kinds of activity that were satisfying before. For example, a woman may take more time to relax enough to achieve an orgasm and her partner may tire before she climaxes, or she may have grown accustomed to time snuggling after sex and her partner now falls asleep quickly afterwards, leaving her less satisfied by the encounter. As a result, desire for sexual activity wanes.
Pain problems can also occur. Women who have had episiotomies and do not heal properly can find intercourse painful. Similarly, changes in lubrication can also cause discomfort. Some women will develop pain related to vulvodynia or other related problems. While not associated with parenting, if these conditions develop during child-rearing years, they will influence the trajectory of the couple’s sexual interactions.
Partners can also have pressures, financially and otherwise, that render them less desirous of sexual activity. In some cases, longer work hours to compensate for lost income because a spouse is now home with children rather than earning produce less interest. Similarly, anxiety about insuring a family’s financial stability can result in decreased sexual desire.
Remarkably, little research exists on the impact of parenthood on sexual function and satisfaction. Twenge et al. [7] reviewed the research on the impact of parenthood on marital satisfaction and noted that having children actually causes small declines in marital satisfaction. They postulated that some of the dissatisfaction is caused by men’s greater desire for sex producing frustration due to the demands that childbearing and child-rearing place on sexual availability of partners. As children grew older, the dissatisfaction of women with their marriages declined. In other words, women with older children had greater marital satisfaction.
Ahlborg et al. [8] reported that average sexual frequency declined from prior to pregnancy and childbirth and remained low between 6 months postpartum and the first child’s fourth birthday. Tiredness as a hindrance to having sex was the primary factor for this decline. Another study of 2081 women 33–43 years old found that multiparous women had fewer orgasm problems compared to nulliparous women. The authors also determined that nulliparous women had more pain problems and had less sexual satisfaction than women with children, irrespective of the number of children, providing a positive perspective on the impact of children on partner sexual relations [9].
Finally, and quite interestingly, a study evaluated the impact of stress on sexual relationships in couples [10]. The majority of partners were 31 or more years old. While the number of children was not specifically studied, it is reasonable to assume that many of the couples had children. Sexual desire problems were the most frequently reported issue for both men and women. The second most common problem for women was orgasmic difficulties. Premature ejaculation was second most reported problem for men. The authors concluded that stress arising from issues between the partners played a significant role in understanding sexual dysfunctions in the women in the study. Stress from life events outside of the partner relationship played a lesser and statistically insignificant role. Several recommendations are offered including the application of stress management and improved partner problem resolution and communication skills.
Anna and Juan benefited from adjusting to the idea that sex would be more likely to take place when they could create time in their schedule for it. Many couples object to the loss of spontaneity that they believe “should” accompany sexual activity. However, once they see that busy lives with complicated schedules leave little “spontaneous” opportunity, they can see the value of a somewhat more plan-full approach. This isn’t to suggest that sex becomes scheduled like a carpool. It does mean that some thought put into “when and how” will make for a more satisfying outcome. Some even find that anticipation of these events leads to greater arousal and closeness.
30.3 Aging
Sharon, 75, and her husband, Robert, 79, hadn’t made love in 8 years. She’d developed arthritic hips and had gained weight over the years, making intercourse difficult. Add to that the discomfort that thrusting caused, and it seemed obvious why they had been sexually inactive. But that wasn’t the full story. Robert had melanomas on both legs, and the treatment was painful. In addition, his erectile dysfunction hadn’t responded to medication interventions. However, the most significant issue was that they never talked about their lack of sex.
Joan and Gary were married 40 years as she was turning 70. Both were retired and engaged in activities together and separately. Fortunately, their health was good and they were mobile. She noticed that while they continued to share an intimate relationship that included sex, it was different than it had been in their 30s. It took both of them longer to become aroused, and they enjoyed a different kind of sensuality that included less frequent intercourse. Instead, they had more manual and oral stimulation which they found satisfying. She continued to be orgasmic and still found their sexual experience very pleasurable.
Both of the vignettes above describe possible outcomes for women as they age. The first describes a woman who has dealt with significant issues of her own. Her sexual experience has been compounded by the physical constraints of her partner. Most importantly, the manner in which she and her husband relate with one another has a substantial impact on her satisfaction. In the second vignette, normal and predictable changes in sexual response seem to have minimal impact on the outcome of the woman’s sexual experience. She and her partner have accommodated to these changes and probably improved what was a good sexual relationship prior to menopause. Could it be that the best predictor of the present is the past?
Women who have regular reproductive health care can be prepared for the inevitable changes that menopause and later life can bring to sexual function. They can be aware that many processes which contribute to a positive sexual experience will slow down or diminish. Thinning of the vaginal epithelium, reduced pelvic blood flow and vaginal lubrication can lead to discomfort with intercourse. Muscles that aren’t as strong, joints that aren’t as flexible, and changes in the nervous system can make some activities less satisfying. All of these normal occurrences can require adaptations to sexual activities in order to ensure a pleasurable outcome. And of course, a partner who is capable and willing to adapt is essential.
The Rancho Bernardo Study highlights the understanding that older women can have satisfying sexual lives [11]. A cohort of women with a median age of 67 and a mean number of years postmenopause of 24.6 years was studied. The researchers note that, as one would expect, sexual activity, frequency, and desire declined with age. At the same time, despite partner status or sexual activity, 61 % of the cohort reported being moderately or very satisfied with their overall sexual life.
The same study also reported that a very small fraction of the women reported sexual desire “almost always” or “always,” and they were in the younger portion of the sample. Interestingly, current hormone use, sexual activity, and frequency of arousal, lubrication and orgasm were positively associated with sexual desire. This suggests that older women who “use it” don’t lose it! In the group of sexually active women over 80 years old, 23 % reported arousal almost always or always, and 28 % of women who were aroused reported lubrication at the same level as arousal. There was no significant relationship between hormone use and lubrication, and 37.5 % of the oldest age group reached orgasm always or almost always. Pain or discomfort with intercourse was reported as low, very low, or nonexistent by 71 % of the oldest cohort. The authors note that there are limitations to their research including the homogeneity of the population studied and response bias that could exist from only those with the best emotional and physical health participating. Nevertheless, the research indicates that sexual function in older age can be satisfying and active [11].
However, there are some women who will not have such a good outcome and will have an experience more like Sharon in the first vignette. For those women who wish to have more satisfying encounters, modifications to their sexual activity will be necessary and can require psychological as well as sexological counseling that involves both them and their partners. Intercourse may not be possible for a variety of reasons. Pain, both from intromission or other physical constraints, may make intercourse very uncomfortable. They may benefit from interventions that increase physical touch along the lines of sensate focus exercises [12]. While a variety of medical interventions such as lubricants, vaginal moisturizers, and hormonal therapies can be useful, communication skills to improve how a woman discusses sexual interaction with her partner can also help. Creating expectations for sexual experience that are in line with their physical realities is also essential. Women may have been led to believe that aging and sexual activity are diametrically opposed. On the other hand, they may have come to believe that sexual activity and satisfaction are invariant throughout the life span. The former group will benefit from an improved awareness of the possibilities and the latter from a recalibration in a different direction. At a minimum, counseling that offers hope and provides direction on how to achieve greater satisfaction is useful.
For example, Sharon and Robert benefited from directed discussion about what each of them found comfortable with regard to physical activity during sex. She was thrilled to have him touch her gently and not necessarily on her genitals. He was pleased that his erection wasn’t the most important thing to her. Sensate focus helped them with this. Separate work with Robert to help him deal with the loss of sexual function was necessary. A therapist competent in dealing with aging issues and the losses inherent in them is essential in these cases.
30.4 Summary
Various normally occurring events in the life cycle can and do have an impact on sexual function and satisfaction. Health-care providers who are aware of these events and can predict some of the possibilities for their patients will serve to limit the potential negative impact of these events. Normalizing changes in sexual function throughout the life span is an essential first step. Providing good resources and referrals is a close second.
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