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HACKER & MOORE'S ESSENTIALS OF OBSTETRICS AND GYNECOLOGY: WITH STUDENT CONSULT
ONLINE ACCESS,5TH ED.


CHAPTER 27


SEXUALITY AND FEMALE SEXUAL DYSFUNCTION

Joseph C. Gambone

Sexuality refers to how individuals express themselves as sexual beings.
Physically, sexuality encompasses sexual intercourse and other forms of sexual
contact. Often patients may have medical concerns about their sexual feelings
and behavior and how these activities may affect or be affected by disease.
Obstetrician-gynecologists should be familiar with the physiology of human
sexual response and the types of sexual dysfunction that women may experience.
Because female sexuality is most often expressed with another individual,
usually male, it is important for healthcare professionals who take care of
women to know the more important aspects of the male sexual response. The
sociologic aspects of human sexuality and sexual behavior, such as cultural,
ethical, moral, religious, or legal, are beyond the scope of this chapter.

 Sexual Development

Although sexuality and sexual expression rarely begins before puberty, gender
identity is experienced much earlier, at about age 3 to 4 years. Children who
are unable to identify with their assigned birth-gender have gender identity
disorder (GID) and may develop transgender issues later in life. The diagnosis
of GID can be made in an individual who has a strong and persistent cross-gender
identity and a discomfort about the assigned gender.

During puberty, many teens begin exploring their bodies as well as experiencing
sexual activity with others. Many teens, especially males, have early
intercourse and are not well educated about contraception, the risks for
pregnancy, or sexually transmitted infections (STIs). Young girls often have
intercourse because of feelings of love, whereas boys are usually driven by
curiosity. It is especially important for physicians to discuss sexuality with
teens and to educate them about contraception and STI prevention. Teens are
often apprehensive about discussing these issues and may fear parental
discovery. They are usually more receptive to open-ended questions.

The early reproductive years are often the time when sexuality is explored and
reproduction or its prevention becomes a priority. Infertility may be an issue
in this age group, and many emotions may be evoked in infertile patients, often
leading to sexual problems.

With increasing age and especially after menopause, the frequency and
satisfaction with intercourse may decline. Decreased estrogen production causes
progressive vaginal atrophy, which in turn leads to decreased vaginal
lubrication, dyspareunia, and more difficulty in achieving orgasm. The decreased
estrogen also decreases the acidity of the vaginal secretions, predisposing the
woman to vaginal infections.



In many older couples, the frequency of intercourse declines because of the male
partner’s inability to have erections. Illnesses or increased use of medications
may also affect sexual functioning. A better understanding of the causes and
more effective treatment for male erectile dysfunction are changing sexual
behavior for many older individuals.

 Variation in Sexual Expression

Human sexual expression is varied and often controversial. Health-care
professionals must be knowledgeable and nonjudgmental about healthy and legal
sexual expression and lifestyles to facilitate open and comfortable
communication.

Heterosexuals are individuals who engage in sexual activity with the opposite
sex. Most individuals engage in heterosexual behavior, which is considered
“normal.” Homosexuals are those who engage in sexual activities with members of
the same sex. Men who are homosexual are referred to as gay, whereas homosexual
women are referred to as gay or lesbian. Although gay men tend to engage in more
physical relationships and may have multiple partners, lesbians are generally
inclined to be monogamous.

The reported incidence of homosexuality ranges from 6% to 20% in men and 3% to
18% in women. Several theories on homosexuality have been proposed, including a
genetic predisposition, the maternal use of prenatal hormones, and other
environmental factors. A multifactorial cause is likely.

Many homosexuals feel a need to conceal their sexuality for fear of loss of
family, friends, or jobs. Familiarity with homosexuals has been shown to
decrease the prejudice, and recently many homosexuals have “come out,” revealing
their identities and expecting equal rights.

Bisexuals are those who engage in sexual activity with both men and women,
either concomitantly or at different phases of their life. The reported
incidence of bisexuality is 1% to 7% of men and 1% to 2% of women. Many
individuals briefly explore same-sex activity at some time in their life but do
not consider themselves bisexual.

Transgender or transsexual individuals are often confused with homosexuals. They
have a strong belief from childhood that they were born into a body with the
wrong sex. Most are heterosexual to their identified gender (i.e., men who
believe they are women are attracted to men), and few are homosexual. Children
with ambiguous genitalia who are assigned a particular gender may later show
regret toward their assignment. Some experts recommend that these children be
given a name that is appropriate to both genders to allow them to decide their
gender for themselves later in life. Female-to-male transsexuals (FTM) are women
that grow up as “tomboys” and often cross-dress. Male-to-female transsexuals
(MTF) are men that grow up dressing as women. Transgender surgery is difficult
to perform, especially FTM, and it is only performed in certain areas of the
United States and the world. Box 27-1 lists some other variations in human
sexual expression along with their definitions.



BOX 27-1 Other Forms of Sexual Expression and Their Definitions

Transvestism: Sexual excitement or gratification from wearing clothing of and
enacting the opposite sex



Fetishism: Sexual excitement or gratification associated with an inanimate
object (i.e., underwear) or body part (i.e., feet)



Pedophilia: Sexual excitement or gratification from children

Zoophilia: Sexual excitement or gratification through intercourse with animals

Exhibitionism: Sexual excitement or gratification from exposing one’s body,
especially the genitals

Voyeurism: Sexual excitement or gratification from watching others

Masochism: Sexual excitement or gratification from enduring physical or
physiologic pain; may be self-inflicted

Sadism: Sexual excitement or gratification from inflicting physical or
physiologic pain onto others; also cruelty not associated with sexual behaviors



 Sexual Response

The process of sexual response was fully described by Masters and Johnson in
1966 based on extensive research. They delineated the female and male physical
sexual response cycles. Although other modifications have been published, their
version remains the classic description of human sexual response. The female
cycle is divided into four phases, whereas in men, five phases are described.
Generally, clitoral tissue is the most sexually sensitive anatomic area for
women. Most women need to experience a caring relationship and nongenital
physical stimulation before satisfactory sexual arousal can occur.

FEMALE SEXUAL RESPONSE CYCLE

The Excitement Phase

This phase starts with physical or psychological stimulation and may last
minutes or hours. There is a sex flush, accompanied by erection of the nipples
and engorgement of the breasts. A sex flush is an erythematous morbilliform skin
change over the chest, neck, and face that occurs to a noticeable degree in 75%
of women. In addition, the uterus elevates, and vaginal lubrication begins. The
clitoris and labia enlarge, and the heart rate and blood pressure increase. Most
muscles become tense (Figure 27-1A).



FIGURE 27-1 The four phases of the female sexual response cycle. A: The
excitement phase. B: The plateau phase. C: The orgasmic phase. D: The resolution
phase.

The Plateau Phase

During this phase, the breasts continue to enlarge, and the clitoris may elevate
and retract under its hood. The Bartholin’s glands may secrete fluid near the
vaginal opening, and there is tenting of the uterus to allow easier passage of
sperm. The vagina and labia become more engorged, and there is increased blood
pressure, heart rate, respiratory rate, and muscle tension (see Figure 27-1B).

The Orgasmic Phase

During this phase, there is release of sexual tension. The orgasmic phase is
possible without actual physical stimulation. This phase is concentrated in the
clitoris, vagina, and uterus. There is contraction of vaginal, uterine, lower
abdominal, and anal muscles, usually 5 to 12 synchronized contractions 1 second
apart. The first few contractions are the strongest and the closest together.
Blood pressure, heart rate, and respiratory rate peak in this phase, and there
is usually loss of voluntary muscle tone (e.g., most women curl their toes at
orgasm). Women can have multiple orgasms before they enter the resolution phase
(see Figure 27-1C).

The Resolution Phase

During this phase, the nipples and breasts decrease in size, and the vagina,
clitoris, and uterus return to normal size and position. The sex flush
disappears, and the blood pressure, heart rate, and respiratory rate also return
to normal (see Figure 27-1D).

MALE SEXUAL RESPONSE CYCLE

The Excitement Phase

This phase begins with physical or psychological stimulation and may last
minutes or hours. The nipples and penis become erect, and there is increased
heart rate and blood pressure. The muscles become tense, and there is blood
pooling in the extremities with vasocongestion in the penis and scrotum with
testicular swelling and elevation (Figure 27-2A).



FIGURE 27-2 The five phases of the male sexual response cycle. A: The excitement
phase. B: The plateau phase. C: The orgasmic phase. D: The resolution
phase. E: The refractory phase (not illustrated).

The Plateau Phase

The testicles enlarge by 50%, and the prostate and penis also enlarge. There is
increased blood flow, and the bulbourethral or Cowper’s gland secretes
pre-ejaculatory fluid, which may contain sperm. There is increased blood
pressure, heart rate, respiratory rate, and muscle tension. There is generally
chest sex flushing (see Figure 27-2B).

The Orgasmic Phase

During the orgasmic phase, there is release of sexual tension; this phase is
possible without actual physical stimulation. There are rhythmic contractions of
the seminal vesicles, vas deferens, and prostate. The ejaculatory ducts push
semen into the urethra, and ejaculation occurs with urethral contractions. The
first few contractions are the strongest and the closest together. During this
phase, the anal sphincter contracts. The point of imminence occurs a few seconds
before ejaculation and refers to the point when a man knows an orgasm is
inevitable (see Figure 27-2C).

The Resolution Phase

In the resolution phase, the genitals and penis decrease in size and return to a
flaccid state. The testes descend, and the sex flush disappears. The blood
pressure, heart rate, and respiratory rate return to normal (see Figure 27-2D).

The Refractory Phase

The refractory phase (not illustrated) occurs only in men. Because of this
phase, men are not able to have multiple orgasms. During this phase, no amount
of stimulation will cause another ejaculation. This phase lasts minutes in young
men and hours to days in older men.

The similarity between the male and female cycles is apparent. Although the
average time spent in each phase may differ (due primarily to learned
behaviors), the elements of each cycle are the same. Because different neuronal
circuits mediate each of these phases, sexual dysfunction may affect some phases
without affecting the others.

 Sexual Dysfunction

The overall prevalence of sexual dysfunction is not known, but female sexual
dysfunction is common. It has been estimated that one third of women experience
decreased libido in situations in which the decrease is not desired. Comorbid
conditions such as diabetes or obesity often play a causative role in sexual
dysfunction, and not all women who lack interest in sexual activity are troubled
by it.

EVALUATION OF SEXUAL FUNCTION

The assessment of sexual functioning should be an integral part of a complete
medical evaluation, especially for the obstetrician-gynecologist. Skills for
taking a sexual history are often overlooked in medical schools and sometimes
ignored by physicians. It is more difficult to inquire about a patient’s
sexuality if the physician is uncomfortable with the topic or is judgmental
about sexual orientation. Clinicians may also be concerned about a patient’s
answers, not knowing what to say or do if a history of sexual trauma is
revealed. They may also feel untrained to deal with problems and solutions for
sexual inadequacies. Often, they worry that the patients will misunderstand or
be offended by the questions.

In taking a history, it is helpful to follow a routine pattern of questioning:
(1) age of menarche, (2) menstrual patterns, (3) pregnancy history, (4)
contraception use, (5) STI prevention, (6) sexual orientation, and (7)
difficulties with sexual relations. Intimate partner violence and sexual abuse
questions can then follow. Some sample questions may include the following:



• “Are you currently sexually active, and if so, with men, women, or both?”



• “Are you having any difficulties with sexual relations?”

• “Have you ever been in a situation in which you have experienced unwanted or
harmful sexual activity?”

There are several factors that may affect taking a sexual history, including the
physician’s own sexuality. A gay physician may be more thorough or may be afraid
to inquire about a patient’s sexual orientation. At times, clinicians of both
sexes may find themselves attracted to patients. In these instances, acceptance
of the feelings as normal is appropriate, so long as behavior is unaffected and
a professional relationship is maintained. Some patients may be seductive or
even make sexual advances, but the physician must make it clear to the patient
that the relationship is professional and not personal.

Appropriate boundaries of behavior during a physical examination must be
maintained, and caution should be used with inappropriate language or overly
friendly conversations. The patient may feel uncomfortable, especially with a
doctor of the opposite sex, and fearful about potentially embarrassing
discoveries, especially during the examination of the breasts and genitals.
Drapes should be used to cover all the private body parts that are not being
examined, and the physician should tell the patient what he or she is doing at
all times. A nursing assistant or chaperone should be present during the
examination.

FEMALE SEXUAL DYSFUNCTION

Sexual dysfunction is categorized by the Sexual Function Health Council of the
American Foundation of Urologic Disease by failure of one or more of the phases
of the sexual response cycle. Sexual dysfunction also includes pain disorders
(Box 27-2).



BOX 27-2 American Foundation of Urologic Disease Consensus Classifi cation of
Female Sexual Dysfunction

Sexual Desire/Interest Disorders∗

Hypoactive sexual desire disorder

Sexual aversion disorder

Sexual Arousal Disorder∗

Female sexual arousal disorder∗

Sexual Orgasmic Disorder∗

Sexual Pain Disorders∗

Dyspareunia

Vaginismus

Other sexual pain disorder (genital pain from noncoital stimulation)

∗ Each disorder can be subtyped as lifelong vs acquired, generalized vs
situational, and by origin (organic, psychogenic, mixed, or unknown).



Female sexual dysfunction is a common condition and often increases with age.
Sexual dysfunction can be subdivided into three different categories, depending
on whether it is primary (realistic sexual expectations have never been met
under any circumstances), secondary (all phases have functioned in the past, but
one or more no longer does), or situational (the response cycle functions under
some circumstances, but not others). When a patient complains of hypoactive
sexual desire, it is important to determine what her preferences are in contrast
to those of her partner. A woman who desires intercourse twice a week may be
perfectly normal but may not function well in a relationship in which her
partner desires coitus daily. Sexual dysfunction can occur in homosexual or
heterosexual relationships, or even in masturbatory situations.

ETIOLOGY OF SEXUAL DYSFUNCTION

As a general rule, primary problems are predominantly psychogenic and tend to be
of longer duration. Secondary problems are often associated with the onset of a
disease process or the use of a pharmacologic agent. If such an association
cannot be established, deterioration in the patient’s relationship or some other
chronologically related change in the patient’s life experience should be
sought. It is important to consider psychological causes, such as depression or
anxiety; organic causes, such as atherosclerosis, diabetes, or genital
infections; and pharmacologic causes (Box 27-3). Factors initiating a problem
may be different from those maintaining it. For example, drugs may precipitate a
problem, but if anxiety and fear of failure sustain the difficulty,
discontinuation of the drug alone may not rectify the problem.



BOX 27-3 Some Drugs that Can Diminish Sexual Functioning in Women

• Antihypertensive agents: reserpine, propranolol, methyldopa, atenolol,
spironolactone

• Antidepressant medications: tricyclics or selective serotonin reuptake
inhibitors

• Hypnotic agents: alcohol, barbiturates, tranquilizers, or diazepam

• Narcotics: heroin or methadone

• Antipsychotic agents: fluphenazine or chlorpromazine

• Stimulants: cocaine or amphetamines

• Hallucinogens: lysergic acid or mescaline

• Diuretics: acetazolamide



SEXUAL FUNCTION DISORDERS

Sexual Desire and Interest Disorders

Sexual desire appears to be an appetite similar to hunger, controlled by a
dopamine-sensitive excitatory center, in balance with a serotonin
(5-hydroxytryptamine)-sensitive inhibitory center. In both males and females,
testosterone appears to be the hormone responsible for initially programming
these centers during gestation and for maintaining their threshold of
response. Stimulation and ablation experiments in cats and other mammalian
species have located these centers within the limbic system, with significant
nuclei in the hypothalamic and preoptic regions. For a woman, desire and
interest in sexual activity result from a complex of both biologic and
psychological inputs, including her feelings about her partner.

Disorders of sexual desire and interest include hypoactive sexual desire
disorder and sexual aversion disorder. Lack of desire involves a decrease or
absence of fantasy. Sexual aversion disorder may result from prior
sex-associated trauma and personal aversion. Often in established relationships,
decreased desire may result from sexual activity becoming too predictable and
routine. Also, lack of privacy or external stresses, especially stress in the
relationship, may initiate this disorder. Another important category of causes
of hypoactive desire arises in the context of unrelated disease. Women may fear
sex with a partner who has had a heart attack or may have decreased desire
themselves following a mastectomy or hysterectomy.

Arousal-Phase Disorder

Sexual arousal disorder is defined as the inability to attain or maintain
sufficient sexual excitement, expressed as a lack of subjective excitement or
somatic response such as genital lubrication. Estrogen is the hormone
responsible for maintaining the vaginal epithelium and allowing transudation and
lubrication to occur. Its deficiency (with breastfeeding or after menopause) is
by far the most common cause of excitement phase dysfunction in women.
Extragenital changes during the excitement phase include an increase in heart
rate and blood pressure, enhanced muscle tension throughout the body, an
increase in breast size, nipple erection, and engorgement of the surrounding
areolae, and a sex flush. Some women do not recognize these symptoms as
excitement and may experience difficulty and even failure on that basis.

Orgasmic-Phase Disorder

During the orgasmic phase, a series of reflex clonic contractions of the levator
sling and related genital musculature occur, mediated primarily by the
sympathetic nervous system.

Orgasmic disorder is characterized by difficulty with or failure to attain
orgasm following sufficient sexual stimulation and arousal. Anorgasmia may be
situational. Many women experience orgasm only with manual or oral clitoral
stimulation but not with penile thrusting alone. If they are willing to increase
direct clitoral stimulation before, during, or after penile penetration, they
may achieve a wholly satisfactory sexual adaptation. Women who have been
orgasmic in the past but have lost that capacity should be screened for organic
or pharmacologic causes, and changes in their relationship or relationships
should be carefully explored.

Most women with primary anorgasmia have had minimal or no effective stimulation
from self or partner. These patients should be encouraged to learn how to
achieve orgasm through self-stimulation, and then to share this new information
with their partners. Increasing the intensity of stimulation should increase the
intensity of response.

Sexual Pain Disorders

Dyspareunia is genital pain associated with sexual intercourse. It is helpful to
categorize dyspareunia into three groups for easier diagnosis and treatment:
(1) pain with intromission (often due to vestibulitis, vaginismus, fissures, or
other vulvar lesions); (2) mid-vaginal pain (often due to lack of lubrication,
surgical scars, or urethral diverticulosis); and (3) deep-thrust
dyspareunia (often due to endometriosis, interstitial cystitis, pelvic
adhesions, or neoplasms).

Vaginismus is defined as severe pain or involuntary spasm of the distal vaginal
and pelvic floor muscles during attempted penetration. Examination reveals no
organic condition, but the pubococcygeal muscles are tight, and vaginal
penetration by speculum or examining finger is painful and difficult, if not
impossible. Often affected women harbor fantasies about the inadequacy of their
vaginas to accommodate a speculum or penis and fear that penetration will damage
them. These women respond remarkably well to education and reassurance. Others
may have been traumatized by early sexual or other abuse and require more
intensive psychological therapy. One important issue is whether they are
motivated to participate with their partners in a stepwise desensitization
program. This involves the slow, gentle vaginal insertion of dilators of
gradually increasing size under the patient’s own control. Once sufficient
progress has been made, the partner’s fingers and, ultimately, his penis may be
substituted for the dilators. Alleviation of the problem is usually accomplished
in 3 to 6 months.

Noncoital sexual pain disorder is pain that is induced by noncoital sexual
stimulation.

MANAGEMENT OF SEXUAL DYSFUNCTION

Hormonal therapy is valuable in a limited number of situations. Estrogen (orally
or vaginally) may improve desire, arousal, and orgasm by decreasing dyspareunia
due to vaginal atrophy. Testosterone may improve desire and arousal but should
be used only in hypoandrogenic women, especially after surgical
menopause. Sildenafil (Viagra), used mostly in men with erectile dysfunction,
inhibits cyclic guanosine monophosphate (cGMP) breakdown, therefore increasing
clitoral and vaginal smooth muscle relaxation as well as improving lubrication.
cGMP functions as a messenger in the nitric oxide–mediated relaxation of genital
smooth muscle,. The use of sildenafil in women has not been as effective as in
men.

A clitoral vacuum device (the EROS-CTD) has been approved by the U.S. Food and
Drug Administration and is said to improve clitoral blood flow and
engorgement. Fantasy therapy is helpful for hypoactive
desire,and sensate-focusing therapy is helpful for excitement-phase defects.

TREATMENT SUCCESS

As a group, orgasmic difficulties appear to respond to treatment most
readily. For example, primary orgasmic difficulties may be resolved by means of
guided masturbatory training and cognitive behavioral sex therapy. Secondary
anorgasmia is more often associated with emotional or psychiatric disorders and
relationship issues, so treatment is less effective. Excitement-phase
dysfunctions do not have such positive outcomes, although problems with
lubrication can nearly always be resolved satisfactorily. Lack of desire is the
most resistant to treatment. Persons with little desire often have little
internal motivation to seek more frequent sexual activity or to pursue help.
Fewer than half of such patients show definite improvement. When the
relationship is poor, behavioral approaches directed toward the sexual problem
are rarely successful. Studies using medical and pharmacologic interventions for
female arousal or orgasmic disorders, in contrast to those for erectile disorder
and premature ejaculation in males, are still ongoing but show some promise.

SUGGESTED READING

Berman J.R., Goldstein I. Female sexual dysfunction. Urol Clin North Am.
2001;28:405-416.

Esposito K., Giugliano F., Ciotola M., et al Obesity and sexual dysfunction,
male and female Jul-Aug. Int J Impot Res, 20(4); 2008:358-365. Epub 2008: April
10

Frank J.E., Mistretta P., Will J. Diagnosis and treatment of female sexual
dysfunction. Am Fam Physician. 2008;77:635-642.

Hayes R.D., Dennerstein L., Bennett C.M., et al. Risk factors for female sexual
dysfunction in the general population: Exploring factors associated with low
sexual function and sexual distress. J Sex Med. 2008;5(7):1694-1701. Jul

Palha A.P., Esteves M. Drugs of abuse and sexual functioning. Adv Psychosom Med.
2008;29:131-149.


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