Human sexuality

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Chapter 30 Human sexuality

In the past 50 years more people than ever before have been able to learn about human sexuality and the human sexual response. Discussion about human sexuality has become more open.

Sexual problems within a relationship are not uncommon, and women and men now feel able to seek advice about them. Often the first reference point is the person’s general practitioner. General practitioners, like other people, have inhibitions about sexuality and a variety of values about sexual behaviour. These inhibitions and values are based on the person’s religious beliefs and upbringing, and on values obtained from parents and colleagues. If a medical practitioner is uncomfortable discussing sexual problems with patients they should refer the patient to a colleague. If the medical practitioner feels able to treat sexual dysfunctions they should try to determine the patient’s sexual values and try to solve the problem within that value system.

Sexual advice can only be given if the practitioner has some knowledge of sexuality and sexual behaviours.

SEXUALITY

Sexuality may be defined as the sum of a person’s inherited characteristics, knowledge, experience, attitudes and behaviour as they relate to being female or male. Human sexuality is as much psychological as physical, and involves feelings as well as physicality. It includes communication with the other person and being open to and respecting their wishes. It also involves touching and exploring each other’s bodies to learn the textures and surfaces, and the sight and smell of another person.

Sexuality includes the sexual drive, which is the sum of the desire to have sex and the ability to accomplish the act. Sexual drive varies considerably between people. In some, a low drive is due to constitutional factors such as ill health or advanced age. In others, low drive is due to a traumatic sexual experience in childhood or adolescence. Recently, more women are reporting that they have been sexually assaulted in childhood or early adolescence, and this can be the basis of a fear of sex and a low sexual drive.

During adult life the intensity of the sexual drive is maximal in the years up to the age of 40, and tends to lessen after this time, but there are considerable variations. Problems may arise if the sexual drive of two partners is markedly different.

HUMAN SEXUAL RESPONSE

The physiology of the human sexual response was not described until 1966, by Masters and Johnson. For descriptive purposes they divided the sexual response in women and men into five phases, although the distinction between each phase is often blurred and one phase tends to merge into the next provided the appropriate stimulation occurs.

The phases are:

• Sexual desire

• Sexual arousal or excitement

• Resolution.

Care needs to be taken to not see these phases as directional, assuming orgasm to be the goal.

Sexual desire is stimulated by the thought, sight, touch or smell of another person. It may be suppressed, or merge into the arousal phase.

In the arousal phase, a man’s penis becomes erect and a woman’s vagina becomes lubricated. In this phase, sexual enjoyment is increased if the couple pleasure each other sexually by cuddling, stroking and exploring each other’s body with fingers, tongue, lips and thighs. Arousal is increased further if the erogenous zones of the body, a woman’s clitoral area, breasts and vulva and a man’s penis and scrotum, are stimulated. A woman’s breasts become larger due to engorgement with blood, and her nipples become erect. Her clitoris increases in width and becomes more sensitive to touch, and her labia and the lower part of her vagina become congested and softer and thicker. The subvaginal tissues become increasingly congested, and fluid transudes between the vaginal cells to increase lubrication.

During the following plateau phase, the sexual pleasure is intensified and the partners desire to have penile–vaginal, penile–oral or penile–anal penetration. The thrusting movement of the penis in the vagina, or its oral stimulation, causes an orgasm in the man, with the ejaculation of seminal fluid. In 90% of women the thrusting of the man’s penis in her vagina indirectly, or the digital or oral stimulation of her clitoral area directly, leads to orgasm. Fifty per cent of sexually active women reach orgasm when the clitoral area is stimulated by finger or tongue; 25% reach orgasm during penile thrusting in the vagina; 15% of women can achieve multiple orgasms; and the remaining 10% are unable to achieve orgasm, although they may enjoy their partner’s pleasure.

Orgasm provides an intense feeling of pleasure. During orgasm, the perineal muscles, the medial fibres of the levator ani and the sphincter ani muscles contract rhythmically and involuntarily, as do the muscles surrounding the vagina. Many other muscle groups, particularly those of the back, contract at the height of the orgasm, and a deep feeling of ecstasy (in its original sense) and relaxation follows.

In the resolution phase, both sexual partners are relaxed. In the initial moments the clitoris and the penis are exquisitely sensitive to touch, but this passes rapidly and the tissues of the lower genital tract, in both sexes, decongest, the penis becoming flaccid, the clitoris small and the woman’s external genitals and vagina decongested.

The physiological basis of the observed changes during sexual response occurs in two parts. Both are mediated by psychic or physical sexual stimulation or, more usually, by both. Both parts can be inhibited by subconscious influences to a greater or lesser degree.

The phases of the sexual response up to orgasm are mediated by the parasympathetic nerves, which lead to vasodilatation and vasocongestion of the genital organs. In a man, this leads to an inflow of blood into the cavernous spaces of the penile cylinders and an inhibition of outflow from the cylinders. The result is an erection. In a woman, the changes lead to the development of congestive ‘cushions’ around the lower part of the vagina and to vaginal lubrication.

Failure of sexual arousal prevents these changes, with resulting erectile failure in a man, and general sexual dysfunction in a woman.

The second, orgasmic, phase is mediated by the sympathetic nerves, the stimulation of which leads to the clonic muscle contraction of the pelvic and other muscles. In a man these contractions lead to ejaculation, and in both sexes to the more general muscle contractions. The feeling of pleasure experienced by both sexes appears to have its origin in a ‘sex centre’ in the thalamic and limbic areas of the old cortex, which are closely related anatomically to the pleasure centres in the paleocortex. The messages that stimulate these centres are initiated from clitoral and vaginal stimulation in women and penile stimulation in men. Failure of the sympathetic element to proceed in an orderly fashion results in premature or restricted ejaculation in a man. Failure of the sensations invoked in the clitoris and vagina to be transmitted to the brain and interpreted as pleasurable is the reason for orgasm failing to occur in women.

SEXUAL DYSFUNCTIONS

Most sexual dysfunctions arise from a poor relationship with the partner, ignorance about sexuality and sexual technique, a low sexual drive, or performance anxiety. Additional factors are physical illness, the fear that sex will aggravate an existing illness, excessive alcohol use, or clinical depression and anxiety. All can appear to be lifelong, or occur after a time of ‘normal’ functioning. What is ‘normal’ for one woman may be ‘disordered’ for another.

As men and women age, changes occur in their sexual desire and sexual response. These are considered on page 324.

Women have four main sexual dysfunctions:

• Inhibited sexual desire

• Impairment of sexual arousal

• Failure to achieve orgasm

• Dyspareunia, including vaginismus.

Table 30.1 lists the sexual dysfunctions that occur in men and women. The approximate prevalences of these disorders are given in Table 30.2.

Table 30.1 Sexual dysfunction

	Clinical Syndrome
	Male	Female
Inhibited sexual desire	No arousal	No arousal
Fear of sexual (genital) activity	Primary erectile failure (impotence)	Vaginismus
Impairment of sexual arousal Absence or inadequate vasocongestion * due to failure to respond to erotic stimulation because of anxiety, guilt, or fear of injury	Reduced libido and secondary erectile failure (impotence)	Reduced libido
Impairment or failure of orgasm. Extremely rapid, or absence of clonic rhythmic contractions of pelvic musculature due to inhibition of genital tactile or psychic erotic stimulation	Premature ejaculation Restricted ejaculation	Orgastic dysfunction

* In the male, penile erection; in the female, vaginal lubrication and perivaginal swelling.

Table 30.2 Prevalence of sexual disorders in the community *

	Females (%)	Males (%)
Inhibited sexual desire	up to 30	10–15
Impairment of sexual arousal	10–20	10–20
Failure to achieve orgasm	10–20
Premature ejaculation		20–30
Dyspareunia	10–15
Vaginismus	1–3
Total sexual dysfunction	30–50	20–45
Total sexual dysfunction causing distress	9–15

* Figures depend on age, presence of partner, medical, psychological and psychiatric status of the community studied.

Inhibited sexual desire or hypoactive sexual desire disorder

Women with this disorder have little or no desire for sexual activity. Its prevalence is not known with any accuracy, but may be as high as 30%. Allied to this disorder is a failure to become sexually aroused, either by sexual fantasies or when sexually stimulated by the partner, and the woman may find sexual approaches distasteful. This may not mean that she will reject sexual advances by a partner, but that she will obtain little or no enjoyment from the contact.

Inhibited sexual desire, or inhibited sexual arousal, may have been present since puberty or may occur after some months or years of sexual activity. In the latter case it may be the manifestation of a deteriorating relationship or a sign of depression. If both partners have inhibited sexual desire a problem is not perceived, but if one has inhibited sexual desire and the other has a normal or raised desire, the problem becomes manifest. Inhibited sexual desire can be associated with a range of gynaecological conditions and treatments, and sexual desire can vary markedly during pregnancy and breastfeeding.

Impairment of sexual arousal or sexual arousal disorder

Sexual arousal disorder involves the inability to become sexually interested and aroused in the situations desired. This may be associated with poor technique, inadequate stimulation and relationship problems, resulting in inadequate lubrication or sensation. Lubrication may occur and be reported by her partner, but the woman may be unaware of the ‘wetness’.

Failure to achieve orgasm (anorgasmia) or orgasmic disorder

Orgasm in women may be achieved during penile thrusting, but not usually simultaneously with the man’s orgasm, or it may only be achieved if the woman’s clitoral area is stimulated by finger or tongue. In both cases orgasm is reached and the woman cannot be considered to be anorgasmic. However, some women (and men) believe that unless a woman reaches orgasm during penile thrusting, preferably simultaneously with the man, she is sexually dysfunctional.

Sexual pain disorders, or dyspareunia and vaginismus

In most cases, when the woman is unable to accept a penis penetrating her vagina the problem is psychosomatic, the woman involuntarily tightening the muscles that surround the introitus and the lower third of the vagina. This is termed vaginismus, and in severe cases the woman is unable to accept an examiner’s finger into her vagina, so marked is the muscle spasm. Vaginismus may be transient or permanent, and affects around 1% of women aged 15–50.

Although the woman is unable to have sexual intercourse, she may be able to enjoy masturbating her partner but avoids any contact with her own external genitals.

The cause of vaginismus lies in inadequate or faulty sex education, particularly in a belief that sex is ‘dirty’, or a fear based on ignorance that the penis may painfully damage the woman’s body. Vaginismus can also be traced to a sexual assault during childhood, or to a painful, brutal early experience of intercourse, or traumatic childbirth.

Dyspareunia, or painful intercourse, is recurrent and persistent pain during or after intercourse. It usually has an organic component, at least when it commences. Examples are vulvovaginal infections, a painful episiotomy scar, atrophic vulvovaginitis, endometriosis, pelvic inflammatory disease, and ovarian cysts or tumours. Organic disorders must be excluded before the condition is ascribed to psychosomatic factors. These are usually found in cases of prolonged dyspareunia. The aetiology of psychogenic dyspareunia is unclear, but lack of sexual knowledge, guilt about sexuality, and childhood sexual assault have been postulated. The problem is aggravated when the woman fails to be aroused sexually and fails to lubricate.

General management strategies

The objectives of treatment are to alter an existing destructive attitude to sexuality; to reduce or resolve any underlying interpersonal sexual conflict, anxiety or fear; and to help a couple create an environment in which sexuality is perceived as a pleasurable experience. To achieve these objectives, the counsellor seeks to help the woman examine her attitudes to her sexuality and to discover what stimulates her sexually; to correct any false ideas or myths about sexuality; and to help her make her partner aware of her sexual feelings, needs and desires, so that they can better express their needs to each other.

The management of sexual dysfunctions in women begins with the medical practitioner obtaining a comprehensive general and sexual history. The general history should pay particular attention to physical illness and psychiatric problems such as depression. The sexual history must be obtained with great sensitivity. During the history, the medical practitioner explores the current relationship and seeks to find out the woman’s attitudes to her body, to menstruation, and to her feelings about her sexuality.

Usually, the doctor needs to:

• Provide information about the female and male body

• Explore the patient’s attitudes to her sexuality, sexual activities and responses

• Examine her relationships

• Reduce her anxiety

• Suggest strategies for helping the patient, such as giving permission and prescribing specific treatment, which may differ for different problems, as discussed later. Pelvic floor exercises (Kegel exercises) are a useful strategy for all women (see Ch. 39, p. 311).

The question of whether the partner should be involved depends on the sexual problem elucidated and, more particularly, on the patient’s wishes.

Management of specific sexual problems

Although the general management of sexual problems is the same for all the sexual dysfunctions, the different categories of female sexual dysfunction require different strategies (Fig. 30.1).

Fig. 30.1 Management of sexual problems.

Inhibited sexual desire

The most-used approach is to involve both partners when possible. The partners attend together and are helped to communicate better with each other, through words and actions. If they are poorly informed, the therapist helps them learn the anatomy and physiology of sexual intercourse. The main part of treatment is for the couple to perform a series of graded ‘tasks’ at short intervals over a period of weeks. The tasks are undertaken at home in a relaxed atmosphere. In the first stage, lasting 1 week, the couple set aside at least 30 minutes each day for non-genital pleasuring. The man fondles, caresses and massages his partner at her direction, avoiding her breasts and genitals, and responding if she says that she does not like a particular area being touched. The couple then change roles.

If the couple have made steady progress, they move to the second phase of genital pleasuring. In this phase they can touch, massage, kiss or lick each other’s bodies and genitals. During the touching the active participant inquires: ‘Do you like me touching you like this?’, ‘Does it feel good?’ and ‘How would you like me to do it?’ After about 15 minutes they exchange roles.

The couple reach the third phase when they feel that they are confident that they have enjoyed the second phase. In the third phase, they proceed through the first two phases fairly quickly and then attempt sexual intercourse, preferably with the woman astride the man facing him so that she can introduce his penis into her vagina at her own speed.

The couple see the therapist at intervals so that their progress can be reviewed and any problems discussed.

Anorgasmia

If a woman wishes to increase her ability to achieve orgasm, or has never achieved orgasm, several techniques are available. Of these, masturbation has produced the most successes. Many young women have masturbated, but have felt guilty about it and have not reached orgasm. Others have never masturbated. Learning to achieve orgasm by masturbation often cures anorgasmia, but the woman needs to supplement this with discussion and counselling with a trained practitioner. For masturbation to be effective in achieving orgasm, the woman has to give herself time and privacy, and be able to fantasize, view or read erotic literature as she masturbates, using either her fingers or a vibrator.

Apareunia and dyspareunia

Any physical cause of these sexual dysfunctions must be identified, discussed with the woman and treated, if possible. If it is not, suggestions may be made about techniques with which the woman may better enjoy sex. For example, if she has a chronic pelvic infection she may find a different position for sexual intercourse more pleasurable. If sexual intercourse is painful whatever position the couple adopt, she may obtain sensual pleasure by body caressing and clitoral stimulation while giving her partner pleasure by oral sex or by stimulating his sexual organs.

If the woman has vaginismus, the therapist reinforces the general strategies discussed earlier by stressing that she is not ‘small made’ and that she can learn to relax her perineal muscles. She may be asked to try to insert a lubricated finger in her vagina, and given instructions to continue with the exercise at home. If her relationship with her partner is good, she may ask him to insert his finger. Once one finger is accepted, she progresses to the insertion of two and then three fingers or, if she prefers, a series of graded dilators. These steps require reinforcement and encouragement by the therapist, who should be visited weekly. Once she has introduced three fingers with comfort and without muscle spasm occurring, she may be ready to sit above her partner and to control his penis so that it touches the entrance to her vagina. In progressive steps, on different days, she inserts his penis into the entrance, then deeper into her vagina. When this is comfortable and accepted, she may move rhythmically with his penis deep in her vagina, and then permit him to thrust. Finally, having become confident that intercourse is painless, she will be able to have sexual intercourse with the man on top.

Evaluation of treatment outcomes

There is much confusion about treatment outcomes, as many of the patients seen have been selected and the data collection uncontrolled. There are no adequate studies of treatment and outcome.

OTHER SEXUAL PROBLEMS

Sexual abuse

Sexual abuse includes incest and rape, and in the medical literature the two terms are included in sexual abuse. It is defined as ‘unlawful carnal knowledge of a woman without her consent by force, fear or fraud’. In over three-quarters of cases of rape the offender is known to the woman. Evidence has been published that between 8 and 13% of women are intimately abused by their partner during pregnancy, in addition to those who are ‘battered’ by their partner. Statistics about the prevalence of rape are difficult to obtain, as fewer than one-third of rapes are reported, but about one woman in 200 has been raped or suffered attempted rape in a year.

A woman who has been raped needs to be treated with great care and consideration when she presents to a medical practitioner. In most cases the woman attends a hospital or a ‘rape crisis centre’ where staff are trained to handle her emotional and physical problems.

The woman should be listened to sympathetically and non-judgementally as she tells her story. She should then be examined. It is important, during the examination, to explain what is being done and why. The presence of scratches or bruises on the woman’s arms or body should be looked for, and the vulva examined for the presence of blood, bruising or seminal staining. A vaginal inspection is made and a vaginal smear taken to detect spermatozoa. The woman should be asked to return later, so that she can be tested to exclude gonorrhoea and so that serological tests can be made to exclude infection, particularly syphilis and HIV. If the rape took place at the time of ovulation, the woman should be given the choice of taking postcoital contraception – the ‘morning after pill’ – or asked to return if she fails to menstruate.

It is important to record all findings carefully.

Sexual abuse in childhood and adolescence

A particular group of females require special consideration. These are children and young women under the age of 16. Data from several western countries indicate that between 5 and 30% have been sexually abused, half of them repeatedly. In half of the girls only the breasts or genitals were touched or fondled, but in 20% the abuser made the girl practise fellatio, or forced her to have genital or anal intercourse. In over 40% of cases the abuser was a family member.

Although most of these young women overcome their disgust and fear as they grow older, women who have been sexually abused in childhood or adolescence are three times as likely to seek psychiatric help in adulthood and, if married, are more likely to be divorced. The reasons for seeking psychological and psychiatric help are many, and common problems are depression, chronic pelvic pain, eating disorders and sexual problems. Women presenting to a doctor with what are perceived as psychosocial problems should be questioned sensitively about any experience of sexual abuse and help offered.

Related

Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology