Gender identity

Just under 50% of the population are diagnosed at birth as being female. They are biologically and legally female, and most tend to follow female biopsychosocial pathways throughout their lifetimes. Similarly, a male gender identity is experienced by the other 50% of the population, who are diagnosed at birth to be male. However, a tiny proportion of the population are transsexual. These are individuals whose biological sex and gender identity do not match. They are, in effect, born into the wrong body and may spend many difficult years undergoing a gender reassignment process. As all transsexuals are female at some stage in their lives, they may come into contact with gynaecology services; therefore, it is important to have an awareness of this condition. A postoperative male-to-female transsexual presents on gynaecological examination as a hysterectomized female. The Gender Recognition Act 2004 allows change of birth certificate under UK law, and transwomen can now present to a gynaecologist without disclosing their trans status.

Sexual orientation

Sexual orientation is the definition of sexual attraction: the people to whom one’s sexual desire is directed. Approximately 93% of the population are heterosexual (i.e. attracted to individuals of the opposite sex). Between 5% and 10% of the population are homosexual (i.e. men who are sexually attracted to men). A further 0.5–2% of women are lesbian (i.e. women who are sexually attracted to women). Seven percent of the population are bisexual and are attracted to both men and women. In the UK National Survey of Sexual Attitudes and Lifestyles, over half of the men who had had a male sexual partner in the previous 5 years had also had a female partner; the figure was higher for females at 75.8% (Wellins et al 1994).

Sexual orientation has particular relevance in well-woman health care. Lesbians may be reluctant to discuss their sexual orientation with a clinician, but as the majority have experienced heterosexual sexual intercourse or had vaginal penetrative sexual activity with fingers or sex toys, they are at risk of cervical dysplasia and sexually transmitted infection. Lesbians should be included in national cervical screening programmes and have the same well-woman checks as the rest of the female population. Lesbians generally have positive attitudes to the new human papilloma virus vaccine programmes, but feel that any health promotion materials should recognize their sexual orientation (McNair et al 2009) in order to increase uptake (see Chapter 66, Lesbian health issues, for more information).

Bisexual women are at the highest risk of sexual morbidity, and may be reluctant to speak openly about their sexuality to clinicians.

Sexual response

The human physiological sexual response is dependent not only on intact endocrine, vascular and neurological input, but also on sensory input. This has been described as the ‘psychosomatic circle of sex’ (Bancroft 2008). Female sexual responsiveness is a result of sensory input through the peripheral nerves of the somatic and autonomic nervous system, as well as through the cranial nerves and psychogenic stimulation. Precisely where and how afferent information is processed within the spinal cord and brain is unknown (Yang 2000). The frontal and temporal lobes and anterior hypothalamus are all shown to have some function in mediating the sexual response, but the extent of this is still unclear. Genital motor responses include pelvic vasocongestion and vaginal lubrication. During sexual intercourse, the vagina lengthens, the labia increase in size, the uterus draws back and the clitoris retracts; at orgasm, there is also contraction of the uterine and pelvic muscles.

Clinical clarification of the human sexual response was based on the Masters and Johnson model of four phases: excitement, plateau, orgasm and resolution. This description was then modified by Kaplan to a triphasic model of desire, arousal and orgasm. These concepts provide the working models on which behavioural therapies for sexual problems are based. Recent scientific arguments have proposed that sexual desire is, in fact, the first early stage of arousal, triggered by a stimulus which has sexual meaning and is modified by situational and partner variables (Janssen et al 2000).

Most human sexuality is non-problematic and will not be within the domain of the clinician. It is only when something goes wrong with the patient’s sexual response that they may seek professional help.

Population prevalence

The majority of the population at any one time have a trouble-free sex life. There is, however, a substantial minority for whom dealing with and expressing their sexuality is problematic. These problems may only be temporary or situational. If they persist and become increasingly distressing, the individual may seek professional help. The population prevalence of some degree of sexual dysfunction is estimated to be approximately 20%. Prevalence increases with age; overall, 40–45% of women and 20–30% of adult men report at least one sexual dysfunction at any one time (Lewis et al 2004). In the National Health and Social Life Survey (Laumann et al 1999), one-third of women reported loss of libido. Almost 25% did not experience orgasm. Approximately 20% had problems with vaginal lubrication, and a similar number did not enjoy sex. This study suggested that there was a substantial comorbidity of sexual problems. A study of US women (West et al 2008) showed that whilst 26.7% of premenopausal women had low sexual desire, 52.4% of naturally menopausal women had the same complaint. For males, the prevalence of some degree of erectile dysfunction has been reported as 30% of all males between the ages of 40 and 70 years. Premature ejaculation occurs in 10–30% of men during their lifetime. In a control group of 591 members of the general population in a Dutch study, 8.7% of men and 14.9% of women reported a sexual dysfunction unrelated to age (Diemont et al 2000), which is lower than that reported in other countries.

Problems of function or desire

Sexual disorders can be divided into problems of function or desire. They are often interlinked. For example, impaired sexual function, such as some degree of erectile problem, can result in the man protecting himself from the distress of failure by emotionally shutting himself off from coitus altogether. This results in loss of libido. If a woman is experiencing loss of function such as dyspareunia, she may subconsciously employ the same defensive mechanisms, and loss of desire develops.

The most common female sexual problems are vaginismus, loss of libido, dyspareunia and inorgasmia. There will be differences in the frequency of presenting sexual complaints in different clinical settings. An American gynaecology clinic sample showed loss of libido (87.2%) with inorgasmia (83%) and dyspareunia (72%) (Nusbaum et al 2000). In a community-based setting such as a family planning clinic, however, loss of libido, dyspareunia and vaginismus are the most common presenting complaints, with a low incidence of inorgasmia.

In males, erectile dysfunction, ejaculatory disorders and loss of libido are the most frequent presenting complaints, all of which will affect the partner to some degree.

Problems relevant to gynaecology

There are many gynaecological conditions which may predispose to sexual problems. Any disease or its treatment which results in alteration of the genitalia may cause functional sexual difficulties. These conditions may range from having colposcopy, where spontaneous interest in sex was found to be lower 6 months post procedure, irrespective of whether or not treatment was needed (Hellsten 2008), to traumatic obstetric delivery or gynaecological malignancy. Trauma or disease, however, may cause an alteration in the woman’s perception of herself, such as distorted body image causing sexual problems. This may or may not be directly related to physical reality. An exceptionally high rate of sexual dissatisfaction was found in a gynaecology clinic sample in the USA. Over 98.8% of the sample reported one or more sexual worries, and body image concerns were reported by 68.5% of the 1480 women who attended (Nusbaum et al 2000). A study of Dutch gynaecologists found that one in 14 of their patients presenting in the previous week had problems of a sexual nature, mainly dyspareunia or lack of sexual desire (Frenken and van Tol 1987). A significant degree of deterioration of sexual function was described in a study of 41 women who had undergone vulvectomy, attributed to disturbed body image rather than physical impairment (Green et al 2000). The rate of sexual problems in women with gynaecological cancers is approximately 50%. The main complaint of this client group is lack of opportunity to discuss these problems.

Once any gynaecological treatment is completed, the treatment approach for the sexual problem is the same as for any other patient.

Vaginismus

Vaginismus is a condition in which nothing is able to enter the vagina. This means that penetrative sexual intercourse does not take place. It is caused by psychogenically mediated involuntary spasm of the vaginal muscles. Vaginismus can be primary or secondary. In primary vaginismus, nothing has ever entered the woman’s vagina. A useful diagnostic question is ‘Have you ever used a tampon’. In a case of primary vaginismus, the answer will always be ‘no’. Secondary vaginismus can appear at any time in a woman’s life, sometimes after childbirth or any other life-changing event.

The vagina is physiologically intact in a case of vaginismus. There is no stenosis or organic disorder. This is a psychogenic condition for which the treatment is psychosexual, never surgical.