Sexuality and Female Sexual Dysfunction

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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.

image 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.

image 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

image 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).

image

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

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