The Obstetrician & Gynaecologist 2007;9:4:217-222
doi: 10.1576/toag.9.4.217.27351
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Current thoughts on psychosexual disorders in women
Catherine Coulson, MIPM, Associate Specialist in Psychosexual Medicine1 and
Tessa Crowley, MIPM, Associate Specialist in Psychosexual Medicine and Genitourinary Medicine2
1. Department of Reproductive Medicine, St Michael's Hospital, Southwell St, Bristol BS2 8AE, UK Email: c.coulson{at}bristol.ac.uk (corresponding author)
2. Department of Genitourinary Medicine, Bristol Royal Infirmary, Upper Marlborough Street, Bristol BS2 8HW, UK
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Abstract
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Key content:- The importance of responsive desire in women, triggered by physical and mental arousal rather than spontaneous desire, is now acknowledged.
- A review of the DSM-IV classification of sexual dysfunction in 1999 led to retention of the categories of desire, arousal, orgasmic and pain disorder and were expanded to include physical, as well as psychological, causes. A new diagnosis of non-coital pain disorder was also suggested.
- Historically, pain syndromes are categorised as dyspareunia or vaginismus, but they often overlap.
- Management of psychosexual disorders requires an understanding of psychosexual function and an ability to communicate about sexual matters.
Learning objectives:
- To gain an understanding of the complexities of the female sexual response and psychosexual problems.
- To understand that sexual problems are common in women attending gynaecology clinics.
- To be more willing to communicate with patients about sexual matters.
Ethical issues:
- The sensitive nature of sexual problems raises the dilemma of how to talk to women about significant events without causing further trauma.
Please cite this article as: Coulson C, Crowley T. Current thoughts on psychosexual disorders in women. The Obstetrician & Gynaecologist 2007;9:217–222.
Keywords difficulty with orgasm / female pain syndromes / loss of desire / sexual problems / vaginismus
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Introduction
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In 1918, Marie Stopes published some letters from women who expressed their anxieties about their ‘unnatural’ sexual desire or lack of pleasure in sexual intercourse. Stopes stated that enjoyment of sex could be brought about through information, education and, of course, good contraception.
Sexual difficulties occur among both heterosexual and homosexual women. They are now well recognised and are reported1,2 by 43% of women. Such problems commonly present at gynaecology clinics.3 Between 16–75% of female sexual difficulties are concerned with desire, 16–48% with orgasm, 12–64% with arousal and 7–58% with sexual pain.2 These problems4 result from combinations of biological, psychological and interpersonal factors and are poorly understood because of a lack of adequate experimental and clinical data.
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The importance of sexual difficulties in gynaecology and obstetrics
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Gynaecological conditions and procedures can distress women and cause sexual problems. Although sexual wellbeing often improves after hysterectomy,5 regardless of the surgical technique used, some women miss the uterine contractions associated with orgasm; removal of the cervix can change the experience of deep penetrative intercourse. Persistent problems that compromise sexual activity have been reported6 following radiotherapy for cervical carcinoma.
In obstetrics, a request for a caesarean section may indicate an underlying sexual problem. Sexual difficulties can appear after birth trauma.
Overt presentation
Some women present with a direct appeal for help with a sexual difficulty. Women expect their doctors to be able to discuss sexual problems, but some doctors feel uncomfortable talking about sex and may not see it as part of their clinical role (Box 1). Routinely asking about sexual function lets the woman know that sexuality is an important aspect of health.
Covert presentation
Covert presentation of a sexual difficulty can take the form of complaints about pelvic pain, distress about menses, general dissatisfaction with a contraceptive precaution, expression of distaste for the genital area or dissociation at the time of genital examination. A sympathetic doctor will be alert to these clues and will ask open-ended questions to explore these issues.
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New thoughts on the classification of sexual problems
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A review of the DSM-IV7 classification of sexual dysfunction in 1999 by a multidisciplinary group of international experts4 retained the categories of desire, arousal, orgasmic and pain disorders (Box 2). These categories were expanded to include physical as well as psychological causes and a new diagnosis of non-coital pain disorder was suggested.8
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Normal sexual response in women
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Female sexual arousal is strongly modulated by thoughts and emotions triggered by the state of sexual excitement. An emotional relationship with the partner and emotional wellbeing are the strongest predictors of absence of sexual distress.9 The new definitions recognise the importance of the context of the sexual relationship and the fact that sexual response phases overlap. There is an acknowledgement of the importance of responsive desire triggered by physical and mental arousal rather than spontaneous desire.
Seventy percent of women in long-term relationships report no spontaneous sexual desire but they are able to access sexual and emotional pleasure from sexual activity (responsive desire). This starts from a willingness to be sexual and, with the appropriate stimulation in context, they are able to access arousal, leading to sexual pleasure and a willingness to be sexual on the next occasion. The willingness to be sexual derives from a wish for intimacy, to stabilise her own and her partner's mood and to satisfy her own sexual needs as well as a wish for non-sexual gains (Figure 1).10 Spontaneous sexual desire is common among younger women and those in new relationships. It can be cyclical in younger women and can be disrupted by medical intervention. However, in some women innate desire can endure for decades.
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Sexual disorders
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Sexual problems can be primary or secondary and generalised or situational. Physical illness and medication should be considered, but psychological factors are often more important. In some cases there is more than one dysfunction; for example, the woman who experiences sex as painful can develop vaginismus and then have problems becoming aroused. Avoidance of sex can follow and this can lead to loss of intimacy and relationship problems.
Sexual desire disorder
Desire disorders become more common as women age. Desire is affected to some extent by hormones; loss of desire can be experienced at the menopause, regardless of age, and is often reported11 after a surgically-induced menopause. However, if a woman expects sexual activity to be rewarding she may well embark on it and enjoy it, whatever her hormonal status. There can be negative psychological factors such as distraction, prediction of a negative outcome because of previous experience of pain, guilt, low sexual esteem, shame, embarrassment and awkwardness.12 These factors can be the result of earlier negative experiences triggered by culture, loss, trauma or past relationships. Women may learn to keep a tight rein on their emotions generally to avoid conflict and, in particular, to suppress anger. There may be problems in the current relationship or with a partner's sexual dysfunction or there may be inadequate stimulation. Depression is a common cause of loss of desire and selective serotonin-reuptake inhibitors (SSRIs) affect the sexual response and orgasm in men and women.13 The role of neurotransmitters is complicated and not yet fully understood.10
It may help women with hypoactive desire disorder to know that many women do not have spontaneous sexual desire. Thus, treatment can be centred away from why a woman does not have such thoughts and focused on how she can access sexual satisfaction. Current evidence14 suggests that testosterone could have a role in the management of sexual desire disorders among postmenopausal androgen-deficient women who show adequate levels of estrogen. There is clearer evidence15 to support the use of testosterone for women who have had a surgically-induced menopause. Tibolone is licensed for the treatment of loss of desire among postmenopausal women.
Sexual arousal disorder
A woman with sexual arousal disorder cannot access excitement when she wishes to be sexual. Studies16 show that she may experience the swelling and lubrication of physical arousal but have little subjective experience of pleasure. She may prevent herself from accessing pleasure for a variety of reasons or she may be mentally disengaged and unaware of any sensations of arousal. There is a small group of women who report subjective feelings of arousal but who do not become physically aroused. Peripheral neuropathy secondary to diabetes, spinal cord injury and surgery may be implicated. Pharmacological and physical treatments include the use of estrogen, lubricants and vibrators. There may be a place for drugs that increase vasocongestion and vasodilation.17 However, the evidence does not show sildenafil to be an effective treatment for women with sexual dysfunction.18
Persistent sexual arousal
Persistent sexual arousal is an uncommon condition that was first reported in 2000.19 The disorder is characterised by sensations of spontaneous and persistent genital arousal that occur without any conscious awareness of sexual desire; orgasm offers only temporary relief. Women are very distressed by this condition, the causes of which are as yet unknown; no definitive treatment can be recommended.
Orgasmic disorder
Anorgasmia is more common among younger women, demonstrating that sexual response is a learned response. The problem of anorgasmia may be constant, or may occur only with a partner or with penetration.20 If a woman can achieve orgasm by herself when masturbating, an exploration of how she can translate this into her relationship may be advantageous. Is she able to ask for what she needs? If she denies that she masturbates, an exploration of what masturbation means to her may be helpful. It may then be beneficial to suggest directed masturbation exercises and the use of a vibrator and to discuss her reactions to that. Sex education, communication skills training and Kegel exercises are often included in cognitive behavioural treatment programmes for anorgasmia.20 There is evidence that group work with women may be effective. To date there are no trials showing that any pharmacological agent is more efficacious than placebo in enhancing orgasmic function among these women.20
Sexual pain disorders
Historically, these conditions are categorised as dyspareunia or vaginismus, but they often overlap. Each case should be considered as a pain syndrome and managed as such.21 Pain impacts on sexual arousal and is associated with an increase in pelvic muscle tension, which can lead to vaginismus.
Dyspareunia
Almost every disease to which the sexual organs are liable can cause dyspareunia; they can be classified by anatomical location.
Chronic vulval pain
If there is chronic vulval pain, dermatological conditions, such as the dermatoses, lichen sclerosis and psoriasis, should be excluded by genital examination. Vulval vestibulitis is characterised by pain at the vaginal introitus on attempted penetration, tenderness in the vestibule and erythema. This is a common presentation among young women that is poorly recognised by primary care doctors and some gynaecologists and frequently misdiagnosed as recurrent thrush. Women may repeatedly seek a correct diagnosis from a variety of clinicians over a long period. Once recognised, it is best to refer the woman to a specialist vulval clinic. Recent work22 has demonstrated that women with vestibulitis have lower pain thresholds in the vestibule and lower tactile pain thresholds compared with controls. Some authors suggest23 that vestibulitis represents one end of a continuum of common vulval signs and symptoms.
Relevant studies24 reporting more depressive symptoms and somatic complaints have found no link between vestibulitis and sexual or physical abuse. A review by Green and Hetherton25 of papers investigating the psychological aspects of vestibulitis found little agreement as to whether women with vestibulitis differed from the general population with regards to anxiety, psychological distress, somatisation, relationship adjustment or satisfaction. The reported problems with sexual function involved pain, lubrication, desire and orgasm.
Pelvic pain
Pelvic pain is a common complaint and many women present because they want an explanation. Consultations that elicit the woman's own ideas about the origin of the pain will result in a better doctor–patient relationship and improved co-operation with investigation and treatment.26 In one study27 a history of physical or sexual abuse in childhood was significantly more common among women with chronic pelvic pain than among those with chronic pain in other locations or among controls. Severe abuse was associated with multiple medically unexplained physical symptoms such as irritable bowel syndrome.28 Child sexual abuse can be a marker for continuing abuse and the development of depression, anxiety or somatisation, which then predispose to the development of chronic pelvic pain. These women often experience their interaction with healthcare professionals as a re-enactment of the abusive dynamic. They often feel their pain is not believed.
Vaginismus
Vaginismus has been reported by 4.2–12% of women attending outpatient clinics. A review4 of the definitions of female sexual dysfunction states that the presence of ‘vaginal spasm’ has never been documented as such. The authors' recommended definition of vaginismus is:
The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and or any object, despite the woman's expressed wish to do so. There is often (phobic) avoidance, involuntary pelvic muscle contraction and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out/addressed.
Vaginismus can arise as part of a conditioned response acquired secondary to adverse physical or psychological stimuli. Predisposing factors include environmental factors, childhood sexual trauma and a background of religious orthodoxy. It has been suggested29 that a cycle evolves in which fear and anticipation of pain following vaginismus increase the likelihood that future attempts at penetration will produce the sensation of pain. This results in avoidance and the accompanying relief reinforces this. There may be an associated fantasy; for example, that the vagina is too small to accommodate a penis.
There are no studies comparing treatments of vaginismus. A Cochrane systematic review30 of published trials states that there is only limited evidence from uncontrolled trials to recommend the use of systematic desensitisation. However, there is some evidence that short-term therapy involving insertion of vaginal trainers is effective where the outcome measure is the ability to have penetrative vaginal intercourse. Success rates from 72–100% have been reported29 with short-term treatment varying from two to 15 sessions.
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General principles of management
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This is a sensitive area and one should tread carefully. Management requires an understanding of psychosexual function and an ability to communicate about sexual matters. The clinician should be alert to non-verbal communications that indicate anxiety. For example, a relationship problem or a history of abuse may be suspected, but the woman may not want to talk about it and will experience direct questioning as intrusive. Management needs to be multidimensional, addressing biological, cognitive, affective, behavioural and interpersonal aspects. Treatment should be individualised for each woman and her partner. See Box 3.
The management of some sexual problems may require more time and expertise than are available in a general clinic. However, listening to the woman in an active way and understanding the exact nature of the problem and its impact on her and her relationship, if she has one, can in themselves be therapeutic. The time of onset and any precipitating factors can be explored with her and the connections made can be helpful.
Some women need permission to enjoy their body and relaxation techniques can be of benefit. Specific self-examination or the use of vaginal trainers may be indicated for vaginismus. Self-exploration with masturbation and vibrators would be suggested by some sex therapists. Education can be helpful, but there is a wealth of readily available information in women's magazines and on the internet; it might be interesting to explore why a woman has not been able to access it herself. Pain syndromes may respond to local anaesthetic creams, tricyclic antidepressants or other interventions such as biofeedback or cognitive behavioural therapy.21 Relationship issues that are identified may be the cause of or secondary to the problem. The Relate organisation offers couple counselling and sex therapy. Individual psychosexual counselling can be obtained from doctors trained at the Institute of Psychosexual Medicine and therapists from the British Association of Sex and Marital Therapy. Clinicians who manage the treatment of women with sexual problems should ideally have access to vulval and pain clinics and a psychologist, therapist or psychosexual medical specialist with experience of dealing with sexual dysfunction of individuals and couples.
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Training
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Training in psychosexual problems should be considered by all obstetricians and gynaecologists. The Institute of Psychosexual Medicine offers a brief, focused course for medical practitioners on psychosomatic therapy for sexual and related difficulties. The initial aim of training is to increase the skills of doctors who encounter women with psychosexual and related problems in their practice. The British Society of Sexual and Relationship Therapists offers training for practitioners of differing backgrounds in psychosexual couple counselling, using a cognitive behavioural approach.
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Sources of information for women and self-help societies
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See Box 4.
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Further reading
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Skrine R, Montford H, editors. An Introduction to Psychosexual Medicine, 2nd edn. London: Arnold; 2001.
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References
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- Laumann EO, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and indicators. JAMA 1999;281:537–44. doi:10.1001/jama.281.6.537[Abstract/Free Full Text]
- Hayes RD, Bennett CM, Fairley CK, Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med 2006;3:589–95. doi:10.1111/j.1743-6109.2006.00241.x[Medline]
- Nusbaum MR, Gamble G, Skinner B, Heiman J. The high prevalence of sexual concerns among women seeking routine gynaecological care. J Fam Pract 2000;49:229–32. PubMed: 10735482[Medline]
- Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, et al. Definitions and classifications. Report of the International Consensus Development Conference on Female Sexual Dysfunction. J Sex Marital Ther 2001;27:83–94. doi:10.1080/00926230152051707
- Roovers J-P, van der Bom JG, van der Vaart CH, Heintz APM. Hysterectomy and sexual wellbeing: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ 2003;327:774–8. doi:10.1136/bmj.327.7418.774[Abstract/Free Full Text]
- Jensen PT, Groenvold M, Klee MC, Thranov I. Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys 2003;56:937–49.[Medline]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Washington DC: American Psychiatric Press; 1994
- Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, et al. Definitions of women's sexual dysfunction reconsidered: advocating expansion and revision. J Psychosom Obstet Gynaecol 2003;24:221–9.[Medline]
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- Basson R. The female sexual response: a different model. J Sex Marital Ther 2000;26:51–65.[Medline]
- Dennerstein L, Alexander J, Kotz K. The menopause and sexual functioning—a review of the population based studies. Annu Rev Sex Res 2003;14:64–82. PubMed: 15287158[Medline]
- Basson R. Biopsychosocial models of sexual response: applications to management of ‘desire disorders’. Sex Relationship Ther 2003;18:107–15.
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- Alexander JL, Kotz K, Dennerstein L, Kutner SJ, Wallen K, Notelovitz M. The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind randomized controlled trials. Menopause 2004;11:749–65. doi:10.1097/01.GME.0000142887.31811.97[Medline]
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- Laan E, van Lunsen RH, Everaerd W, Riley A, Scott E, Women J. The enhancement of vaginal vasocongestion by sildenafil in healthy premenopausal women. J Womens Health Gend Based Med 2002;11:357–65.[Medline]
- Shields KM, Hrometz SL. Use of sildenafil for female sexual dysfunction. Ann Pharmacother 2006;40:931–4. doi:10.1345/aph.1G471[Abstract/Free Full Text]
- Leiblum S, Nathan S. Persistent sexual arousal syndrome: a newly discovered pattern of female sexuality. J Sex Marital Ther 2000;27:365–80. doi:10.1080/009262301317081115
- Meston CM, Levin RJ, Sipski ML, Hull EM, Heiman JR. Women's orgasm. Annual Review of Sex Research 2004;15:173.[Medline]
- Schultz WW, Basson R, Binik Y, Eschenbach D, Wesselmann U, Lankveld V, et al. Women's sexual pain and its management. J Sex Med 2005;2:301–16. doi:10.1111/j.1743-6109.2005.20347.x[Medline]
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- Munday P, Green J, Randall C, Fox D, Singh M, Ismailjee F, et al. Vestibulitis: a common cause of dyspareunia? BJOG 2005;112:500–3.[Medline]
- Lotery HE, McClure N, Galask R. Vulvodynia. Lancet 2004;363:1058–60.[Medline]
- Green J, Hetherton J. Psychological aspects of vulvar vestibulitis syndrome. J Psychosom Obstet Gynaecol 2005;26:101–6. doi:10.1080/01674820400023226[Medline]
- Royal College of Obstetricians and Gynaecologists. The Initial Management of Chronic Pelvic Pain. Green-top Guideline No. 41. London: RCOG; 2005
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- Walker EA, Katon WJ, Hansom J, Harrop-Griffiths J, Holm L, Jones ML, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658–64. PubMed: 1454959[Abstract/Free Full Text]
- Crowley T, Richardson D, Goldmeier D. Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction. Int J STD AIDS 2006;17:14–18. doi:10.1258/095646206775220586[Abstract/Free Full Text]
- McGuire H, Hawton K. Interventions for vaginismus. In: Cochrane Database Syst Rev 2003; (1):CD001760.
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Abstract
Introduction
