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Sexuality and Sexual Dysfunction

A sexual history should be included as a routine part of a woman's periodic health assessment. A history of childhood sexual abuse or adult sexual assault should be routinely sought because these experiences are common and often have a lasting and profound effect on a woman's sexuality and general well-being. Concerns about sexuality and sexual dysfunction are common in the general population. Almost two thirds of the women questioned have concerns about their sexuality. One third of the women lacked interest in sex, 20% said sex was not pleasurable, 15% experienced pain with intercourse, 18-48% experienced difficulty becoming aroused, 46% noted difficulty reaching orgasm, and 15-24% were not orgasmic sexual dysfunction, sexual disfunction, vaginismus, vagismus, orgasm, orgasmic dysfunction, dysparunia, disparunia, low libido


Two recent comprehensive surveys provide an interesting and useful description of the sexual behavior of Americans. Sexual activity among American adolescents has increased significantly during the past 20 years. By age 19 years, most women and men will have had intercourse. Most young men and women in

A survey of American men and women between the ages of 18 and 59 years revealed that since age 18, men had an average of six partners and women had an average of two. American women have sex with a partner from a few times a month (47%), to 2-3 times a week (32%), to 4 or more times a week (7%). Twelve percent of women have sex a few times a year, and 3% have never been sexually active. The most appealing sexual activity for both men and women is vaginal intercourse. Watching their partner undress and receiving and


Despite the importance of sexuality in their lives, many women find it difficult to talk to their physicians about sexual concerns, and many physicians are uncomfortable or unable to discuss sexual issues with their


The sexual-response cycle in women is mediated by the complex interplay of psychologic, environmental, and physiologic (hormonal, vascular, muscular, and neurologic) factors. The initial phase of the


Sexual desire is the motivation and the inclination to be sexual. It is a subjective feeling that may be triggered by both internal (fantasy) and external (an interested partner) sexual cues and depends on


The arousal (excitement) phase is mediated by the parasympathetic nervous system and is characterized by erotic feelings and the appearance of vaginal lubrication in women and erection in men. Sexual arousal increases blood flow to the vagina. The resulting vasocongestion and changes in capillary permeability...


During the plateau phase, sexual tension, erotic feelings, and vasocongestion reach maximum intensity. The skin becomes more mottled; the breasts become more engorged; and the nipples become more erect. The


Orgasm is a myotonic response mediated by the sympathetic nervous system and is experienced as a sudden release of the tension that has built up during the arousal and plateau stages. Orgasm is the most


After the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The physiologic changes that took place during arousal are reversed, and the body returns to a resting state. Complete uterine descent, detumescence of the clitoris and orgasmic platform sexual dysfunction, sexual disfunction, vaginismus, vagismus, orgasm, orgasmic dysfunction, dysparunia, disparunia, low libido


Intrapsychic Factors

Intrapsychic causes of sexual dysfunction include religious orthodoxy, anhedonic or obsessive-compulsive personality (these patients may lack the capacity for play and find it difficult to display emotion), sexual deviation (eg, transvestitism), concerns about pregnancy or STIs, and object-choice issues (ie, the patient

Relationship Factors

The way a couple functions sexually is often a good barometer of how things are going in the rest of the relationship. Therefore, whenever a women presents with sexual concerns or sexual dysfunction, it is important to inquire about the relationship in general. If significant relationship problems exist in addition to sexual concerns, the couple should be referred for counseling.

Relationship causes of sexual dysfunction include lack of sexual attraction for the partner, poor lovemaking skills or sexual inexperience in one or both partners, marital conflict, or fear of closeness due to distrust of the partner or a sense of vulnerability. Some couples experience sexual difficulties because of differences

Aging and Menopause

Aging and the cessation of ovarian function accompanying menopause can significantly affect the sexual-response cycle of women. Sexual desire and frequency of intercourse decrease as women age, although women remain interested in sex and continue to have the potential for sexual pleasure for their entire lives. The need for closeness, love, and intimacy does not change with advancing age. The way women function sexually as they grow older is largely dependent on partner availability and how frequently


A variety of prescription and nonprescription medications and illicit drugs can alter the sexual response in men and women. These include antihypertensives, thiazide diuretics, antidepressants (especially the serotonin reuptake inhibitors), antipsychotics, antihistamines, barbiturates, narcotics, benzodiazepines, oral contraceptives, and recreational drugs like cocaine and marijuana. Alcohol also can affect sexual response.

Sexual Dysfunction

The sexual dysfunctions include sexual desire disorders (eg, hypoactive or inhibited sexual desire and sexual aversion), sexual arousal disorders, orgasmic disorders, sexual pain disorders (eg, vaginismus and dyspareunia), and sexual disorders due to general medical conditions and substance abuse. Each disorder

Desire-Phase Disorders

Desire-phase disorder (hypoactive or inhibited sexual desire) is the most common sexual dysfunction in both women and men and the most difficult to treat. Hypoactive sexual desire is a deficiency or absence of sexual fantasies and desire for sexual activity often leading to marked distress and interpersonal difficulty. Patients with desire-phase disorders have little interest in seeking sexual stimuli but often retain the ability to become sexually aroused and experience orgasm if they are approached sexually by their partner. This disorder usually develops in adulthood, often after a period of adequate sexual interest and functioning. Some individuals may experience sexual aversion, which is complete avoidance of all sexual activity with a partner. Desire-phase disorders are often accompanied by another sexual dysfunction like dyspareunia or anorgasmia.

Physiologic causes of hypoactive sexual desire include medications, chronic medical illnesses, depression,

Orgasmic Dysfunction

Orgasmic dysfunction in women is characterized by persistent or recurrent delay in or absence of orgasm after a normal sexual-arousal phase. Orgasmic dysfunction is more prevalent in younger and less sexually experienced women. Primary (lifelong) anorgasmia is found in approximately 510% of women and is more common than secondary (acquired) anorgasmia. Some women develop secondary anorgasmia because of relationship problems, depression, substance abuse, prescription medication (eg, fluoxetine), chronic

The most common psychologic cause of anorgasmia is obsessive self-observation and monitoring during the arousal phase ("spectatoring"), often accompanied by anxiety and distracting, negative, and self-defeating thoughts. A woman with orgasmic dysfunction may be so busy monitoring her own and her partner's

Numerous programs have been proposed for the treatment of orgasmic dysfunction. Treatment approaches include evaluation and treatment of medical and psychiatric disorders (including substance abuse), sex education, communication and sexual-skills training, marital therapy, group therapy, erotic fantasy, and counseling to reduce sexual anxiety and performance anxiety.

The most effective treatment for primary anorgasmia is a program of directed masturbation with erotic fantasy. Success rates of 80-90% have been reported with this technique. Several excellent self-help books are available to help women learn how to become orgasmic through masturbation. These self-help books instruct women to increase their self-awareness by exploring their genital area in a nondemanding


Vaginismus is the recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with a penis, finger, tampon, or speculum is attempted. Vaginismus is an involuntary reflex precipitated by real or imagined attempts at vaginal penetration and can be global (the woman cannot place anything inside her vagina) or situational (she can use a tampon and can

Vaginismus can be a conditioned response to an unpleasant experience (eg, past sexual abuse, a painful first pelvic examination, or a painful first attempt at intercourse) or may be secondary to religious orthodoxy or sexual-orientation concerns. Many women with vaginismus have an extreme fear of penetration and

Treatment of vaginismus is directed toward extinguishing the conditioned involuntary vaginal spasm. This can be accomplished by helping the woman become more familiar with her anatomy and more comfortable with her sexuality, teaching her techniques to help her relax when she anticipates vaginal penetration, instructing her in the use of Kegel exercises so that she can gain control over the muscles surrounding her introitus,


Dyspareunia ("difficult mating" or "badly mated") is genital pain that occurs before, during, or after intercourse in the absence of vaginismus. The repeated experience of pain during intercourse can cause marked distress, anxiety, and interpersonal difficulties, leading to anticipation of a negative sexual experience and eventually to decreased frequency of intercourse or to sexual avoidance. As with other

Erectile Dysfunction

Obstetrician-gynecologists may be called upon to counsel women about their male partner's sexual health. Therefore, they should be familiar with the male sexual-response cycle and the common causes and treatment of sexual dysfunction in men. Erectile dysfunction is the inability to develop an erection or to

Erectile dysfunction that occurs suddenly and intermittently is often associated with psychologic causes such as depression and anxiety, whereas erectile dysfunction that is gradual, persistent, and progressive is usually organic in etiology. Most men with erectile dysfunction are now thought to have an organic cause for their condition, especially circulatory insufficiency, with psychologic issues as important contributing factors. Common causes of erectlie dysfunction include surgery (prostatectomy), aging, cigarette smoking, and


The assessment of erectile dysfunction should begin with a careful evaluation of the duration, severity, and chronicity of the condition. Relationship factors (eg, communication, expectations, marital difficulties) and intrapersonal factors (eg, anxiety, depression, fear of failure or performance anxiety) should also be