Introduction

Sexual health is an important area of public health and the World Health Organization (WHO) gives credence to this by linking it to sexual well-being. Its working definition of sexual health focuses on positivity and respect, when it comes to sexuality and sexual relationships and not just the physical. A 2022 systematic review and meta-analysis on ‘what is the added value of incorporating pleasure in sexual health interventions’ by Zaneva et al. came to the conclusion that sex education has for long concentrated on safe sex practices, which involve risk reduction, preventing disease and unwanted pregnancy. It is time to acknowledge, safe, consensual sex can also promote intimacy, pleasure and well-being.

Gynaecology is a subject where the woman presents some of the most intimate parts of her body to a specialist. It is also a speciality to which she brings her sexual problems, either overtly or covertly. However, gynaecologists who examine a woman are bound by the lengthy guidelines on the Intimate Examination by the General Medical Council and Royal College of Obstetricians and Gynaecologists, and work within the boundaries set. This means, acknowledging the embarrassment faced by the patient when being examined, obtaining consent, having a chaperone at examination, remaining professional at all times and avoiding questions that may be sensitive. It is also paramount that the patient feels safe and in control, and that the examiner is alert at all times to any signs of discomfort or distress. This guideline, while very pertinent and useful, places a huge responsibility on the doctor to ensure the examination is conducted professionally. Emphasis is therefore placed on physical symptoms and findings, detecting and treating pathology and as an ‘expert’ doctor working towards a clear-cut diagnosis. Succumbing to the pressure of having to come up with all answers, may, unconsciously block out any attempt to work with the patient to piece together her individual truth.

Prevalence

Sexual difficulties are common in both men and women. One large British study using the criterion of 6 months or longer duration for dysfunction identified 11% of women, of whom 28% sought help (proxy measure for distress). Nationally representative surveys of US women, suggest a prevalence of desire disorder of 8.3% and 9.5% with minimal variation across most ages, and with a drop in woman over 60 years. Prevalence reaches 12.5% for surgically menopausal women and 19.9% for women under 45 years. The effect any sexual problem has on an individual will depend on the relationship and the circumstances under which the alteration occurred. Studies have indicated that prevalence of sexual problems in primary care is also high with 22% of men and 40% of women indicating a diagnosis of sexual dysfunction as evaluated by questionnaire, although this was poorly recognized and documented in notes. This is also reflected in gynaecology clinics where symptoms may frequently be representative of the somatisation of sexual problems, yet, these go unrecognized or not acknowledged. Up to 40% of gynaecological consultations have a psychosexual component. Difficult consultations where the ‘hidden agenda’ is not revealed are often covert presentations of female sexual dysfunction. The patient and/or the doctor may subconsciously collude in avoiding to identify the actual problem. Despite these high numbers there is scant data on the approach used by gynaecologists to tackle these problems.

Psychosexual medicine is a brief dynamic intervention between a practitioner and the patient where unconscious feelings surfacing in the interaction are explored to gain an understanding of the problem the patient is presenting with. It is a specific type of mind-body doctoring based on the work of Drs Michael Balint (a physician) and Tom Main (a psychoanalyst) but remains firmly rooted in the medical tradition.

The basic principles encompass observation and active listening during the consultation and paying close attention to the practitioner–patient relationship that evolves and culminates in the psychosomatic physical examination . Michael Balint compared the interaction to the use of a knife by the surgeon, slowly cutting through the layers of the body to expose the root cause of the problem.

To a psychosexual practitioner, the physical examination is a very important part of the interaction. This is when the patient’s defences are dropped and he/she may get a peek into the vulnerability behind the facade. This may be the point when the ‘unconscious’ speaks and the ‘moment of truth’ may be arrived at.

Consultation and the practitioner–patient relationship

The setting and the patient’s expectation influence the practitioner–patient relationship. The primary obligation of a gynaecologist is to identify and detect any pathology. For this ‘expert’ doctor it is difficult to avoid generalizing and putting people into neat diagnostic boxes which he/she is good at. Patients on the other hand could also be resistant to the idea that their emotions may have something to do with their symptoms – “it is not in my head, doctor”.

‘Too tight’ or ‘too loose’, ‘uneven lips’ (labia), ‘all stitched up’

These complaints have to be given the acknowledgement they deserve. Dismissing their complaints/fantasy or telling them it ‘all looks all right’ will only increase the frustration! It usually helps to look at ‘the area’ with the patient and actively listen to their complaint.

A vagina with anatomical problems such as an imperforate hymen or a vaginal septum is likely to have presented early on in the reproductive life. An examination will usually have led to the diagnosis. However, for someone to present in their 20’s or 30’s accompanied by other complaints such as non-consumation, avoiding vaginal examinations etc., there is most likely a psychosexual cause to look for!

With uneven lips it is important to exclude body dysmorphia which may not be addressed with psychosexual medicine. Body dysmorphia is characterized by an unhealthy preoccupation with an imagined defect or a minor abnormality in the body.

Similarly, “too loose” or “cannot feel anything” can be difficult to understand especially when not related to childbirth and the examination is unremarkable. The underlying cause may be a lack of arousal and in the formation of the ‘orgasmic platform’. The orgasmic platform as described by Masters and Johnson is brought about by swelling of the bulbus vestibuli, tightening of the pubococcygeus muscle, resulting in narrowing of the vestibulum and extending of the lower one third of the vagina. However, despite adequate knowledge, it is the meaning one attaches to a symptom that starts the development of a psychosexual problem – “Am I not man enough for her”, “am I too small”, “am I a loose woman” etc.

Dyspareunia

Fertility clinic

Artificial reproductive techniques (ART) have allowed a lot of childless couples achieve a pregnancy. With the gains, the downsides of this process are, sex by the clock, medicalized intimacy, cold, calculated, intrusive procedures and introduction of a crowd, a third party, in what should be an intimate process.

The best diagnostic tool in medicine remains the spoken word. The best therapeutic tool is the listening ear.

If they have presented to us “they” (one or both partners) want a child. Do they?

Some have found their way in saying “they have been trying” for very many years. Have they really?

Whose agenda is it – their presence in your clinic – is always worth asking.

‘Difficult’ cases are not uncommon which may leave you feeling frustrated and hopeless. Some signs to watch out for

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  Patients who do not adhere to their medication despite wanting a child – look beyond the chaos

  
  
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  Patients who are regularly late for appointments, keep you waiting.

A new term “inferto sex syndrome” to bring sexual dysfunction and subfertility together was suggested to help awareness among clinicians of the ‘pressure’ of childlessness, reaction to failure, need for sex by the clock, intrusiveness of ART and how it impacts emotional and psychological side of the couple, precipitating or manifesting as sexual dysfunction.

A couple-centred approach, awareness of anxiety that accompanies subfertility and giving the permission to voice it may help improve outcomes and decrease drop outs.

Bladder problems and sex

Sex and living with cancer

In the UK 3 million people are living with cancer and the number is expected to rise further. 70% have never been spoken to by any health professional on sex. 80% are on treatment and would like more information on sex and 35–50% have sexual dysfunction. 70% said they would not be able to bring up the topic themselves for discussion.

The diagnosis of gynaecological cancer has a huge impact on a woman’s sexual identity. Studies have shown that dysfunction appears early and is unlikely to resolve over time. However, many have concentrated on the ability to have penetrative sex rather than the overall quality of physical intimacy and pleasure which is important after a life-threatening diagnosis. Considerations include changes in patients self-perception as a sexually attractive being, grief at her loss of fertility, bodily changes that may be unacceptable, worries about recurrence (especially with cervical cancer and its links with sex), fears of transmitting to partner or anger at the partner “who gave it to me”.

Detailed, factual information before and after surgery and or radiotherapy, of the impact on sexual function for both partners should be frankly discussed. It is best for such information to be written as well, as many will not take in an oral discussion fully. At follow up visits, the topic sould be brought up, to see whether they are experiencing any difficulties and any fears or fantasies can be addressed. A psychosexual approach would of course help with uncovering any feeling that may interfere with arousal and enjoyment, and giving the permission to sort it out for themselves.

Sexual dysfunction in the colposcopy clinic

The finding of an abnormal smear and referral to a colposcopy clinic raises anxiety in many women. Many may have found it difficult to process the information provided about the wart virus and pre-cancerous changes, leading to unfounded fear for their life and fertility. Besides, the cervix is hidden so they cannot monitor it visually. The HPV being labelled a sexually transmitted virus may confirm fears of this being a punishment for sexual promiscuity. For some, it raises fears about a partner’s faithfulness and for others, the possibility of transmitting the virus. Feelings, triggered by a normal vaginal examination may be heightened, when, on a couch with stirrups, and a practitioner seated at the foot end between the legs. Loss of control, passivity and exposure to a larger number of staff are all thoughts that can surface. Watching the cervix on a monitor before and after treatment could help alleviate anxieties, and, reassure patients that healing is occurring.

Case 1

Patient A was a 34-year-old Asian woman looking fraught and anxious, making little eye contact. The friend held her hand all through the consultation. Once on the colposcopy couch, the friend had her arms around her – almost shielding her in a very protective manner.

I was conscious of my mounting anxiety and sought her consent at almost every step of the examination. She insisted I proceed.

At colposcopy I got the impression of a body divided into two halves, the lower half for me to examine while the upper had distanced itself.

Following the examination, I wondered if there were any difficulties at sex. She jumped on the invitation to see me in clinic.

Sex was painful and difficult since she turned sexually active. She disliked her vulva and almost shunned it! It was a “no-go area” for her.

On the examination couch she exhibited the same disengagement. She wondered if I could see any genital warts that had kept reappearing. These negative associations she had with her vulva, I wondered, what did this all mean to her. What could have led to her shunning this part of her body? I remembered my anxieties at the examination and how I felt I was doing something without consent. To my surprise, suddenly, her eyes misted over and then in between sobs and tears I heard of what happened in the past.

As a 13 year old, on one of her visits to India, she was sexually assaulted by a neighbour’s 18 year old son. She felt trapped, humiliated and let down. When she did tell her mother, it was hushed up and the topic never brought up again. I felt sorry for the 13-year-old and cross with the mother who appeared to have given her little support. Keen to explore her feelings at that time, I heard of her disappointment and anger as she had expected better from her mother.

At later visits she professed to finding pleasure with sex. She was in a committed relationship for the first time. Some years later, I was pleasantly surprised to run into her with a baby boy in her arms, looking radiant!

The extreme anxiety at presentation, her posture on the couch and the friend trying to shield her suggested a need to be protected when an intimate examination was about to happen.

The doctor’s anxiety and the need to obtain consent at every step, was possibly related. Was the doctor picking up feelings that were being transferred from the patient?

This disconnect was evident on the couch between the two halves of her body could be happening at sex too. This was what prompted the doctor to open up the topic of sex in a busy colposcopy clinic, and invite her back.

When reflecting back to the patient, the doctors feelings at examination, the mention of the examination simulating a non-consensual act (despite her consent) appears to have triggered a reaction. This is the first-time defences appeared lowered and the patient’s vulnerability exposed. She recalls being trapped and humiliated.

Furthermore, running back to safety and not confronting the persecutor, left her with a sensation of possible shame. The blame appeared to have been dumped on her. She felt disgust and anger at an area of her body that could attract a stranger, while, at the same time, have the potential to humiliate her and the family.

Being observant of how she was at examination, reflecting the practitioners feelings back to her appears to have opened a small window to the vulnerability. She makes the connection between her mind and body.

It is important to note that no closed questions were asked. The disclosure by the patient took even the doctor by surprise and helped her understand the reason for the disconnect.

Case 2

She was referred to my menopause clinic with soreness at intercourse. She was 53 years old, a short, portly Caucasian lady dressed in frills and pink earrings. The referrer wondered whether she could be a candidate for systemic HRT and maybe Testosterone as she was responding marginally to local oestrogen cream.

Sexual dysfunction started very soon after an operation in 2009 when a “big chunks” of her lips (labia) were removed for a pre-cancerous condition. “It has never been the same for me afterwards”. At that point I could only guess what ‘it’ was. She had further surgery in 2010 and later in 2012 but had kept off sex since then as there was ‘just a big black hole there’.

Her tone of voice as she said all this was flat, well controlled and not even a hidden tear betrayed her. However, I felt a huge wave of sadness sweep over me. She talked of soreness accompanying almost every ordinary act that people take for granted – passing water, opening bowels, bathing and of course sex. Intercourse that was so important to them as a couple was impossible! I therefore acknowledged the difficulty that she must be going through with all the medicalization and encouraged her to tell me what she thought about it now. “To me it is like “one big black Hole”. Did she sound more angry than sad I wondered?

She was on the table while the first consultant pointed out, with his fingers, the area he would remove – “I am afraid you are going to lose all of this”. “No, you are not” she thought. She was angry, but, there was nothing she could do then. Over years she had friends who lost various bits to cancer – Breast, cervix, the uterus and she had witnessed their grief. To her this was nothing less. Did she get a chance to talk to him about this post surgically? No, she was referred on to the Vulval clinic at our hospital. She was full of praise for the kind professor who had done her surgery but still could not bear to look at it – It was ONE BIG Black hole. My imagination pictured the big black hole in the universe that had sucked all the light in because of the strong gravitational force. Here, this black hole had done so with her sexual feelings!

She described herself as a control freak, unable to cope when things go wrong.

On her return visit, a copy of my letter to the Professor had reached home. She couldn’t read it but gave it to her husband to read. He felt their daughter should read too. “It was just great that I could be understood, my family found sharing of that very useful in their understanding of me”.

On examination she lay there with eyes closed. The vulva looked as normal as it possibly could with minimum disfigurement and scarring. I murmured that the Professor had done the repair well. I remembered vividly her earlier account of a speculum examination that had hurt her no end so offered it to her to self-insert. With much trepidation she tried but when she could get it in completely, looked really surprised. “You know this is fine, there is no pain. If I can do this, everything else should be fine too.” She jumped off the couch. “It is making a lot of sense to me”. “Can we leave it open for now?” when I brought up the topic of follow up. I haven’t heard from her since.

Her feelings around the loss of vulval skin, describing it as akin to losing feminine bits to cancer, were most likely being projected on to me by the patient. My acknowledgement of her anguish, making sense of her fantasies and interpreting this back to her may have helped in the healing process. It was important for her distress to be acknowledged for real, even more that her family does so.

Surgical procedures

Removal of the womb has emotional significance for a lot of women involving loss of fertility, feelings of femininity and sexuality. To some it may be a relief from heavy periods, unwanted pregnancies and cervical screening. Others go through a bereavement reaction, even surprising their rational self, by the strength of the emotion over the loss of an organ that was the cause of ill-health or was unnecessary. Such illogical feelings may surface at sexual contact leading to lack of arousal, avoidance of sexual contact, a “feeling of nothing inside” which sets up a cycle of failure and disappointment and further avoidance. Her partner, too, may harbor his own fears of not wanting to be forceful, resulting in erectile problems for himself.

Some without any pathology may escalate their problems to such a degree, such as, pressure the gynecologist to remove the organ. It is worth exploring what their expectations are. It may be an underlying unhappiness with their femininity, sexual disappointment or a need to control the messy business of bleeding. If one can successfully explore with a set of open-ended questions, without confrontation, it may be possible for the patient to help appreciate what the procedure can or cannot achieve. Low self-esteem, relationship problems, pelvic pain without an organic cause are unlikely to resolve with hysterectomy and could only lead to long lasting regret and ongoing symptoms.

Conclusion

Training in psychosexual medicine can be a boon for the gynaecologist. It is thought that 15–20 mins of consultation time is too short to deal with such problems. However, it is surprising how really useful work can be done within this short time. Uncovering the problem by ensuring sexual wellbeing is given its due importance in history taking, using sensitive language when providing feedback on an examination, examining the area of discomfort ‘with the patient’ and actively listening to her, all helps towards helping the patient develop an insight into her problem. As they say “It only takes a moment to switch on the light”.