History of Present Illness

A 25-year-old female, gravida 4 EAB 4 (elective abortion), presents to clinic complaining of vaginal discharge present for one week. She has had visits every several months over the last two years to multiple providers with diagnoses of gonorrhea, chlamydia, trichomonas, and genital warts. She reports being sexually active, and does not provide specific answers to questions about risk factors or living arrangements. She insists she is in a hurry and requests treatment so she can “get back to work.” She answers “no” to all questions on the clinic’s standard intimate partner violence screen on the intake form, and again replies “no” when asked by the provider. She smokes one pack per day. She denies substance use. She received depo medroxyprogesterone acetate 150 mg 8 weeks ago at her last visit to the clinic and takes no other medications.

Physical Examination

General appearance

Well-appearing thin woman in no apparent distress. No visible bruising or signs of physical trauma.

Temperature

37.0°C

Pulse

80 beats/min

Blood pressure

90/60 mmHg

BMI

24.2 kg/m²

Abdomen

She has a tattoo in her left lower quadrant that says “Daddy.” Soft, non-tender, non-distended, no guarding, rebound

External genitalia

Unremarkable

Vagina

Foul grey-white discharge

Cervix

Nulliparous, no mucopurulent cervicitis, no cervical motion tenderness

Uterus

Normal size, mobile, non-tender

Adnexa

Normal size, non-tender

Urine pregnancy test

Negative

Wet mount

Motile trichomonads

KOH prep

No clue cells or hyphae.

Gonorrhea and chlamydia nucleic acid amplification tests (NAAT)

Obtained and returned negative the next day.

How Would You Manage This Patient?

The patient has trichomonas, which you treat with metronidazole. You counsel her regarding need for partner treatment and sexually transmitted infection prevention. You are deeply concerned about the pattern of multiple abortions and recurrent sexually transmitted infections and her reticence to discuss her risks. Concerns include engaging in high-risk sexual behaviors, intimate partner violence, prostitution, and human sex trafficking. While the patient has not responded to any of your questions in a way that confirms the diagnosis, you are aware that traffickers often use tattoos to brand their victims, and decide to probe further. Using principles of trauma informed care, you aim to raise awareness, build trust, and facilitate the patient seeking help when ready.

You observe for behavioral cues and ask questions like those suggested by the University of Kansas Human Trafficking Medical Assessment Tool (Box 88.1). The patient listens to the questions, but makes no clear responses. You conclude by briefly expressing your concerns that she is at significant risk, and you are worried that she may be the victim of intimate partner violence or human trafficking. You give her your standard discharge paperwork, as well as two “shoe-sized,” easy-to-hide cards, one with contact information for the local domestic violence shelter, and the other for the National Human Trafficking Resource Center hotline. You leave the exam room before she does. She leaves the discharge paperwork, but takes the shoe cards.

Human Sex Trafficking

Human sex trafficking, also known as commercial sexual exploitation (CSE), is defined by the Trafficking Victims Protection Act of 2000 as compelling a person to perform a commercial sex act through force, fraud, coercion, or where the person induced to perform the act is less than 18 years of age. A person under the age of 18 engaged in any commercial sex act is considered a victim regardless of whether force, fraud, or coercion is present. CSE is an egregious violation of human rights where victims are treated as commodities, and repeatedly bought, sold, and serially raped by an untold number of buyers who are usually unknown to the victim. Traffickers use ongoing humiliation to destroy a victim’s self-esteem and anything that gives them reason to leave. The skillful use of force, fraud, and coercion by the trafficker can make a victim feel bonded to their trafficker and “personally responsible” for “choosing” to be prostituted [1].

The majority of CSE victims in this country are US citizens and almost half are under the age of 18 [2]. Children and teens are at increased risk of becoming victims because of their inability to fully comprehend the sophisticated and manipulative practices used by traffickers to target, recruit, and control. CSE occurs when victims are compelled or entrapped into the sex industry by traffickers who use physical and psychological violence, including an array of deceptive tactics, to exploit vulnerability. A CSE victim has no life predictability, agency, safety, or control, and cannot leave their trafficker without fear of violent retribution. CSE victims may be engaged in street and internet-based prostitution and pornography, as well as in “legitimate” businesses like escort services, massage parlors, and stripping. CSE victims can be involved in sex tourism, phone sex, and mail order bride industries. Despite being engaged in the sex trade, victims are not prostitutes, but are victims and survivors of CSE, entitled to protections under the law. Prostitution and CSE are different and the terms should not be used interchangeably.

Many gynecologists have seen CSE victims in their office and are not aware of this. Clinicians need to have a high index of suspicion because human trafficking is clandestine by nature. Studies estimate that anywhere from 28 to 88 percent of trafficked persons access medical services at some point during their exploitation, but are frequently not recognized [3,4]. Victims have limited access to preventative care and management of chronic conditions because entering a health-care system presents a high risk to the trafficker about exposing their crimes. Given these circumstances, it is likely that trafficking victims typically enter hospitals and clinics only when injuries and ailments are life threatening or debilitating enough to affect the victim’s ability to make money. Health-care providers are one of the few groups of professionals who interact with victims while they are still under the control of their abuser, so the clinic visit may be the only chance a victim may have to be assisted in recognizing their exploitation, consider exit strategies, and reclaim their basic human right to freedom, health, and safety. CSE has a tendency to intersect with related crimes and can coexist with domestic violence, dating violence, survival sex, truancy, homelessness, running away, drug addiction, or any type of call to the police.

Key Teaching Points

• 
  

  Many gynecologists are unaware that they have treated victims of sex trafficking in their office, and clinicians need to have a high index of suspicion for potential victims of sex trafficking.

  
  
• 
  

  Sex trafficking victims and survivors are reticent to disclose their victimization.

  
  
• 
  

  Clinicians should have a plan for screening and referral of human trafficking victims.

  
  
• 
  

  Clinician should respond to potential victims with trauma informed and victim-centered care.

  
  
• 
  

  The National Human Trafficking Resource Center hotline (1-888-373-7888) is an important resource for potential victims and providers.

History of Present Illness

A 41-year-old female, gravida 3, para 3, presents to your office with little interest in having sex over the past two years with her partner. This worsened over the past year, and it affects her relationship. She and her partner always use lubrication; however, lately she feels like it isn’t enough and she has irritation for a few hours to one day after sex. She currently has sexual intercourse two times per month because of obligation to please her partner. She reports difficulty getting her partner to understand the pressures she feels regarding sex. She orgasms with clitoral stimulation with her partner and during masturbation. She has not masturbated in the past three months because she doesn’t have time or interest. Her baseline sexual function was previously normal without difficulties with desire, lubrication, or orgasm. She uses depo-medroxyprogesterone (DMPA) for contraception and has had amenorrhea for three years. Her menses prior to using DMPA were every 21–23 days and lasted 2–4 days. She is hesitant to talk about past sexual experiences and denies any history of sexual trauma or abuse at this visit. She has had anxiety and depression intermittently since college for which she took SSRIs. She recently started a new job, which increased her stress level and led her to restart her antidepressant, paroxetine, three months ago. She is otherwise healthy and takes no other medications. Her children are aged 4, 6, and 10. Her mother underwent menopause at 43.

Physical Examination

General appearance

Well-developed woman in no acute distress

Vital signs

Within normal limits, Height 65 inches, weight 130 lb, BMI 21.6 kg/m²

Abdomen

Thin, soft, non-tender, non-distended, no rebound, no guarding

External genitalia

Normal BUS, labia minora and majora, mild atrophy in posterior forchette

Vagina

Rugae diminished, mild atrophy

Cervix

Parous, no lesions or cervical motion tenderness

Uterus

Anteverted, mobile, normal size, non-tender

Adnexa

No masses or tenderness bilaterally

Laboratory studies

Not indicated

Imaging

Not indicated

How Would You Manage This Patient?

The causes of this patient’s loss of interest in sex are multifactorial. While this patient has low sexual desire, she does not meet criteria for sexual interest/arousal disorder (SIAD) because she does not report reduced initiation of sexual activity, being unreceptive to her partner’s attempts, nor does she mention reduced genital sensation, arousal, pleasure, or excitement during sexual encounters. Finally, her depression and SSRI use precludes the SIAD diagnosis. At this visit, her concerns regarding lubrication and her mood that were affecting her sexual function were addressed, as well as clarifying her definition of sexual satisfaction and what she considers normal sexual function.

Her physical causes include vaginal atrophy due to DMPA contraception, which inhibits ovulation. It is also possible that she has overall declining estrogen due to ovarian aging. She was switched to oral contraceptive pills and prescribed vaginal estrogen. For her anxiety and depression, she is currently taking paroxetine, which can have a negative effect on sexual function in up to 20 percent of women. She was changed to bupropion, which in some cases can enhance sexual function. Anxiety and depression put her at higher risk for SIAD; therefore she was encouraged to add cognitive behavioral therapy (CBT) to her treatment plan.

On an emotional level this patient is distracted and may have negative thoughts during sex. She has increased stress due to a job change and three small children. She was provided counseling on communication tips with her partner, limiting distractions by setting aside time for adults, and optimizing her mental health. She saw value in CBT for herself, and declined couples therapy at this time.

At follow-up visits, she felt more comfortable discussing past trauma and we strove to understand her past experiences/relationships and determine if there are cultural factors that play a role in her low desire. We discussed how pressure from her current partner could trigger emotions from a sexual assault she revealed that she experienced during college. She received counseling at the time and while she stated she was past it, she was open to discussing it in future therapy sessions. She had good understanding of her body and the biology behind sex; however, she struggled with the body composition changes in her 40s now that she is less active. We discussed the topics of attraction and attractiveness as well as diet and exercise as ways to bolster her self-confidence. In follow-up, she noted stable mood, small improvement with sexual desire, and improved vaginal lubrication.

Loss of Interest in Sex

Low sexual desire is the most common sexual complaint in women across all age groups, and is reported in up to 40 percent of individuals in cross-sectional studies [1]. Each patient has a unique context of their expectations, norms, and personal history regarding sex and intimacy. Practitioners should aim to see the patient’s view of their sexual health through understanding the patient’s cultural pressures, gender, sexual identity, and any history of trauma.

Sexual function is often simplified from a diagnostic standpoint as a linear process that goes from desire to arousal to orgasm. However, it is important to understand how emotional intimacy and sexual satisfaction play a role, as highlighted by Basson’s model of sexual response (Figure 89.1). In this model, the sexual response is a positive feedback loop in which emotional intimacy is the driver of desire and arousal. Many women may not initially experience desire on initiation of intimacy. Further, emotional and physical satisfaction are sought after, which may or may not involve orgasm. Clinicians should be cognizant that “normal” sexual function varies among women, and also can vary within the same woman throughout different phases of her life.

Figure 89.1 Basson’s nonlinear model demonstrates how emotional intimacy, relationships, and sexual satisfaction affect female sexual response. Basson R. Human Sex-Response Cycles. J Sex Mar Therapy 2001; 27:1: 33–43

The diagnosis of SIAD, according to the DSM-5, is made when a woman experiences three of the following for at least six months: (1) reduced or absent desire for sex, (2) reduced or absent sexual thoughts/fantasies, (3) reduced or absent initiation and receptivity of sexual activity, (4) reduced or absent sexual pleasure, (5) reduced desire triggered by sexual stimuli, and/or (6) reduced or absent genital or nongenital sensations [2]. These symptoms must cause significant distress and cannot be caused by severe relationship distress, emotional stress, the effects of a substance or medication, or the effect of another medical condition or other nonsexual mental disorder. The diagnostic criteria should be used cautiously, as women who experience less than three criteria or for a shorter duration may still have significant distress and warrant treatment, as is the case with this patient.

The most common physical factors that may be associated with a loss of interest in sex include comorbid medical conditions (hypertension, diabetes), pain with intercourse due to dryness or vaginismus, and medications (particularly antihypertensives and SSRIs) [3]. Neuroendocrine changes with aging, such as decreased testosterone and estrogen, can change intensity of sexual desire and sensation. Declining estrogen levels in the peri-menopausal period can result in vulvovaginal atrophy; however, this is not necessarily associated with loss of sexual desire. Progesterone-only methods of contraception can also contribute to atrophy. Of note, DMPA preferentially suppresses LH and ovulation. Up to one-third of users have normal estradiol; however, others, especially long-term users, can experience low estradiol levels that result in vulvovaginal atrophy. Consider treating with estrogen cream preparations, estradiol (0.01 percent) or conjugated estrogen (0.625 mg/gram) 0.5 grams nightly for two weeks, then twice weekly or estradiol vaginal tablet (10 mcg) nightly for two weeks, then twice weekly for maintenance. Both topical estrogens and ospemifene 60 mg daily (a selective estrogen receptor modulator) are FDA-approved for vaginal atrophy and dyspareunia [3]. DMPA should not be overlooked as a factor contributing to low desire in this case.

Depression and anxiety are found in approximately 25 percent of women with low sexual desire [4]. In addition, SSRIs used to treat depression are common medications linked to sexual dysfunction. Decreasing the dosage or switching to another medication may alleviate some of the symptoms [3]. Serotonin pathways play a role in sexual inhibition, specifically the 2 A receptors. Drugs that are more selective will activate stimulatory pathways or reduce inhibitory pathways to improve sexual side effects. Buproprion (150 mg–400 mg daily), a norepinephrine-dopamine reuptake inhibitor, has been shown in studies to improve sexual function in women with and without depression [4]. Multiple new medications such as gepirone, vilazadone, meclobamide, and agomelatine have been brought to market to decrease side effects noted with initial SSRIs. Post hoc analyses of phase IV clinical trials of these medications show improved sexual function in women though serotonin 5HT1A partial agonist properties. This patient has anxiety and depression and is taking paroxetine, both of which are likely factors in her symptoms.

CBT attempts to modify negative thoughts and behaviors that can interfere with desire. Discussion and education can reduce performance anxiety and shift focus to pleasure instead of sexual form and expectations. The use of CBT is recommended by the International Society for Sexual Medicine (grade B level of evidence) and is a widely used treatment for women with low sexual desire. This patient could benefit from CBT for both anxiety and depression as well as for low sexual desire. In a meta-analysis of 20 studies, CBT had a significant positive effect on desire and sexual satisfaction, with stronger results in women diagnosed with hyposexual desire disorder (HSDD) [5]. Studies show CBT for sexual dysfunction also decreases frequency of comorbid mood disorders such as anxiety and depression.

Sex therapy for couples incorporates aspects of CBT, such as improved communication methods, sexual skills, and sensate focus exercises. It is most useful for vaginismus, aversions, and orgasm dysfunction. In the setting of low desire, sex therapy can educate couples, address misconceptions, identify distractions and provide couples tools to address relationship building and promote behavior change [1]. Couples therapy allows partners to boost trust, explore sensuality, and enhance and restore intimacy. Women are more likely to improve sexual desire using these modalities if both partners are highly motivated and there is underlying satisfaction with their relationship.

After addressing modifiable factors and psychosocial influences, patients may request pharmacotherapy. Flibanserin is the only FDA-approved medication for hypoactive sexual desire disorder in women. It is only approved for use in premenopausal women. It is thought to work by increasing the release of the neurotransmitter hormones dopamine and norepinephrine, while decreasing serotonin release in the area of the brain that regulates sexuality. It has only a modest effect on sexual desire, with an increase of 0.5–1 satisfactory sexual events (SSE) per month over placebo [6]. Side effects include hypotension, syncope, somnolence, and fatigue. Women should not drink alcohol or use birth control pills while taking it because they can worsen the side effects. Sildenafil citrate has not been shown to improve sexual function over placebo in women, but may have some utility in women with spinal cord injury (SCI) and multiple sclerosis (MS). In separate small studies of 19 women each, subjective arousal to visual and manual stimuli improved in women with SCI and lubrication improved in women with MS with no adverse events noted in either group.

Younger surgically menopausal women have a higher prevalence of hypoactive sexual desire disorder compared with women who undergo natural menopause. A recent systematic review and meta-analysis of short-term transdermal testosterone showed significant improvement in number of SSEs, number of orgasms, and sexual desire along with a reduction in personal distress in surgical and naturally menopausal women at the 300 mcg twice weekly dose [7]. While small studies on premenopausal women with low testosterone levels using topical testosterone over a short duration (3–4 months) show minimal improvement (0.8 SSE/month), the data are not adequate to recommend it [8]. Side effects included acne and hair growth, but none were rated as severe.

It is important to note there is no current FDA-approved testosterone treatment for low sexual desire and long-term data regarding breast cancer and coronary artery disease outcomes in premenopausal women, and duration of safe long-term use is lacking [1, 3]. If a decision is made to use topical testosterone, close follow-up is necessary and clear improvement in sexual function and satisfaction must occur. Data are limited on use longer than six months and does not support laboratory monitoring of free testosterone.