Changing attitudes towards sex

This shift in attitudes has been highlighted by the findings from the consecutive UK National Surveys of Sexual Attitudes and Lifestyles (Natsal) conducted over the last three decades. In the most recent survey of individuals aged 16–74 years who lived in Britain (England, Scotland and Wales) that was completed between 2010 and 2012, data were available for 6777 women (and 4913 men) [2]. Some of the key findings for women were that low sexual function was associated with increased age and, after age adjustment, with depression and self‐reported poor health status. Low sexual function was also associated with experiencing the end of a relationship, an inability to talk easily about sex with a partner and not being happy in the relationship. Associations were also noted with engaging in fewer than four sex acts in the preceding 4 weeks, having had same‐sex partners and having 10 or more lifetime partners; 51.2% of women reported one or more problems in the past year, although self‐reported distress about their sex lives was much less common. For women in a sexual relationship for the past year, 27.4% (and 23.4% of men) reported an imbalance in the level of interest in sex between partners, with 17.1% of women reporting that their partner had had sexual difficulties.

Trends were reviewed over the three decades that the surveys have taken place (Natsal 1, 1990–1991; Natsal 2, 1999–2001; Natsal 3, 2010–2012). Some of the findings were as follows. The percentage of women who thought that one‐night stands were ‘not wrong at all’ increased from 5.4% in Natsal 1 to 12.2% in Natsal 2 and 13% in Natsal 3. The percentage of women thinking that female same‐sex partnerships were ‘not wrong at all’ increased from 27.7% in Natsal 1 to 51.5% in Natsal 2 and 66.1% in Natsal 3. The authors conclude in their review that sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seemingly greater in women than men. The continuation of sexual activity into later life, albeit reduced in range and frequency, emphasizes that attention to sexual health and well‐being is required throughout the life course [3].

In another recent study involving middle‐aged and older UK individuals (40–80 years), 56% of women reported having sexual intercourse in the last year and 18.8% of women engaged in sexual intercourse at least weekly. The most common problems reported were lack of sexual interest (34%) and lack of pleasure in sex (25%). Of some concern, 57.7% of women took no action when they had a sexual problem and only 16.7% of women reported talking to a medical doctor, with most women (82.3%) having sought no advice from a health professional. Talking to their partner was the most common action taken by women (32.5%) [4]. Only 4.2% of women had been asked by a doctor about possible sexual difficulties during a routine visit in the previous 3 years yet 29.2% of women thought that a doctor should routinely ask patients about their sexual function.

Despite this emerging evidence of patient need, it has been reported that women may present to a gynaecology or obstetric clinic without ever being asked, or disclosing any information, about their sexual lives. One study identified that over 98% of women reported one or more sexual concerns that often changed as women aged but that most of the women had not had the topic of sexual health ever raised by their physicians [5]. The clinic environment may not be conducive to routine enquiry but this should be addressed by changes to the patient clinic space to ensure patient confidentiality.

Sexual response: models of sexual function

Humans have three primary emotion–motivation circuits and these brain systems have evolved to direct and influence sexual behaviour. These are lust (sex drive, libido), driven by androgens; attraction (passionate romantic love), driven by dopamine; and attachment (bonding), driven by oxytocin [6,7]. Evolving evidence suggests that individual differences in human sexual behaviour may be in part due to allelic variants coding for differences in DRD4 dopamine receptor gene expression and protein concentrations in key brain areas [8]. A variant of the DRD4 dopamine receptor gene (a polymorphism found on chromosome 11 in humans) has been linked with uncommitted sexual behaviour and infidelity [9].

The aetiology of unhappiness within a relationship is multiple but failing to find a partner to love may arise when psychological intimacy is unable to be reached during courtship or is lost once in a stable relationship. When this arises, couples work may be appropriate should both partners be willing to attend to explore, amongst many issues, their ways of connecting, communicating and negotiating together. Other key areas may include dealing with issues of power and trust within a relationship.

The early models of sexual response were described as linear in nature, incorporating concepts of sexual drive (endocrine), sexual desire and libido (emotional and cognitive), excitation and plateau (vascular and emotional), orgasm (neurological, muscular and emotional) and resolution (Fig. 66.1). More recently, an intimacy‐based model of a women’s sexual response cycle was introduced by a team of experts (Fig. 66.2). This model reflects the key roles of emotional intimacy and sexual stimuli, unlike the earlier models which tended to neglect the importance of emotional intimacy as a motivator to find or be responsive to sexual stimuli. The basis of the more cyclical model is that the goal of sexual activity in women may not necessarily be physical satisfaction (by attaining orgasm), but rather emotional satisfaction (a feeling of intimacy and connection with a partner) [10]. However, there are additional models that may be important when considering sexual function and dysfunction and the interested reader is referred to a recent review [11].

Sexual response: anatomy and physiology

The anatomy and physiology of sexual function and dysfunction is not always overtly taught at medical school or in postgraduate courses, with several obstacles preventing sexual health from being adequately addressed in health professionals’ curriculum. These include low priority given to the topic and a lack of standardized objectives and means for evaluating any current curriculum. Given the raised awareness that medical conditions can result in sexual dysfunction and the fact that sexual problems may be the presenting symptom for significant underlying disease, the argument for mandatory awareness and training in the field is increasing [12].

Vaginal lubrication comprises vaginal transudate, often with secretions from the Bartholin’s glands and the paraurethral Skene’s glands. The process of transudation depends on both intact innervation and normal oestrogen levels. The process of parasympathetic activation via the sacral nerves S2–S4 leads to an increase in vaginal blood flow. It has been shown that the process of vasomotion occurs with the random opening and closing of the capillaries of the vaginal wall (Fig. 66.3). The normal low basal flow is maintained by both high sympathetic (T12–L2) inhibitory tone and vasomotion [13].

Concurrent with any increase in vaginal blood flow is an increase in the blood flow to the clitoris, an organ which is much hidden from routine inspection of the vulva. The perineal urethra is embedded in the anterior vaginal wall and is surrounded by erectile tissue in all directions, except posterior where it relates to the vaginal wall [14]. The erectile tissue brings about swelling and protuberance during sexual arousal. The clitoris appears to exist solely for the purpose of sexual pleasure. There has been much debate about the differences and importance (if any) between clitoral orgasm and vaginal orgasm and whether the presence of a G‐spot exists to bring about sexual pleasure. In recent years a number of papers have been published with regard to the possible isolation of tissue identified to be the G‐spot and the evidence and arguments are summarized in a recent commentary [15].

Sexual diversity

The gynaecologist should strive to offer a non‐judgemental approach when exploring a woman’s sexual identity regardless of any sexual dysfunction and this will be considered further in the following section. The principle issues involve sexual orientation, gender identity and the presence of any paraphilic patterns of sexual arousal.

Sexual orientation should be routinely enquired about with women in the clinical setting. It is difficult to be certain of the true prevalence of lesbianism but in one study, among women, 97.7% identified as heterosexual, 0.8% as lesbian or homosexual and 1.4% as bisexual. However, during this computer‐assisted telephone interview, among women, 84.9% reported only opposite‐sex attraction and experience. Thus, some same‐sex attraction or experience was reported by 15.1% of women (compared with 91.4% of men). Of women, 8.2% reported sexual attraction and sexual experience that was inconsistent. Factors associated with this agreement or disagreement included age group, non‐English‐speaking background, education and socioeconomic status [16].

It is also important to distinguish and to ask about the gender that an individual may identify as. This may not always be as a binary female. The terminology and use of pronouns can be a difficult maze for the uninformed clinician and a review of the various terms has been published [17].

Trans people may transition with psychological and medical care that requires endocrinology and surgical intervention. For some trans men (i.e. woman to man), there may be a need for chest surgery and hysterectomy. If the individual has not yet decided to progress for phalloplasty, a gynaecologist may be approached, with medical recommendations and support for hysterectomy (and usually oophorectomy). Some women may present to gynaecologists having transitioned from a male gender role. These men and women should be offered the same clinical care as any women whilst recognizing there will be some differences in clinical needs during the post‐perioperative care period and in the postoperative anatomy. Once transition has occurred, and where necessary, liaison with the surgeon involved in the gender confirmatory surgery may be indicated but it is not appropriate to access mental health services unless there are relevant clinical indications to do so. On some occasions, the gynaecologist may be the first person with whom a patient may raise the issue of a desire for gender transition (which if towards the male role would be as a trans man). An overview of guidelines for clinical care for trans people is available [18].

Sexual dysfunction

It is important to remember that there will be some women who do not openly share the details of their sexual life or sexual preference, even when asked about it. This can lead to some difficulties when a clinician first hears about a particular preference or practice, especially any that may be outside their own experience. An awareness of different sexual practices, particularly in the area of sexual preference as a normal part of the sexual repertoire for arousal and sexual pleasure, is considered next.

The paraphilias, or sexual preference disorders as listed in section F65 of the International Classification of Diseases (ICD‐10), are a group of preferences that were considered outwith ‘normal behaviour’. With the increasing acceptance of diversity over recent decades, many of the conditions historically described as ‘sexual perversions’ are no longer considered such and have been removed from the recent fifth revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and many will most likely be removed in the forthcoming revision of the WHO classification system (ICD‐11). Although paraphilias have not disappeared completely from DSM‐5, there is an attempt to clearly distinguish between the behaviour itself (e.g. receiving of pain for sexual pleasure: sexual masochism) and a disorder stemming from that behaviour (i.e. sexual masochism disorder) [19].

To differentiate between an atypical sexual preference and a mental disorder, DSM‐5 requires that, for diagnosis, people with such interests exhibit the following: (i) ‘feel personal distress about their interest, not merely distress resulting from society’s disapproval’; or (ii) ‘have a sexual desire or behaviour that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviours involving unwilling persons or persons unable to give legal consent’ [20]. To take the example of fetishism, a fetish is an object or body part that a person must focus on to become sexually aroused and in extreme cases to achieve sexual satisfaction. The reliance on some non‐living object as a stimulus for arousal and sexual gratification may arise for a number of reasons. For many people there is experimentation with fetishistic behaviour, which is not a fetish by definition. Numerous sexual aids and ‘toys’ are easily available from high‐street shops and mail order. Some fetishes require no inanimate objects but merely non‐genital parts of the body. Preference for the feet or toes (such as sucking the toes of the partner and/or having their own toes or feet licked or rubbed) was the most prevalent fetish by a considerable margin in one recent large study [21].

Likewise, in a study to try to identify ‘what exactly is an unusual sexual fantasy’, the themes that were most reported by women included an exotic or unusual private place for sex (such as a deserted beach or forest) with a focus on her own submissive behaviour. Around one‐sixth of women mentioned involvement of a stranger and around 8% mentioned either homosexual activities or group sex. The themes were very different from those mentioned by men, where voyeurism and fetishism were the highest reported. Clearly, this matter may lead to some difficulties for partners if they were to declare these openly or try to enforce these into the sexual repertoire, especially if they were not negotiated or discussed in advance [22].

Throughout this chapter, no attempt is made to discriminate against any of these sexual choices, and for brevity reference to a partner may be made whilst recognizing that many women may be without a partner at a certain time through preference or otherwise or may have multiple partners.

Psychosocial and psychosexual factors contributing to sexual well‐being

The fourth International Consultation on Sexual Medicine (ICSM) convened in Madrid in 2015. The committee reviewing psychological and interpersonal dimensions of sexual function and dysfunction made a number of recommendations that are summarized here for women presenting with sexual problems. Exploration of the attachment style of the woman, her personality, her cognitive schemas, any infertility concerns, and sexual expectations should all be noted. Assessment of depression, anxiety, stress, substance use and post‐traumatic stress (and their medical treatments) should be carried out as part of the initial evaluation. Clinicians should attempt to ascertain whether any anxiety or depression is a consequence or a cause of the sexual complaint, and treatment should be administered accordingly.

Assessment of physical and mental illnesses that commonly occur in later life should be included as part of the initial evaluation in middle‐aged and older persons presenting with sexual complaints [23]. Further recommendations are to assess multiple aspects of sexual functioning, including, but not limited to, subjective aspects such as sexual self‐esteem and sexual satisfaction, not just sexual dysfunction. A developmental approach to assessing the onset of sexual activity is recommended, including self‐focused as well as partnered activity ranging from non‐genital to genital expressions, the context around those experiences, as well as any associated beliefs and emotions associated with them. Crucially, there should be an attempt to explore their possible role in the individual’s current sexual function and behaviour.

Clinicians should explore sensitively childhood experiences including sexual abuse and, if this occurred, its characteristics regarding frequency, duration and whether the perpetrator was known or not.

In addition, a number of life‐stage stressors are evident for women, including infertility, postpartum experiences, ageing and menopause, and these can have a specific impact on psychosocial and psychosexual experiences. The prevalence of sexual dysfunction in women reporting infertility was higher than that in the fertile control group in one study using the FSFI questionnaire [24]. The recommendation to clinicians is that during all phases of infertility diagnosis, investigation and management the clinician, whenever possible, assess sexual function and satisfaction.

Approximately half (52%) of women resume sexual activity by 5–6 weeks post partum. However, it is less clear the extent of sexual dysfunction at 2–6 months post partum, with various studies suggesting this affects 22–86% of women (see Brotto et al. [23] for full review].

With regards to normal ageing, a survey of 3005 respondents in the USA (ages 57–85) found that the prevalence of sexual activity was 74.8%. Women were much less likely to report being sexually active than men. Half of the women (and half of the men) reported at least one bothersome sexual problem and were concerned about the impact of ageing changes on their sexuality. The most prevalent sexual problems among women were low desire (43%), difficulty with vaginal lubrication (39%), and inability to orgasm (34%) [25].

Stressors and adverse life events that may affect sexual function and satisfaction include sexual experience throughout life, attitudes toward sex, dysfunctional sexual partner, death of partner, sexual performance issues, impaired self‐image, physical or mental fatigue, disturbed family relationships, divorce, physical illnesses and disabilities, need for special care, changes in employment and financial status [23]. A drop in testosterone levels, and increase in cognitive and depression issues with older age may also impact on sexuality. Clinicians should be aware of the relationship between symptoms of ageing and psychological health (e.g. anxiety, irritability, insomnia, memory impairment and depressed mood) in older men, and request further investigation when needed.

Menopausal status has an independent effect on reported changes in sex life and difficulties with intercourse. The results from the Study of Women’s Health Across the Nation (SWAN) [26] highlight the importance of including social, health and relationship factors in the context of menopause and sexual functioning. These factors and, in particular, feelings toward one’s partner or starting a new relationship have also been identified by others as highly important [27–31]. Similar to a previous study [33], Avis et al. [26] found declines in all areas of sexual functioning according to menopause status. Controlling only for age, the Melbourne Women’s Midlife Health Project also found greater declines in sexual functioning among 197 women who transitioned from premenopause to postmenopause compared with women who remained premenopausal. Previous sexual function and relationship factors were more important determinants of libido and sexual responsiveness than estradiol level [32,33].

Finally, there are limited data on the impact of sociocultural factors on female sexual function as well as on ethical principles to follow when clinical care falls outside traditional realms of medically indicated interventions. It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. There are a number of practices with complex ethical issues (e.g. female genital cutting, female cosmetic genital surgery) that may need careful reflection and discussion with the woman and within professional peer supervision for the gynaecologist [34].