Psychosexual problems

Article Outline

• Abstract
• Introduction
• Female sexual function
• Hormones
• Case 1
• Case 2
• Female sexual dysfunction classification
  • Desire disorders
  • Sexual arousal disorder
  • Orgasmic disorder
  • Pain and vaginismus
• Case 3
• Prevalence
• Case 4
• How to ask about sex
• The examination
• Case 5
• Conclusion
• Further reading
• Copyright

Abstract 

Sexual problems commonly present in gynaecology clinics. They require both a physical and psychological approach to their management due to the combination of mind and body involvement in sexual activity. The skills involved in psychosexual medicine can be practised by all gynaecologists as they use the consultation and examination to recognise and treat the underlying problem in addition to addressing any physical factors.

Keywords: arousal disorder, desire disorder, dyspareunia, female sexual dysfunction, orgasmic disorder, psychosexual medicine, vaginismus

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Introduction 

Sexual health is a significant component of general well-being as determined by the World Health Organisation, a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. As gynaecologists are primarily involved with the function of the pelvic organs with respect to both physical and psychological performance, the ability to engage with sexual difficulties is paramount. The health professional may feel inadequate in the face of overt or covert presentations of sexual dysfunction (see Table 1) and the patient frequently brings her awkwardness during sexual activity to the consultation. Encouraging the doctor and patient to share these difficulties and from there to ‘problem solve’ is helpful for both. Approaching the patient as the ‘expert’ in her condition and using the feelings generated between the doctor and patient during the consultation to explore the meaning and context of her difficulties can lead to resolution and satisfaction for both patient and doctor. A simple pathway of care and an understanding of psychosexual medicine may enable the general gynaecologist to help their patients without referral to another health professional.

Table 1. Common presentations of sexual problems in the gynaecology clinic

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Female sexual function 

The range of sexual behaviour in women makes categorisation of abnormality more difficult than the quantitative measures in men – e.g. erection and ejaculation. Sexuality in women may be more qualitatively measured. The models of female sexual behaviour have been modified over time: from the Freudian concept of sexual dysfunction being symptomatic of adverse childhood experiences leading to disorders of maturation and personality, abnormal child–parent relationships and an inability to form future intimate bonds to the next pivotal perspective of Masters and Johnson in the mid 20th century. Figure 1 illustrates the linear model reflecting male sexuality more accurately than female: progression from desire to arousal and excitement, leading to single (or multiple) orgasm followed by a refractory period. These phases were observed within laboratories using sex workers and volunteers – perhaps not a true representation of heterosexual intercourse? More recently, an International Consensus group has expanded the female sexuality models developed over the latter 20th century to include the importance of intimacy and sexual stimuli for the innate sexual drive (Figure 2). This suggests a female perspective where an innate drive or libido may not be necessary for a healthy and satisfying sexual life. Sexual motivation in women is complex and may start from a position of sexual neutrality. Reasons for being sexual include the desire to reinforce the physical and, therefore, emotional intimacy of their relationship. Sexual stimuli can then be processed in the mind, influenced by biological and psychological factors. This may result in arousal, sexual excitement and satisfaction, with or without orgasm. However, mental and physical pain may easily disrupt this cycle and the ability of the woman to focus. Sexual satisfaction in turn promotes further sexual activity. There may be pressures from outside influences such as the media that propose criteria for ‘normal’ function. This promotes performance anxiety in women as well as men. A negative feedback cycle may develop that then facilitates the development of a psychosexual disorder.

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• Figure 1 

  Masters and Johnson model of female sexual response cycle (Source: Masters WH, Johnson VE. The human sexual response. Boston: Little, Brown & Co; 1966).

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• Figure 2 

  International Consensus group female sexual response cycle.

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Hormones 

It is not clear at present what role hormones play in female sexuality. Low sexual desire is frequently found in younger, oophorectomised women without hormone replacement and is a licensed indication for testosterone replacement in addition to oestrogen. However, androgen levels do not correlate with other measures of sexual behaviour although there is some correlation noted in studies of the menopause indicating oestrogen maintains higher sexual functioning. Overall, the most important factor in persistent sexual activity with age is presence of a sexually functioning partner. For this reason, hormone assays are rarely helpful.

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Case 1 

A 65-year-old married Caucasian woman presented to a clinic with overactive bladder symptoms. After she reported her symptoms having improved with anticholinergic medication and bladder retraining, she seemed reluctant to leave a follow-up consultation. ‘It is odd that now I can't feel my bladder, I also can't feel anything during intercourse.’ Vaginal oestrogens were prescribed and a follow-up consultation organised for further discussion. It is important to note the opportunity for the patient or the doctor to ‘flee’ in the ‘hand on door’ situation when a significant problem is brought up at a time the patient can leave if she/he senses discomfort from the doctor. The doctor had recognised the hesitation of the patient and not avoided the important topic introduced, even though it was not pursued at this time.

At the next appointment the vaginal oestrogens and atrophic vaginitis were discussed. Although treatment had made physical intercourse easier, the lack of sensation was still present. ‘Maybe it is normal for my age?’ When the doctor asked when it had started, she described a very satisfying sexual life until her husband's retirement. What had changed then? A distinct tone changed in her voice – the rather timid, ‘maybe I am too old for sex, lady became a strident, controlled matriarch.’ ‘He thinks he can tell me how to run the household, which I have done for the last 30 years with no complaints and tell me there is time after the washing up for an afternoon of sexual interlude as he feels too tired at night. I have far too many things to do in the afternoon and he really needs to get something else to fill his time.’ The inability to communicate this to her rather forceful husband was demonstrated through a very powerful defence by the wife – lack of sensation – in this case an unconscious physical rejection of his advances. At the next consultation the problems had resolved – she would seduce him at a time of her choosing and he had found a part-time job that occupied him in the afternoon! Both the physical and the psychological played a part in improving these symptoms.

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Case 2 

A high-powered lawyer walks into the consultation room, taking her notebook out of her briefcase. She has a list of complaints that almost appear to have been copied from a textbook, details downloaded from the Internet and a prescription written by herself of the drugs she requires. She had taken part in drug trials for female sexual dysfunction in the past but feels what she is lacking is hormones. The doctor feels powerless to explore her needs as her requests are perfunctory and efficient but presented without any feeling. This is reflected to her – ‘what is it about these symptoms that concerns you?’ The doctor tries to inject some emotion into the consultation. It is only when she is asked about her relationship (a detail lacking from her comprehensive history) that a chink appeared. A tear rolled down her cheek slightly and was brusquely wiped away. She revealed her fear in fact – she was losing her partner, younger by 10 years. She felt she needed to be the sexual being she had been in the past, irrespective of age and hormonal status. Her partner had made comments about her not keeping up with him. Tearfully she explained that she had no time to keep up with the high maintenance activities required to preserve her youthful self. Her libido had deserted her. But was it due to hormones or was it a more unconscious control of the situation? This postulation allowed her to take stock of how much was under her control. The hormones may give her confidence and fulfil her need to turn on her sexual ‘emotions’ as she wished. Yet an understanding with her partner of how she was feeling would be a more powerful position from which to resolve or improve her sexual difficulties.

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Female sexual dysfunction classification 

The modified framework of the International Classification of Diseases (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) categorisation may be helpful to distinguish the predominant problem but there is frequently significant overlap of conditions, with little clarity as to which was the preceding problem.

Desire disorders 

Hypoactive sexual desire disorder (HSDD) is the persistent or recurrent deficiency or absence of sexual desire, sexual fantasies or thoughts, and/or the desire for or receptivity to sexual activity, which causes distress. The emphasis on causing distress and focus on sexual thoughts allows the flexibility of definition to include those who are not in a relationship or have lost their relationships secondary to their HSDD.

By contrast, the more severe sexual aversion disorder is the persistence of phobic aversion to and avoidance of sexual activity, which causes personal distress and is less common.

Sexual arousal disorder 

This is defined as the persistent or recurrent inability to attain or maintain sexual excitement causing personal distress, which may be described as subjective feelings and/or lack of physical changes.

Orgasmic disorder 

The persistence or recurrent difficulty or absence of achieving orgasm following sufficient stimulation and arousal. It may follow from either desire or arousal disorders or be truly independent.

Sexual pain disorders include dyspareunia, defined as persistent or recurrent genital pain associated with sexual intercourse. This may be physical and/or psychological (i.e. psychosomatic) in origin.

Non-coital sexual pain disorders are genital pain disorders induced by non-sexual stimulation, most commonly vulval pain disorders that result in sexual problems.

Pain and vaginismus 

Pain is a symptom easily reported by patients and a secure question for physicians to ask. It is important to acknowledge both the physical and psychological components. It should not be dismissed as non-organic pain without sufficient exploration but this may not always require physically invasive investigations such as laparascopy. Vaginismus has been described by the International Consensus group as recurrent or persistent involuntary spasm of the pelvic musculature that interferes with intercourse. However, it may be situational, such as with only certain partners or just at speculum examination. This should be more often interpreted as a sign not a symptom of pelvic problems and, therefore, not considered as a diagnosis alone. If a woman complains of vaginismus, explore what this means to her. Where did she find this diagnosis? Was it a diagnosis given to her from a health professional or did she find it on the Internet? Language used by health professionals and patients is very different – to assume the meaning of words used without seeking clarification is likely to limit understanding of the patient's complaints. Basic language and euphemisms can allow misinterpretation and often proves difficult with patients whose native language is different to that of their health professional. This works both ways. Letting the patient explain the meaning in her words and feelings and using the words the patient uses can clarify the difficulties and consequently the solutions. The patient is the expert in her own problems. The doctor may need to assume a position of ignorance to interpret the patient's symptoms and feelings. This is difficult when we are trained to be the expert and ask closed questions to streamline care down pre-planned pathways. Just as expectations and frequency of intercourse are individual to a particular woman or couple, so are the difficulties that ensue.

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Case 3 

A woman was referred with pain several months postpartum. She was anxious about the length of time she had avoided sex with her partner. She described the powerlessness of an overwhelmingly quick delivery that everyone else had judged as ‘easy’. She remembered her partner looking at her as if she was mad. She felt ‘out of control’ and judged. When talking about sex, it was like talking to a teenager. She was coy and timid. The doctor needed to teach her about sex – use of lubricants, the association between breastfeeding and atrophic vaginitis. When offered topical vaginal oestrogens, she shied away and could not talk about lubricants without a blush. The pain she had been referred with was non-existent as she had not even tried penetration. An exploration of her current responsible role as a parent preceded by a shocking episode (for her) of infantilisation allowed her to recognise the change in her relationship – her resentment of her husband's reaction and his subsequent treatment of her as a child rather than an equal had done much damage to their intimate relationship. Equipped with her ‘tools’ (lubricants and topical oestrogen), she left the consultation a more confident, sexual woman.

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Prevalence 

Sexual difficulties are common in both men and women. A frequently cited paper from the USA reported a sexual dysfunction rate of 43% in women and 31% in men aged 18–59 years, yet this is often criticised as ‘medicalising’ normal, temporary changes in sexual function. What effect any sexual problem has on an individual will depend on the relationship and the circumstances under which the alteration occurred. As this may happen on an unconscious level over a period of time, the role of a psychosexual doctor can be to facilitate the understanding and interpretation of these difficulties. Yet to determine a dysfunction – the patient must be ‘distressed’ by the symptoms.

British 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 recognised or documented – only 3–4% had an entry in their medical notes. This is also reflected in gynaecology clinics where symptoms may frequently be representative of the somatisation of sexual problems. Up to 40% of gynaecological consultations have a psychosexual component. Referrals from primary care may include diagnoses of vaginismus, superficial dyspareunia and lack of libido, yet exploration of chronic pelvic pain, vulval pain disorders and requests for labiaplasty may frequently unmask primary sexual disorders. Women complaining of perimenopausal or urogynaecological symptoms may be thankful for the opportunity to discuss their sexual lives, even if they are a secondary concern.

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 identifying the problem. Even when it is apparent that there is not a physical reason for presentation, it is important to acknowledge the limitations of the gynaecologist – relationship issues should be recognised as such and dealt with by an appropriate counsellor.

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Case 4 

A 55-year-old woman came with an unusual complaint – ‘I have too much libido’. The doctor checks her records again – she is not on testosterone implants – the one occasion where this is sometimes reported although not generally unwelcome. She had a history of ovarian cancer but had been treated, was in remission and had a good prognosis. ‘You seem distressed by this?’ the doctor tries to say neutrally. ‘But that means I must have a recurrence of my cancer!’ The doctor looks puzzled. She explained: ‘Your sex drive comes from your hormones and they come from ovarian tissue so I must be producing loads from tumour tissue – my cancer is back isn't it?’ This thought process may seem more logical when the patient explains her understanding. The doctor was able to reassure the patient that this was not the case and the patient returned to a satisfying sexual life. This case illustrates the importance of the health professional not to making assumptions and seeking an individual's perspective of their complaints – particularly with respect to sexual problems.

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How to ask about sex 

Sensitivity and care must be used and tailored to the individual when asking about sexual activity, yet it must also be considered routine questioning in gynaecology. If there are no problems or the patient does not wish to pursue them then, their sex life will remain private. Later in the consultation, the patient may bring up a sexual symptom if they feel the doctor is comfortable and interested. The doctor may feel it is appropriate to raise the subject when another seems inexplicable.

The following routine questions can help to open the discussion – they can be adapted according to the circumstances. A full sexual history is rarely indicated.

Assumptions regarding sexual orientation and inquisitiveness without a perceived therapeutic endpoint can potentially damage the consultation so encouraging the patient to lead the conversation and interpreting her own words is most useful. Understanding her conceptualisation of the symptoms presented and reflecting this back to her, can be therapeutic in itself. This can be acquired by using the five basic tenets of the psychosexual medicine consultation:

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The examination 

The physical examination is a crucial component of the gynaecologist's assessment and diagnostic pathway. This is also used in psychosexual medicine as the ‘moment of truth’ – when the vulnerabilities and behaviour during exposure can reflect the difficulties of the patient. For instance, her disgust at your job and having to perform speculum examinations reveals her disgust with her genitals; the tugging of the ‘elongated’ labia by a patient requesting labiaplasty displaying her dislike; the adductor spasm of the distrusting, timid childlike non-consummator. Talking about these behaviours gives credence to their complaints even if the findings are seemingly ‘normal’.

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Case 5 

A young woman was referred with an inability to become aroused. She had had a hysterectomy at the age of 31 years. Both she and her husband had been traumatised by the sudden appearance of her contraceptive coil strings at the vaginal introitus a few months after the birth of her second child, necessitating a trip to Casualty, a rapid referral to a gynaecologist and subsequent vaginal hysterectomy, pelvic floor repair and a continence mesh procedure all in the space of a few weeks. It was not until after the operation that the two started to mourn the loss of their fertility. The unexpected emotion was played out in their relationship and the resentment displayed in their sexual lives. The mid-urethral tape eroded through the vagina and all intimacy ceased. After further operations, she could not think of the vagina as a place of pleasure – it no longer belonged to her – it was a place where operations occurred and pain was induced. She had flashbacks to an episode of dyspareunia with the eroded tape and her husband had also become terrified of the ‘vagina with teeth’ – fibres of the tape had caused penile grazes. Although they both felt desire, arousal was dampened by confrontation with the scary genitals. Acknowledging these concerns and exploring them together in the safety of the consultation room, gave them both the courage to look again. The doctor examined her vagina, was able to test the prolapse repair, the integrity of the vaginal walls and the health of the mucosa. Together the doctor and patient admired it in a mirror. Lubricants were suggested as strategy to remove the physical arousal component with positive reinforcement of the healthy, fully functional pelvis. She went home keen to try out her ‘new vagina’. On her return she reported how she had initiated sex, felt relaxed and experienced ‘great, enjoyable sex’. Finally she was able to put her disappointment behind her and had made extensive plans for themselves as a couple and their ‘new’ life together.

These skills take time to develop but become useful in all consultations. Using physical interventions while addressing the psychological enables delivery of holistic and enduring improvement in sexual health and quality of life for our patients. Physical treatments can help direct attention to the problem and may be an adjunct to the understanding of the difficulties. Table 2 details treatments that gynaecologists may use to improve some sexual problems for limited indications.

Table 2. Interventions for sexual problems

DHEA, dehydroepiandrosterone.

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Conclusion 

Gynaecologists are uniquely positioned in daily practice to manage women's sexual problems yet are infrequently trained to do so. With a few basic techniques, assorted limited physical treatments and an understanding and willingness to explore with the patient, women who present to a gynaecology clinic can be cured of long-standing sexual problems by their gynaecologist rather than referral to another counsellor. The genital examination is a revelation of the physical causes and the psychological vulnerabilities of the patient that can be used to understand their distress.

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Further reading 

1. Basson R. Women's sexual dysfunction: revised and expanded definition. CMAJ. 2005;172:1327–1333
2. In:  Cockburn J,  Pawson M editor. Psychological challenges in obstetrics and gynaecology. London: Springer-Verlag; 2007;
3. Laumann E, Paik A, Rosen R. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537–544
4. In:  Montford H,  Skrine R editor. Psychosexual medicine: an introduction. London: Hodder Arnold; 2001;
5. Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: cross sectional study. BMJ. 2003;327:423–426
6. In:  Rees M,  Mander T editor. Sexual health and the menopause. London: Royal Society of Medicine Press Ltd; 2005;
7. Trigwell P. Helping people with sexual problems: a practical approach for clinicians. London: Mosby Elsevier; 2005;