Female sexual dysfunction is a multidimensional problem that can impact on a woman's quality of life. Women complaining of sexual difficulties need a comprehensive assessment that includes taking a sexual history, making a medical evaluation and, if appropriate, performing a manual examination in order to diagnose, treat or identify factors relevant for each woman. Biological, psychological, emotional and relationship issues all have a part to play.
Biological factors that impact on a woman's sexual function directly, such as vaginal dryness and pelvic floor dysfunction, or indirectly, such as chronic pain, need addressing at the earliest opportunity to help prevent more complex problems developing. Sexual problems are sometimes the cause of and sometimes the result of difficult relationship dynamics. Although psychological and emotional factors can create sexual difficulties, they can equally be the result of unaddressed or untreated biological/medical issues, with sexual problems therefore persisting long after the original cause.
Barriers identified by health professionals for not addressing or discussing sexual function are related to a lack of time, personal discomfort, lack of training and concern that it will cause offence (Dyer and das Nair, 2013). Giving women the opportunity to talk about sexual problems, however, is a fundamental part of health care (Nappi and Lachowsky, 2009). Embarrassment or lack experience are likely to be cited by some nurses as barriers to having such conversations, but these issues are of less concern for nurses who perform such consultations daily or weekly (Temple-Smith et al, 1999).
Female sexual response
To fully understand how sexual difficulties arise it is useful to consider the physiology of the sexual response cycle. In the 1960s the pioneers in this field were William Masters and Virginia Johnson who in laboratory conditions observed, monitored and assessed individuals and couples engaging in sexual activity. Their research formed the basis of a model of human sexual response that is still widely accepted today (Masters and Johnson, 1966). In this model, there was no distinction between male and female sexual responses.
Their model identified four distinct phases and described the physiological changes that occurred in each phase. They believed that sexual problems occurred during breaks in this sexual response cycle and designed a treatment approach called ‘sensate focus’ therapy (Masters and Johnson, 1970), from which the field of sex therapy grew. At the time, all problems with sexual function were considered psychological or relational in origin. Masters and Johnson argued that there was no such thing as an uninvolved partner in a relationship where sexual dysfunction exists. Beliefs and assumptions about the aetiology of male sexual response dramatically changed with the approval of Viagra (sildenafil) on 27 March 1998, the first oral therapy for erectile dysfunction. Alongside enhancing the sexual performance of millions of men, the medical research its launch produced was equally dramatic. Scientific research provided evidence of a wide range of medical conditions that could negatively impact on male erectile function and satisfaction.
For women, there has been no revolutionary medical treatment; however, interest and research into female sexual response, sexual difficulties and treatment interventions has grown steadily over the past two decades. Fundamental to this change was the number of female sex researchers whose discoveries changed the way we think about female sexual response and sexual functioning (Gurney, 2020). These include Rosemary Basson (Basson, 2000), research by Lori Brotto on the use of mindfulness to improve sexual distress (Brotto et al, 2015), Amy Stein on the role of the pelvic floor in pelvic pain (Stein, 2009) and Alessandra Graziottin's work on mast cells and their role in sexual pain disorders (Graziottin, 2009). The vast majority of knowledge about sexual difficulties has been gathered from research and clinical practice with heterosexual couples. The concepts and methods in contemporary sex therapy are highly applicable to those in same-sex relationships, but it is also important to address any factors unique to a person's sexual orientation (Nicols, 2014). Binary distinctions are present in much of the research that has been produced to date but, hopefully, this will change in the future.
In 2000, Basson revisited Masters and Johnson's linear model of human sexual response and argued that this model does not adequately reflect female sexual response (Basson, 2000). She described women's sexual experience as more complex and better described as a circular model of response affected by biological, psychological and relationship factors (Figure 1). This model is useful in helping women and their partners understand the changes that can occur in their sexual experiences.
Figure 1. Non-linear model of female sexual response (Basson, 2001)
The standard narrative of sexual interest or desire is that it is spontaneous and just appears but some women only feel interest or want sex after intimate or arousing touch is already happening. This is normal, which means a lack of spontaneous desire is not in itself dysfunctional. These women have ‘responsive desire’ rather than ‘spontaneous desire’—they just need more than the sight of someone attractive to feel sexual interest or become aroused. For others sexual desire is context dependent, so if their partner approaches them at night when they feel tired or stressed the outcome may be a negative one but the same approach in the morning after a good night's sleep might be very different. Women can feel relieved when they realise that responsive or context-sensitive desire is normal for some.
Key points from Basson's model
- ‘Spontaneous sexual desire’ is common in younger women and in the early months or years of a relationship but will vary over the longer term
- Women's subjective arousal is complex, often only minimally influenced by genital feedback, and motivation to be sexual often stems from intimacy needs
- Multiple biological factors can impact on a woman's sexual response and inhibit sexual desire/interest and arousal
- Desire/interest/arousal can be ‘triggered’ and is often contextual, resulting in the term ‘responsive desire’ commonly being used to help women understand that it is normal for some not to experience spontaneous sexual desire or interest and help reframe the changes that can occur as a relationship progresses, as they age or in response to illness, medication or surgery
- Desire/interest/arousal is often contextual, so how a woman experiences sensation is context dependent and perception can change depending on the context.
Classification of female sexual dysfunction
Perhaps the most frequently used and widely adopted diagnostic criteria for female sexual dysfunction are contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association (APA), 2013). This was updated in 2013 and in DSM-5 the definition of sexual dysfunction was changed to:
‘A group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure.’
The symptoms should be present for at least 6 months, cause distress and have been experienced in 75-100% of sexual encounters. The classification of female sexual desire disorder was removed and female arousal disorder was renamed female sexual interest/arousal disorder. Dyspareunia was revised to genital/pelvic pain. Vaginismus was replaced with penetration disorder. Female orgasmic disorder remained unchanged.
When opening a discussion with a woman experiencing sexual dysfunction, it is important that the clinician is relaxed and comfortable talking about sexual issues. A solid understanding of sexual anatomy and sexual response will enable them to be confident and informative, thus ensuring that patients find it easy to talk about their sexual concerns. The effectiveness of any intervention is often dependent on the patient having a positive opinion of the clinician (Rantell, 2021a). One way to introduce the subject could be to introduce a preconsultation questionnaire or a sentence in an appointment letter advising that questions of a personal nature may be asked. Once face to face, good conversation starters include (Rantell, 2021b):
- ‘I am going to ask you a few questions about your sexual history. I ask these questions at least once a year of all my patients because they are important for your overall health. Everything you tell me is confidential. Do you have any questions before we start?’
- ‘Many women with incontinence/prolapse/vaginal dryness, or after surgery/childbirth/menopause (for example), report that it can cause problems with their sexual relationships. Is this something that you have noticed or would like to discuss?’
Sexual interest/arousal disorder
The DSM-5 (APA, 2013) definition of this disorder is ‘a complete lack of or significant reduction in sexual interest or sexual arousal’. The problem may be primary (lifelong) or secondary (acquired), situational or generalised.
A woman who presents with complaints regarding sexual function should first undergo a medical assessment and physical examination to ensure the source of the problem is not physical. Abnormal physical examination findings or suspected comorbidities should be addressed. This may require medical or surgical interventions or pharmacological treatment prior to a recommendation for psychotherapy or psychosexual input (Kirana, 2013a).
Factors affecting sexual interest/arousal disorder
Medical factors
These include various chronic diseases that interfere directly with the physiology of the central and peripheral sexual response and the psychological consequences of being ill (Kirana, 2013b). Conditions such as urinary incontinence, diabetes, arthritis, spinal cord injury, multiple sclerosis and hyper- and hypothyroidism are associated with sexual difficulties. Various medications have also been associated with low desire and problematic arousal, including antihypertensives, anticholinergics, psychotropic drugs and combined oral contraceptives (Kirana, 2013a; 2013b).
Psychological factors
These may reduce a woman's motivation to engage in sexual encounters or provoke negative thoughts concerning sexual activity, which may lead to low sexual interest. Although many factors can contribute to a woman's motivation and thoughts about sex, the following have been associated with sexual interest/arousal disorder:
- Sexual abuse and traumatic or humiliating experiences (Elmerstig et al, 2009)
- Stress and fatigue (Maserejian et al, 2010)
- Difficulty focusing attention on sexual cues, high distraction (Dove and Wiederman, 2000)
- Anxiety disorders such as obsessive compulsive disorder and panic disorder (Trudel et al, 1997)
- Depression has been found to have a strong and clear relationship with sexual desire, although order of causality has not been established (Bartlik et al, 1999)
- Personality characteristics: low/fragile self-esteem is related to impaired sexual desire (Apt and Hurlbert, 1994)
- Body image self-consciousness (Seal et al, 2009).
Relationship characteristics
Problems in a relationship may influence a women's motivation to get involved in sexual encounters. These may include:
- Partner's sexual dysfunction (Dean et al, 2008)
- Global dissatisfaction with the relationship (Trudel et al, 1993)
- Poor sexual communication skills: difficulties expressing sexual needs, fears and wishes (Trudel et al, 1993).
Psychosexual therapy
Historically, psychosexual therapy was a specialised form of cognitive behavioural psychotherapy that explored, challenged and reframed detrimental cognitions and utilised specific behavioural strategies carried out by individuals and couples in their home environment. The behavioural aspect of this treatment approach is often referred to as ‘sensate focus’. However, contemporary psychosexual therapy may also include an array of other technical interventions known to effectively treat sexual difficulties such as systems/couple interventions and sometimes psychodynamic/psychoanalytic interventions (Kirana, 2013a). Ideally, these should be combined with a medical assessment and pharmacological therapy, if appropriate, thus providing a holistic treatment approach.
Psychosexual assessment of sexual interest/arousal
Assessment/history
The main focus of assessment/history taking is to identify whether a sexual difficulty is primary or secondary, generalised or situational. It focuses on highlighting the relevant predisposing, precipitating ‘triggering events’ and maintaining factors. Predisposing factors relate to any negative experiences during childhood or teenage years that could make a person vulnerable to developing a sexual difficulty in later life. Precipitating factors or ‘triggering events’ are related to what was happening at the time sexual problems became apparent, such as childbirth, incontinence, menopause, traumatic experiences, work-related stress, relationship distress, bereavement, divorce, commencing medication, surgery or illness.
It is important to ask patients about the quality of their sexual relationship before the event, what they first noticed, how the sexual problem developed and the context in which it is experienced. Identifying current maintaining factors helps to explain why problems persist long after the original predisposing or precipitating event.
A common maintaining factor for women with sexual difficulties is avoidance of sexual intimacy and affection, which, if identified, can be addressed during treatment. Asking specific and detailed questions can highlight maintaining factors relatively easily and can be employed in a variety of clinical settings. It should be noted, however, that in some complex cases therapy or counselling may need to focus on the predisposing or precipitating events, if emotional issues related to these are still current and would interfere with a woman's ability to engage in a sex therapy programme. A common example would be post-traumatic stress related to childhood trauma, sexual abuse, sexual assault or bereavement.
Relationship
Questions should focus on current levels of intimate/sexual activity. This identifies issues of avoidance and helps clarify the appropriateness of suggestions given to a couple in the form of homework assignments. Those who have experienced long periods of avoidance generally require more input to re-establish a satisfying sexual relationship. With some couples the starting point of treatment is about creating quality couple time outside of the bedroom.
Exploration of a couple's general relationship can establish whether there is significant relational distress or contextual factors such as work-related stress, disability, financial worries, shift work or caring for family members that are significant in maintaining sexual difficulties. These could impede therapy and highlight whether a couple needs to access relationship counselling in the first instance. In the UK, Relate offers couple and relationship counselling which can be accessed via its website (www.relateorg.uk).
Negative behaviours
Negative behaviours can arise as a consequence of sexual difficulties. Common behaviours include: apologising during sexual activity, arguments, and avoidance of any intimate or sexual activity. In general, negative behaviours lead to further failure and dissatisfaction and increase fear and anxiety. Negative behaviours will often contribute to the maintenance of sexual difficulties, and explaining their role provides the rationale for behaviour change.
Previous treatments
Questions about any previous treatments, psychological or pharmacological, and what benefit they had, if any, is important. For example, some women treated for post-menopausal vaginal atrophy with local hormonal or non-hormonal vaginal treatment may report a lack of benefit as they continue to experience pain and discomfort despite no evidence of further pathology. In such cases it is essential that questions regarding general levels of sexual interest/arousal are asked, anxiety about penetration with its negative impact on sexual response is assessed and pelvic floor muscle dysfunction is considered, as each could potentially be the cause of continued vaginal discomfort (van der Velde and Everaerd, 2001). Women who have previously been prescribed vaginal trainers (dilators) with little success need a detailed assessment of how these were used and what guidance, instruction or support was provided because, too often in clinical practice, these are insufficient to achieve a successful outcome.
Medical history
Sexual dysfunction is often multifactorial and therefore it is necessary to identify all maintaining factors including biological factors and prescribed medications. Although therapy alone cannot alter physical changes as a result of medication, cancer treatment, diabetes or menopause etc, it can address the psychological or behavioural consequences.
Education
Education is an essential aspect of sex therapy as it helps patients understand how the body works and the human sexual response. Education can normalise some of their experiences, especially around age/disease-related changes and highlights possible reasons for unsuccessful pharmacological treatment. For women experiencing genital/sexual pain, where underlying pathology has been excluded or treated, discussing the role of the pelvic floor is essential.
Education provides an opportunity to explain the role of fear and anxiety, a common feature with both organic and psychogenic sexual pain and discomfort particularly related to its impact on arousal and pelvic floor hypertonicity. Performance anxiety is the fear of future pain or failure based on previous experiences and it interferes with sexual arousal, distracts from sensual feelings, undermines sexual self-confidence and ultimately contributes to sexual avoidance (Zilbergeld, 1999).
Key points for assessment
When assessing a woman reporting sexual dysfunction, the following key points should be noted (Rantell, 2021b):
- Use neutral and inclusive terms such as ‘partner’ and pose your questions in a non-judgemental way
- Avoid making assumptions based on a person's age, appearance, marital status or any other factor. Unless you ask you cannot know a person's sexual orientation, behaviours or gender preference
- Ask for preferred pronouns or terminology when talking to a transgender person.
Questions to consider
- Check that the person is open to answering personal questions
- Ask the person to describe the sexual difficulties they are having
- How long have they had a problem?
- If there are medical issues, how would they describe their sexual/intimate relationship prior to this?
- When was the last time she was sexual with her partner? And before that?
- Ask about distracting thoughts before or during sexual intimacy
- Ask about sexual skills, sexual stimuli and context, including interaction in the preceding hours
- Does she masturbate?
- Have they tried any previous treatments? (Check compliance/benefit)
- Assess ‘why now’ and motivation for treatment
- How would they describe their general relationship?
- Do they have fun together?
- What about emotional intimacy?
- How has each partner responded to the problem?
- Does their partner experience any sexual difficulties?
Treatment strategy
A basic sex therapy behavioural treatment strategy for absent or reduced sexual interest/arousal or an inability to orgasm may include the following:
- Education. Basson's model provides education and information about female sexual response and the concept of ‘responsive desire’. If there are any relevant medical/biological factors that could impact on a women's sexual response these need to be discussed and explored.
- Arousal and orgasm. Education is needed regarding female arousal and orgasm. An orgasm occurs after sufficient sexual arousal. Stimulation of the clitoris is required for the majority of women. Only 30% of women are reliably orgasmic from vaginal penetration alone; the remaining 70% are sometimes, rarely or never orgasmic in this way (Nagoski, 2017). The physical impact of childbirth, prolapse and menopause can impact negatively on a woman's ability to enjoy orgasmic responses with penetration alone. Information is provided on sex toys, vibrators and clitoral suction devices and how these can be used to enhance pleasure.
- Identify accelerators and brakes. In her book, Come as You Are, Nagoski (2017) introduces the concept of ‘sexual excitation’ and ‘sexual inhibitory systems’. This helps women identify their own individual accelerators that ‘trigger’ sexual interest/arousal and relevant sexual brakes that inhibit sexual responses (Nagoski, 2017). The sexual temperament questionnaire she describes helps women distinguish between their accelerators and brakes, what activates them and how sensitive they are. Worksheets are available to download at www.emilynagoski.com
- Context exercise. This exercise illustrates the importance of context, which may be relevant for some women (Nagoski, 2017). The woman can be asked to think of a past positive sexual encounter/experience and describe it with as many relevant details that they can recall that includes the following:
- Mental and physical wellbeing
- Partner characteristics
- Relationship characteristics
- Setting
- Other life circumstances
- Things they did.
- Next repeat the exercise but this time she should consider a past negative sexual experience, the focus should be on a situation that she did not really enjoy rather than something bad or traumatic.
- Discovering pleasure. Mindfulness exercises for sexual interest/arousal problems teach women to use sustained attentional focus to bring sensory information, both sexual and not, into their awareness. For women who experience inhibited orgasm, strategies such as ‘orgasmic yoga’ or therapeutic masturbation can be introduced (Nagoski, 2017). Websites such as www.omgyes.com explore the latest science on female sexual pleasure; games, sex/intimacy apps introduce new ideas, and listening to erotic podcasts can ‘trigger’ sexual interest and identify accelerators.
- The pelvic floor. Information and exercises for strengthening and maintaining a healthy pelvic floor (for women with a normal or weak pelvic floor) is especially important for those who suffer from incontinence or prolapse (Stuart, 2001). Apps, such as www.squeezyapp.com, can be used to remind women to do their exercises regularly
- Sensate/self-focus programme. For individuals and couples who would benefit from a more structured approach to rebuild their intimate/sexual relationship or to address body image issues and improve individual arousal and pleasure, seeing a therapist can be helpful. Unfortunately, the provision of NHS services in the UK is variable. See Box 1 for details of therapists/clinicians.
Box 1.Sources of information about therapy
- College of Sexual and Relationship Therapy: www.cosrt.org.uk
- Institute of Psychosexual Medicine: www.ipm.org.uk
- Relate: www.relate.org.uk)
- Pink Therapy: hosts a directory of therapists in the UK who identify as or are understanding of gender, sex and relationship diverse people: www.pinktherapy.com
Genito-pelvic pain/penetration disorder (dyspareunia and vaginismus)
The DSM-5 definition (APA, 2013) of these conditions is that one of the following should occur persistently or recurrently to establish a diagnosis: difficulty in vaginal penetration, marked vulvovaginal or pelvic pain during penetration or attempt at penetration, fear and anxiety about pain in anticipation of, during or after penetration, and tightening or tensing of pelvic floor muscles during attempted penetration.
Goldstein et al (2009) stated:
‘Unfortunately, too many women suffering from sexual pain disorders have not been helped by their health care providers—through being ignored, being told their pain was purely psychogenic without a biological evaluation, being told it was purely biological without a psychological assessment, being prescribed medications without full disclosure regarding potential side-effects, being treated with ineffective therapies or simply not being referred to a specialist when the problem warranted.’
Assessment of sexual pain
Medical factors
Pain is often multifactorial and can be caused by vaginitis, a Bartholin gland abscess, episiotomy scarring, sexually transmitted infections, pelvic inflammatory disease, endometriosis, prolapse or vaginal dryness. The most frequent cause in post-menopausal women is vaginal dryness/atrophy, which can be treated with local oestrogen preparations (Lev-Sagie and Nyirjesy, 2009). For women not suitable for local oestrogen treatment, a non-hormonal vaginal moisturiser should be suggested. These products help rehydrate the vagina and can be used alongside a lubricant. Silicone/oil-based lubricants make penetration more comfortable and are less likely to dry up than water-based products. Sexual/genital pain can also be caused by inhibition due to body image concerns such as incontinence, reduced sexual interest/arousal, infrequent sexual intercourse and pelvic-floor hypertonicity.
Muscular factors
Pelvic floor muscle hypertonicity may contribute to:
- Interstitial cystitis (Peters et al, 2007)
- Provoked vulvodynia (Reissing et al, 2005)
- Generalised vulvodynia (Glazer et al, 1998)
- Heightened anxiety (FitzGerald and Kotarinos, 2003).
Genital pain may also trigger pelvic floor dysenergia (van der Velde and Everaerd, 2001).
It is essential that all women are offered the opportunity to be examined to determine or exclude any underlying pathology, and ideally assessed by a specialist physiotherapist. However, the clinical reality is that some women struggle with examinations. In such cases the goal of therapy may be to help a woman achieve a genital examination or cervical cytology.
The Lamont classification scale (1978) (Box 2) illustrates the wide range of women's responses and can be a useful tool in helping women understand that their fear responses are triggered instinctively, outside their conscious control, and that simply being told to relax will not be sufficient or helpful. The importance of classifying the severity of a woman's response (Box 2) impacts on the clinician's ability to diagnose and treat vaginismus and understand the woman's experience (Rosenbaum, 2009).
Box 2.The Lamont scale of vaginismus
- First degree vaginismus: spasm of the pelvic floor that could be relieved with reassurance and the patient could relax for her examination
- Second degree vaginismus: generalised spasm of the pelvic floor as a steady state despite reassurance, and the patient was unable to relax for the examination
- Third degree vaginismus: the pelvic floor spasm was sufficiently severe that the patient would elevate her buttocks in an attempt to avoid being examined
- Fourth degree vaginismus: the most severe form of vaginismus described by Lamont. The patient would totally retreat by elevating the buttocks, moving away from the pelvic exam, and tightly closing the thighs to prevent any examination
- Fifth degree vaginismus, described by Pacik et al (2019): a visceral reaction manifested by increased adrenalin output and resulting in any of the following: Increased heart rate, palpitations, hyperventilation, trembling, shaking, nausea or vomiting, crying uncontrollably, a feeling of light-headedness and fainting, a desire to jump off the table, run away or even attack the doctor
Source: adapted from Lamont, 1978; Pacik et al, 2019
Questions to consider
- Ask the woman whether she is happy for you to ask some personal questions so you can fully understand her difficulties
- Ask the woman to describe the sexual difficulties she is having
- Does she have periods? If so, does/can she use tampons?
- If no, has she ever tried to use them? What happened?
- Has she ever had a cervical cytology or been examined? If yes, what happened?
- Does she attempt penetration (penis, vibrator, finger)?
- Has penetration ever been pain free? When was the last time?
- If penetration occurs, how often and how long does it last?
- If penetration does not occur, is she still sexually intimate in other ways?
- When and where does she experience pain? (Before, on, during or after penetration?)
- How would she describe the sensations she feels? (Sharp, burning, stinging, painful, uncomfortable)
- Does anything make it better or worse?
- Does she feel dry or well lubricated?
- Can she keep her legs open?
- How does her partner respond/react?
- Does her partner experience any sexual difficulties?
- How would she describe her experience of sexual interest/arousal/orgasm?
Treatment strategy
A basic sex therapy behavioural treatment strategy for sexual/genital pain may include:
- Education. When treating sexual/genital pain it is important to acknowledge sexual comorbidity (Petersen, 2013). Using Basson's sexual response model (2000), provide education and information about genital/sexual pain, how it impacts negatively on sexual interest/arousal/orgasm or how changes in sexual interest/arousal can trigger discomfort during penetration, which, if unaddressed and persistent, can result in pelvic floor dysfunction, irrespective of the original aetiology.
- The pelvic floor. A diagram/model illustrating the pelvic floor muscles is useful when shown alongside a discussion of pelvic floor responses, especially during attempted penetration or tampon use. This is invaluable in helping women make sense of their pain experience and provides a rationale for using vaginal trainers. Women should also be offered a physiotherapy assessment.
- Exercises. Instruction on diaphragm breathing exercises and pelvic floor release/relax techniques.
- Information and resources. Box 3 includes some useful sources of information for patients.
- Exposure/desensitisation exercises. These can be performed using a finger, vibrator, vaginal trainer or tampons.
- Sexual positions. Discuss penetration positions. For those who are unsure which positions would be most comfortable, or if they feel inhibited, suggest they practise different positions, initially with their clothes on. This can help them discover what is practical and comfortable.
- Cognitive restructuring. This involves replacing unrealistic/irrational beliefs about pain, penetration and sexual functioning. For example, when using vaginal trainers, it is ‘normal’ to feel a stretching sensation. Or it may involve challenging beliefs about sexual interest/arousal using Basson's model.
- Relaxation/meditation/distraction techniques. These can be used to manage anxiety generally or to use prior/with/during or after any form of sexual intimacy. YouTube has an enormous selection, and mindfulness apps such as ‘Smiling Mind’, ‘Headspace’ or ‘Calm’ are often suggested.
- Challenging negative thoughts. Patients can be advised to rehearse coping self-statements that challenge negative thoughts with positive statements. This is known as ‘getting your mind on your side’. Such statements might include: ‘Now I know that it's my pelvic floor muscles that are causing my pain, I can consciously learn to control and relax them.’
- Communication skills. These are specifically related to romantic/sexual partners. If a woman is in a relationship, then there needs to be a discussion regarding their current sexual/intimate activity and clear boundaries should be encouraged because it is difficult to experience good levels of sexual arousal when anxious or afraid.
- Vaginal trainers. In the author's clinical practice, at the end of an assessment, most women are given the smallest vaginal trainer available, along with a silicone-based lubricant. If a woman is reluctant to use a trainer she could consider using a cotton bud, her own or her partner's finger or a small vibrator. The starting point for those with strong fear/panic responses (refer to the Lamont scale) who struggle to keeps their legs open can be given adductor stretching exercises (Stein, 2009). Sometimes using a mirror can help a woman familiarise herself with her genital area before she feels confident enough to use a trainer. Putting the trainer at the vaginal entrance might be suggested. Women who struggle to keep their legs apart could practise sitting with their legs open when clothed. They can then place their or their partner's hand on the genital area over clothes or underwear initially and, when comfortable, move their hand underneath their clothes while consciously keeping their legs apart.
Box 3.Sources of informationWebsites
- www.vaginismus.com: information about vaginismus
- www.sexualadviceassociation.co.uk: information on all aspects of sexual problems for both women and men from the Sexual Advice Association
- www.menopausedctor.co.uk: My Menopause Doctor provides information and advice
- www.jostrust.org.uk: Jo's Cervical Cancer Trust provides information and support for those with questions about cervical screening, HPV, cell changes or cervical cancer
Helpful further reading
- The Wonder Down Under by Nina Brochmann
- Womanhood: The bare reality by Laura Dodsworth
- Me and My Menopausal Vagina by Jane Green
- Come As You Are by Emily Nagoski
- Mind the Gap by Dr Karen Gurney
- Heal Pelvic Pain by Amy Stein
Follow-up appointments are used to take feedback on the success or failure of a woman's ability to engage with the treatment plan and adjustments can be made, where necessary. The next sized vaginal trainer can be given (if appropriate). Although a woman's ability to increase the size of the vaginal trainer is important, frequency of use is crucial because this helps with confidence and reduces anxiety, thereby helping to reduce/retrain the muscular responses. At some point, a discussion will take place regarding the benefits of using a small vibrator to help with both physiological arousal and muscular relaxation when used in a circular motion inside the vaginal entrance. For women who experience reduced sensation related to medical treatment or menopausal changes, it can be helpful to use a vibrator or clitoral suction device for a couple of minutes daily to improve the vascular response and provide nerve stimulation. Although there is no guarantee of full restoration of sensation this can facilitate some improvement.
Using the vaginal trainers can be sufficient for some women to achieve penetration. For others, specific couple suggestions may be needed, such as using the trainer or vibrator together, thus allowing a woman to accommodate feelings of being less in control. Other techniques such as outercourse, where a partner simulates the movement of penetration between the woman's legs, or vaginal containment, whereby the penis or a vibrator is inserted vaginally with no movement initially and then with minimal movement initiated by the woman, can be suggested to help build couple confidence in a structured way (Hawton, 1993).
Some women also prefer to use a buffer that prevents deep penetration initially, and there are a range of products on the market, such as the Ohnut buffer ring. Also available are a wide variety of vaginal trainers, the main differences are related to the number of sizes in a set and the material from which they are made—silicone trainers are softer than plastic ones. Some vaginal trainers such as Amielle Comfort can be bought in boxes of one size, which can be purchased and given individually, thus preventing fear and anxiety related to the larger sizes. This product has five different sizes but, before giving the largest size, enquire about a partner's erect size, if he is similar in size to the final size this stage may not be necessary.
In the author's clinical experience, patients do not always fit neatly into this treatment programme and it is necessary to develop a flexible attitude and tailor the treatment to the needs of each individual, while making pain and their sexual function the central focus of therapy.
Conclusion
Sex is good for our physical and mental health, a vital part of most intimate relationships and an intrinsic aspect of what it means to be human. It is therefore important that help is offered to women who experience sexual difficulties and that issues with sexual function are addressed in all specialties where sexual problems may arise as a result of disease, illness or surgery.
Women's healthcare providers have an essential role in assessing sexual function, urogenital conditions and pelvic floor disorders. Intervention at the earliest opportunity may prevent more complex problems developing, thus reducing the need for more intensive input. For all women, a multidisciplinary team approach is strongly recommended and essential when biological factors are present (Hatzichristou et al, 2013). For those unfamiliar with asking about sexual function, it is important to have an awareness of local services such as Relate and sexual health services. Online help and resources can also be recommended, such as the Sexual Advice Association or other websites mentioned in this article.
After 20 years in clinical practice assessing and treating men and women with sexual difficulties, the author concludes that the long-term impact of sexual dysfunction can be devastating for both the individual and their partner and rob them of the most intimate part of their relationship. Therefore helping women maintain or regain their sexual functioning is not a lifestyle issue but a quality of life issue and all health professionals have a role in providing an opportunity for early discussion and treatment of sexual difficulties.
KEY POINTS
- Female sexual dysfunction can greatly affect a woman's quality of life and the reasons can be biological, psychological, emotional or due to relationship distress
- Understanding female sexual response and Basson's model is important
- It is important to know the different types of sexual dysfunction and their treatments, and how to provide advice or refer to other services
CPD reflective questions
- What do you feel are the barriers to discussing sexual concerns and what can you do about them?
- Why is it important that you assess your own comfort and pay attention to your body language when discussing sexual concerns with your patients?
- How can you build your own confidence is discussing sexual matters?
- If you do not address and normalise sexual discussions with your patients, do you know where to refer them for help and support?