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Sex is a motive force bringing a man and a woman into intimate contact. Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. Though generally, women are sexually active during adolescence, they reach their peak orgasmic frequency in their 30 s, and have a constant level of sexual capacity up to the age of 55 with little evidence that aging affects it in later life. Desire, arousal, and orgasm are the three principle stages of the sexual response cycle. Each stage is associated with unique physiological changes. Females are commonly affected by various disorders in relation to this sexual response cycle. The prevalence is generally as high as 35-40%. There are a wide range of etiological factors like age, relationship with a partner, psychiatric and medical disorders, psychotropic and other medication. Counseling to overcome stigma and enhance awareness on sexuality is an essential step in management. There are several effective psychological and pharmacological therapeutic approaches to treat female sexual disorders. This article is a review of female sexuality.
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Indian J Psychiatry 57 (Supplement 2), July 2015
Sex is a motive force bringing a man and a woman into
intimate contact. Satisfying usual experience is an essential
part of a healthy and enjoyable life for most people.
Sexual activity is a multifaceted activity involving complex
interactions between the nervous system, the endocrine
system, the vascular system and a variety of structures that
are instrumental in sexual excitement, intercourse, and
satisfaction. Though essentially it is meant for procreation,
it has also been a source of pleasure, a natural relaxant,
it confirms one’s gender, bolsters one’s self‑esteem and
sense of attractiveness for mutually satisfying intimacy and
relationship.[1] The World Psychiatric Association has defined
sexual health as “a dynamic and harmonious state involving
erotic and reproductive experiences and fulfillment, within
Female sexuality
T.S. Sathyanarana Rao, Anil Kumar M. Nagaraj1
Department of Psychiatry, JSS Medical College, JSS University, 1Department of Psychiatry, Mysore Medical College and
Research Institute, Mysore, Karnataka, India
Address for correspondence: T.S. Sathyanarana Rao,
Department of Psychiatry, JSS Medical College, JSS University,
Mysore, Karnataka, India.
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Sex is a motive force bringing a man and a woman into intimate contact. Sexuality is a central aspect of being human
throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and
reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors,
practices, roles and relationships. Though generally, women are sexually active during adolescence, they reach their peak
orgasmic frequency in their 30 s, and have a constant level of sexual capacity up to the age of 55 with little evidence that
aging affects it in later life. Desire, arousal, and orgasm are the three principle stages of the sexual response cycle. Each
stage is associated with unique physiological changes. Females are commonly affected by various disorders in relation to
this sexual response cycle. The prevalence is generally as high as 35–40%. There are a wide range of etiological factors
like age, relationship with a partner, psychiatric and medical disorders, psychotropic and other medication. Counseling
to overcome stigma and enhance awareness on sexuality is an essential step in management. There are several effective
psychological and pharmacological therapeutic approaches to treat female sexual disorders. This article is a review of
female sexuality.
Key words: Anorgasmia, arousal, dyspareunia, female sexuality, vaginismus
How to cite this article: Sathyanarana Rao TS, Nagaraj AM.
Female sexuality. Indian J Psychiatry 2015;57:296-302.
a broader physical, emotional, interpersonal, social, and
spiritual sense of well‑being, in a culturally informed, freely
and responsibly chosen and ethical framework; not merely
the absence of sexual disorders.” This can be considered
the most comprehensive definition of sexual health as it
incorporates many domains like historical, physiological,
psychological, interpersonal, sociocultural, and ethical
views, including attention to human rights issues.[2]
Sexuality is a central aspect of being human throughout
life and encompasses sex, gender identities and roles,
sexual orientation, eroticism, pleasure, intimacy, and
reproduction. Sexuality is experienced and expressed
in thoughts, fantasies, desires, beliefs, attitudes, values,
behaviors, practices, roles, and relationships. While
sexuality can include all of these dimensions, not all of
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Indian J Psychiatry 57 (Supplement 2), July 2015 S297
them are always experienced or expressed. Sexuality is
influenced by the interaction of biological, psychological,
social, economic, political, cultural, ethical, legal, historical,
religious, and spiritual factors.[3] This article is a review of
female sexuality.
In the first millennium BC, human cultures clearly experienced
a “axial period” in a striking transformation of human
consciousness. The transformation occurred independently
in three geographical regions: In China, in India and Persia,
and in the Eastern Mediterranean, including Israel and
Greece. In this cultural transformation, a prevailing mythic,
cosmic, ritualistic, collective consciousness embedded in
a tribal matrix with the female in the foreground, slowly
gave birth to a male dominated, rational, analytical, and
individualistic consciousness. This transition in cultural
values began very slowly after the last ice age retreated.[4]
In a developing country like India, modern Hindu cultures
even today contain a general disapproval of the erotic aspect
of married life, a disapproval that cannot be disregarded
as a mere medieval relic. Many Hindu women, especially
those in the higher castes, do not even have a name for
their genitals. Though the perception of modern Indian
women is transforming, many of them still consider the
sexual activity a duty, an experience to be submitted to,
often from a fear of abuse.[5]
According to Sigmund Freud, both sexes seem to pass
through the early phases of libidinal development in the
same manner. Psychologically, the male‑female difference
in sexuality starts only during the phallic phase, with
the appearance of Oedipus complex. However, the
difference becomes most clear only during the genital
phase.[6] Though generally, women are sexually active
during adolescence, they reach their peak orgasmic
frequency in their 30 s, and have a constant level of sexual
capacity up to the age of 55 with little evidence that aging
affects it in later life.[7]
Masturbation is a mode of sexual activity for both men and
women though it has been a source of social concern and
censure throughout the human tradition. It has been said that
99% of young men and women masturbate occasionally, and
the hundredth conceals the truth. In women, masturbation
can happen in many ways. Here the stimulation of the clitoris
is the central issue. Typically the hand and finger make circular,
back and forth or up and down movements against the mons
and clitoral area. Most women avoid direct stimulation
of the glans of the clitoris because of extreme sensitivity.
Some women thrust the clitoral area against an object such
as bedding or pillow, others by pressing thighs together
and by teasing the pelvic floor muscles that underlie the
vulva. Contrary to what is depicted in pornography, vaginal
insertion to reach an orgasm is not common. Some women
can reach orgasm by pressing the breast alone and a few
women (2%) by fantasy alone. Some individuals use vibrators
for added enjoyment and variation. By masturbation, many
women need <4 min to reach orgasm.[8]
Following the pioneering work of Masters and Kaplan, the
sexual response cycle in both sexes is often categorized
as a four‑phase process, desire, excitement, orgasm, and
The first stage, sexual desire, consists of the motivational
or appetitive aspects of sexual response. Sexual urges,
fantasies, and wishes are included in this phase. The second
stage, sexual excitement, refers to a subjective feeling of
sexual pleasure and accompanying physiological changes.
This phase includes penile erection in males and vaginal
lubrication in females. Plateauing, sometimes classified
as a separate phase, is a heightened state of excitement
attained with continued stimulation. There is marked
sexual tension in this phase, which sets the stage for the
orgasm. The third stage, orgasm or climax is defined as the
peak of sexual pleasure, with rhythmic contractions of the
genital musculature in both men and women, associated
with ejaculation in men. Graph 1 shows three different
patterns of orgasm in females. Pattern 1 shows multiple
orgasms. Pattern 2 shows arousal that reaches the plateau
level without going onto orgasm (note that resolution
occurs very slowly). Pattern 3 shows several brief drops
in the excitement phase followed by an even more rapid
resolution phase. This is the final phase, during which a
general sense of relaxation and well‑being is experienced.
Then, there is a refractory period in males, which is usually
absent in females. Table 1 shows the physical changes in the
female during the sexual response cycle.[10]
Graph 1: Different patterns of orgasm among females
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Indian J Psychiatry 57 (Supplement 2), July 2015
Based on the phases of sexual response cycle, both
International Classification of Diseases (ICD) 10 and
Diagnostic and Statistical Manual of Mental Disorders (DSM)
V have listed a variety of sexual disorders in women.
In ICD 10, the sexual dysfunction is classified under
F52, which is “sexual dysfunction, not caused by
organic disorder or disease.” In DSM V, there are several
modifications compared to the previous version that
is, DSM IV. Now it is segregated from gender identity
disorders and a separate chapter by name “sexual
dysfunctions” is elaborated in DSM V. With respect to
female sexuality, an important deviation from the earlier
concept is that the difficulties in desire and arousal often
simultaneously characterize the complaints of women.
Thus, the two entities are merged in DSM V. The sexual
desire disorder in women is not listed separately. It is now
called “female sexual interest/arousal disorder” and is
listed under arousal disorders. The Table 2 compares the
nosological status of sexual dysfunction in females among
the two diagnostic manuals.
In general, there has been an acute dearth of valid or
reliable statistical data on the epidemiology of female
sexual disorders. This is particularly true when it comes to
nonwestern settings.
In a survey of the US general population, sexual dysfunction
was more prevalent in women (43%) than men (31%)
and was associated with various sociodemographic
characteristics including age and educational attainment.
Women of different social groups demonstrate a different
pattern of sexual dysfunction. The experience of sexual
dysfunction is more likely among women (and men)
with poor physical and emotional health.[11] In England,
a study asserts that about two‑fifths of women (41%)
reported having a current sexual problem. The most
common problems were a lack of desire, vaginal dryness,
Table 2: Comparison of no sociological status of sexual
dysfunction under ICD 10 and DSM V
Lack or loss of sexual desire Not listed
Sexual aversion and lack of
sexual enjoyment
Not listed
Failure of genital response Female sexual interest/arousal disorder
Orgasmic dysfunction Female orgasmic disorder
Nonorganic vaginismus Vaginismus (not due to a general
medical condition)
Nonorganic dyspareunia Genito-pelvic pain/penetration disorder
Excessive sexual desire Not listed
Other sexual dysfunction not caused
by organic disorder or disease
Other specied sexual dysfunction
Unspecied sexual dysfunction not
caused by organic disorder or disease
Unspecied sexual dysfunction
Not listed Substance/medication-induced sexual
DSM – Diagnostic and Statistical Manual for Mental Disorders;
Table 1: Physical changes in the female during the
sexual response cycle
Physiological changes
Desire phase Has no specic physical changes
Excitement Vaginal lubrication begins
Inner two-thirds of the vagina expands
Color of vaginal wall becomes darker
Outer lips of vagina atten and move back from the vaginal
Inner lips of the vagina thicken
Clitoris enlarges
Cervix and uterus move upward
Nipples become erect
Breast size increases modestly
Sex ush appears (late and variable)
Heart rate and blood pressure increase
General neuromuscular tension increases
Plateau Vaginal lubrication continues, but may wax and wane
Orgasmic platform forms at outer third of the vagina
Cervix and uterus elevate further
Inner two-thirds of vagina lengthens and expands further
Clitoris retracts beneath the clitoral hood
Lips of the vagina become more swollen and change color
Sex ush intensies and spreads more widely
Further increase in breast size; areola enlarges
Heart rate and blood pressure increase further
Breathing may become more shallow and rapid
Voluntary contraction of rectal sphincter used by some
females as a stimulative technique
Further increase in neuromuscular tension
Visual and auditory acuity are diminished
Orgasm Onset of powerful involuntary rhythmic contractions of
orgasmic platform and uterus
Sex ush, if present, reaebxs maximum color and spread
Involuntary contractions of rectal sphincter
Peak heart rates, blood pressure, and respiratory rates
General loss of voluntary muscular control; may be cramp
like spasms of muscle groups in the face, hands, and feet
Resolution Clitoris returns to normal position within 5-10 s after orgasm
Orgasmic platform disappears
Vaginal lips return to normal thickness, position, and color
Vagina returns to resting size quickly; return to resting color
may take as long as 10-15 min
Uterus and cervix descend to their unstimulated positions
Areola returns to normal size quickly; nipple erection
disappears more slowly
Rapid disappearance of sex ush
Irregular neuromuscular tension may continue, as shown by
involuntary twitches or contractions of isolated muscle groups
Heart rate, respiratory rate, and blood pressure return to
baseline (preexcitation) levels
General sense of relaxation is usually prominent
Visual and auditory acuity return to usual levels
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and infrequent orgasm.[12] Another study from England
reports the prevalence rate of sexual dysfunction in
women as 42%, vaginismus was reported by 30% of them,
and anorgasmia by 23%.[13]
A recent cross‑sectional study from a different geographical
area (Iran) using Female Sexual Function Index (FSFI) also
found a similarly prevalent sexual problems in the range
of 22% (<20 years) to 75% (40–50 years). Problems with
desire were found with 45%, arousal problems in 37%, the
lubrication problem in 41%, the orgasmic problem in 42%
and pain problem in 42%. Some of the important associated
etiological factors were older age, infrequent sexual activity,
more than 10 years of marriage, more than three kids and
husbands more than 40 years. The authors consider that
the female sexual dysfunction is a significant public health
problem of women in that nation.[14]
The literature on etiological factors associated with
sexual dysfunction infers that in women, the predominant
association with arousal, orgasmic, and enjoyment
problems was marital difficulties. Vaginal dryness was found
to increase with age after menopause. In general, sexual
dysfunction was commonly associated with social problems
in women.[15]
Sexual dysfunction includes disorders of (i) desire, (ii) arousal,
(iii) orgasm and (iv) sexual pain disorders.[16,17]
Disorders of sexual desire
It is explained as an independent entity in ICD 10 (and not
in DSM V as mentioned before). It includes lack or loss of
sexual desire, sexual aversion and lack of sexual enjoyment.
Lack or loss of sexual desire is manifest by the diminution of
seeking out sexual cues, of thinking about sex with associated
feelings of desire or appetite, or of sexual fantasies. There
is a lack of interest in initiating sexual activity either with
a partner or by masturbation. Sexual aversion is defined
as a disorder in which the prospect of sexual interaction
with a partner produces sufficient aversion, fear or anxiety
that sexual activity is avoided. In the disorder of lack of
sexual enjoyment, genital response (orgasm) occurs during
sexual stimulation, but is not accompanied by pleasurable
sensations or feelings of pleasant excitement.
It has been estimated that about 20% of the female
population have the hypoactive sexual desire. Chronic
stress, anxiety, depression, prolonged period of abstinence
from sex, hostility in relationship with partner, previous
bad experience with sex, childhood sexual abuse,
religious taboos, low biological drive, dysfunction of the
hypothalamic pituitary axis, endocrinal disorders, ovarian
failure, psychotropic, and cardiovascular drugs are the
various etiological factors associated with low sexual desire.
Disorder of arousal
The failure of genital response in females is experienced as
the failure of vaginal lubrication, together with inadequate
tumescence of the labia. However, a subjective sense of
arousal is often poorly correlated with it in that a women
complaining of lack of arousal may lubricate vaginally,
but may not experience a subjective sense of excitement.
There is also a lack of vaginal smooth muscle relaxation and
decreased clitoral enjoyment. Though, exact prevalence
is not known, about 35% of women report difficulty in
maintaining adequate sexual excitement. This dysfunction
causes marked distress in women. The etiological factors
include vasculogenic, neurogenic and endocrine factors,
systemic diseases, psychotropic drugs and psychosocial
Orgasmic disorder
Achieving orgasm adequately is highly treasured by
women as it is seen as a mark of high self‑esteem, and
confidence in one’s feminity resulting in a high desire
for sexual activity. Persisting and recurring difficulty
in achieving orgasm is termed as anorgasmia. The
appropriate, reported prevalence of this disorder is in the
range of 5–10%. Women who suffer solely form orgasmic
dysfunction may have normal desire and arousal, but have
great difficulty in reaching climax. However, the distress
over inability to reach orgasm may lead on to decrease in
desire and arousal.
Among the etiological factors for orgasmic disorders, the
organic factors include neurological conditions that affect
the nerve supply to the pelvis, like multiple sclerosis, spinal
card tumors or trauma, nutritional deficiencies, diabetic
neuropathy, vascular causes, endocrine disorders and
drugs like methyldopa, antipsychotics, antidepressants,
and benzodiazepines. An important psychosocial factor
implicated in orgasmic disorders is the negative cultural
conditioning. Specific developmental factors like traumatic
sexual experiences during childhood, negative attitude
toward sex and interpersonal factors like hostility toward
spouse are also implicated in orgasmic disorders.
Sexual pain disorders
These are of two types: (1) Dyspareunia (2) vaginismus.
Dyspareunia is defined as recurrent or persistent genital
pain before, during or after sexual activity. It can be divided
into superficial, vaginal and deep. Superficial dyspareunia
occurs with attempted penetration, usually secondary to
anatomic or inflammatory conditions. Vaginal dyspareunia
is pain related to friction. Deep dyspareunia is pain related
to thrusting, often associated with the pelvic disease.
The prevalence rate of dyspareunia reported in the literature
is anywhere between 4% and 55%. The reason for this wide
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range could be that many prevalence studies do not include
dyspareunia within their list of dysfunctions or fail to
distinguish it from vaginismus, as dyspareunia is related to
and often coincides with vaginismus. Dyspareunia should
not be diagnosed when it is primarily due to vaginismus or
lack of lubrication.
Traditionally the etiology of dyspareunia has been divided
into organic and psychological. The organic factors are
further divided into anatomic, pathologic and iatrogenic.
Anatomic factors are congenital factors like agenesis of
the vagina and rigid hymen. The pathologic factors include
multiple conditions like vulvar atrophy, cervical erosion,
fibroids, ovarian cyst, endometriosis, prolapsed uterus,
tender uterosacral ligaments, tender bladder, squamous
metaplasia, infections, etc., Iatrogenic factors are usually
the consequence of a surgical procedure like episiotomy.
The psychoanalytic and learning theories are the two major
psychological theoretical perspectives. The psychoanalytic
theory treats dyspareunia as a hysterical or conversion
symptom symbolizing an unconscious intrapsychic conflict
and considers dyspareunia to be a result of phobic reactions,
major anxiety conflicts, hostility or aversion to sexuality.
Learning theory posits that dyspareunia is attributable
to lack of or faulty learning which may contribute to a
woman entering sexual relations with a set of negative
expectations. Also developmental (attitudes toward
sexuality), traumatic (prior aversive coital experiences) and
relational (interpersonal disputes with a partner) factors are
the other psychological factors.
It is a recurrent or persistent involuntary spasm or constriction
of the musculature surrounding the vaginal outlet and
the outer third of the vagina that interferes with vaginal
penetration. It causes severe personal distress. Women with
this disorder are even unable to insert tampons or permit the
insertion of a speculum during gynecological examination.
However, they can go through all stages of the sexual cycle
including arousal and orgasm. Vaginismus may be complete
or situational. This psychophysiological syndrome may affect
women of any age and most often afflicts highly educated
women and those in the higher socioeconomic status. Most
of these cases present as unconsummated marriage.
Vaginismus may be due to organic or nonorganic causes.
Most of the organic causes are lesions of the external
genitalia which lead on to vaginismus as a result of natural
protective reflex to pain. Among the frequent organic causes
are hymenal abnormalities, genital herpes, obstetric trauma
and atrophic vaginitis. Most commonly, however, no organic
causes can be implicated. Vaginismus is hypothesized
to be the body’s expression of the psychological fear of
penetration, hence shares features of a psychosomatic
disorder, phobia, and conversion disorder. Analytically
oriented theorists speculate that this disorder reflects the
women’s rejection of the female role or as a resistance against
a male sexual prerogative. Learning theory understands this
dysfunction as a conditioned fear reaction reinforced by the
belief that penetration can only be accomplished with great
difficulty and will result in pain and discomfort. A variety
of psychosocial factors may be operative, like religious
orthodoxy and regarding sex as dirty and shameful. Fear
of pregnancy, disgust regarding genitalia and homosexual
orientation are other causes. The diagnosis is arrived by a
careful history and unhurried methodical examination.
Success in treatment depends on accurate diagnosis which in
turn depends on an elaborate sexual history and appropriate
examination. Biochemical and other investigations also
form an essential part of the evaluation. Serum levels of
prolactin, estrogen, progesterone, follicle‑stimulating
hormone and luteinizing hormone are most commonly
implicated. The doctor‑patient relationship and the patient
interview are however, the key aspect in management.
FSFI is a questionnaire that can be easily used by health
professionals to complement the diagnosis and to detect
treatment‑related changes. The FSFI recognizes the need
for a subjective criterion in defining sexual dysfunction
and determines, through the nineteen item answers,
five separate domains: (a) Desire/arousal, (b) lubrication,
(c) orgasm (d) satisfaction and (e) pain.[18] Another
questionnaire widely used is the sexual history form. This
instrument, through 28 items, evaluates the frequency of
sexual activity, desire, arousal, orgasm, pain and overall
sexual satisfaction for women and men.[19]
Apart from these general interventions, sexual health in
elderly women needs specific attention. Due to increase
in life expectancy and more than one consecutive sexual
partner, the couple expect being sexually active even after
65 years of age. However, age decreases the frequency of
genital sexual activity. This issue needs to be addressed.
The clinician should educate that the quality of relationship
and an understanding of the physical and psychological
changes due to increasing age play a key role in sexual
satisfaction in old age. Chronic ill health and other
psychosocial situation need to be addressed. Alternatives
techniques are encouraged for better sexual functioning.
Vaginal lubrication products are equally essential.[20,21]
Managing sexual desire disorders
Historically, attempts to treat hypoactive sexual desire
disorders typically followed the sex therapy prototype
developed in 1970s. However, recently researches
and practitioners have begun to explore concomitant
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• Group therapy in conjunction with orgasm consistency
training, which consists of directed masturbation and
sensate focus exercises[23]
• A comprehensive program of multimodal cognitive
behavioral approach which entails sexual intimacy
exercises, sensate focus, communication skills training,
emotional skills training, reinforcement training,
cognitive restructuring, sexual fantasy training and
couple sex group therapy[24]
• Multistage treatment approach[25]
• Affectual awareness training: To identify negative
emotions through techniques such as list making,
role‑playing, and imagery
• Insight and understanding: To educate couples about
their feelings using a variety of strategies like gestalt
therapy and transactional analysis
• Cognitive and systemic therapies are included to
provide coping mechanisms as well as to resolve
underlying rational problems
• Behavioral therapy is aimed at initially improving
nonsexual affectionate behavior with an eventual goal
of introducing mutually acceptable sexual behavior
• If the organic pathology is treatable or controllable,
(e.g., by hormone replacement or stopping a particular
drugs which may cause disorders of desire) this should
be done
• Testosterone administration is the principle
pharmacological treatment for hypoactive sexual desire
disorder in women. However, the risks and benefits of
its administration are yet to be clarified[26]
• For disorders of sexual aversion, interventions are on
the some lines.
Management of disorder of arousal
The clinician should be able to delineate the disorders
of desire or orgasm which usually manifest as arousal
disorders. If the woman would have experienced arousal
by a particular way of stimulation, the partner should be
sensitized about it. Encouraging adequate foreplay or use
of vibrators to increase stimulation may be useful. Fantasy
training, use of erotic materials, attention‑focusing skills,
Kegel exercises (voluntary relaxation and contraction of
pubococcygeus muscles) and enhancing the partner’s
sexual skills are the other useful female arousal facilitation
techniques. Anxiety may inhibit arousal and strategies to
alleviate anxiety by employing distraction techniques are
Pharmacological treatment is also found to be useful in
female arousal disorders. However, the major drawback
here is that it cannot be used on a regular basis, and they
are not curative. Nitric oxide enhancers like sildenafil and
tadalafil facilitate vaginal lubrication. Estrogen‑containing
vaginal creams, phentolamine, prostaglandin E, L‑arginine
are also useful in female arousal disorders.[27]
Management of orgasmic disorders
Treatment commonly includes positive sexual attitudes
work, self‑pleasuring exercises, fantasy enhancement,
positive body image work, as well as Kegel (pelvic) muscle
exercises to facilitate easier orgasms. Masturbation by
self‑stimulation of genitalia or with a vibrator can provide a
woman with an opportunity to experience orgasm. Sensate
exercises to reduce anxiety are also useful.[28]
Treatment of dyspareunia
Dyspareunia has been a neglected area in sex therapy,
probably because of its not so frequent presentation in
clinical practice. Vaginal dilatation is the oldest and most
widely used treatment here. A method of the therapy called
physical therapy, which comprises Kegel exercise along
with other procedures like relaxation, postural education,
and biofeedback has also been found to be useful.[29]
Treatment of vaginismus
Cognition behavior therapy (CBT) has been found to be
most useful and successful in the treatment of vaginismus;
especially if it is of psychogenic origin. CBT strategies
mainly consist of:
• Information about the diagnosis of vaginismus including
the description of its anatomy, possible etiology, and
• Sensate focus ‑ to reduce performance anxiety
• Vaginal dilation in a graded manner either with the
help of instruments or use of self‑finger approach for
• Cognitive restructuring ‑ to change the dysfunctional
thoughts interfering with sexual functioning.[28]
Today we are into the 21st century. Yet when it comes to the
female sexuality, many cultures, and religions, especially in
the developing world impose social restrictions. This ongoing
restriction for ages has evolved a strong negativity among
women regarding sex. So even today the first healing step is
to create a factual awareness among them, as well as in the
entire society as to what is sexuality. This would probably
answer most of the problems related to female sexuality.
There are several sexual disorders specific to females based
on a sexual response cycle. The prevalence of these disorders
is not clear, mainly due to stigma associated with sex.
However, there are several therapeutic approaches that can
be utilized in effective management of these disorders.
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Source of Support: Nil, Conict of Interest: None declared
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... It acts as an integral component of the female identity which manifests as the perception of personal body image, gender identity, sexual orientation, fertility and femininity. Moreover, it serves as the core of a woman's personality and sexual self-concept which is expressed and experienced through behaviors, beliefs, values, fantasies and relationships [4,5]. Gynecological malignancies can be treated with surgeries, chemotherapy and radiation, either solely or in combination. ...
... As a consequence, these bodily responses might result in emotional deviations and provoke feelings of anxiety. Furthermore, the physiological responses related to the sexual response cycle including sexual desire, arousal and orgasm can be markedly affected [4,5]. Unfortunately, little attention has been paid to the resultant sexual complications that women experience. ...
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Background: Radiotherapy, as a method of treatment of cervical and uterine cancers, may induce severe late-onset vaginal side effects. Unfortunately, little evidence on the management of adverse effects has been presented. This study aimed to evaluate the available interventions which reduce symptoms of vaginitis and vaginal atrophy by improving dyspareunia, mucosal inflammation, vaginal pH and vaginal dryness in women who have undergone brachytherapy or radiotherapy due to uterine or cervical malignancies. Materials and methods: A comprehensive literature search was performed following PRISMA guidelines. The systematic search was conducted using electronic databases, namely Scopus, Web of Science and PubMed, between October and November 2020 to identify randomized controlled trials (RCT) and, prospective randomized studies (PRS). Results: The analyzed population consists of 376 patients with uterine or cervical cancer, treated with hyaluronic acid, vitamin A, vitamin E, alpha-tocopherol acetate and dienestrol. Intervention with HA along with vitamin A and vitamin E revealed advantage in endpoints such as reduced dyspareunia, vaginal mucosal inflammation, vaginal dryness, bleeding, fibrosis and cellular atypia. Administration of alpha-tocopherol acetate reduced vaginal mucosal inflammation and improved vaginal acanthosis, whereas dienestrol resulted in reduced dyspareunia, vaginal caliber and bleeding. Conclusions: Vaginal suppositories were found to be clinically effective at the management of late-onset vulvovaginal side effects after radiotherapy.
... Usually sexual activity in women begins during adolescence, reaches peak around the age of 30 years, and remains the same up to the age of 55 years. 16 TitOr/OL increases in those nearing menopause and in the postmenopausal age group. 17 Irrespective of the age, a positive selfebody image positively affects orgasm, indirectly affecting TitOr/OL positively. ...
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Background: Orgasm in women is a complex phenomenon, and the sparse data about time to orgasm (TitOr) in women are an impediment to the research on this complex phenomenon. Aim: To evaluate the stopwatch measured TitOr in women in a monogamous stable heterosexual relationship. Methods: The study was conducted through web-based and personal interview using a questionnaire, which addressed the issues related to TitOr. Sexually active women older than 18 years and women in a monogamous stable heterosexual relationship were included in the study. Those with comorbidities such as diabetes, hypertension, asthma, psychiatric illness, sexual dysfunction and those with partners with sexual dysfunction were excluded. The participants reported stopwatch measured TitOr after adequate sexual arousal over an 8-week period. The data analysis was performed using GraphPad software (©2018 GraphPad Software, Inc, USA). Outcomes: The outcomes included stopwatch measured average TitOr in women. Results: The study period was from October 2017 to September 2018 with a sample size of 645. The mean age of the participants was 30.56 ± 9.36 years. The sample was drawn from 20 countries, with most participants from India, the United Kingdom, the Netherlands, and the United States of America. The mean reported TitOr was 13.41 ± 7.67 minutes (95% confidence interval: 12.76 minutes-14.06 minutes). 17% of the participants had never experienced the orgasm. Penovaginal intercourse was insufficient to reach orgasm in the majority, in whom it was facilitated by certain positions and maneuvers. Clinical implications: The knowledge of stopwatch measured TitOr in women in real-life setting helps to define, treat, and understand female sexual function/dysfunction better and it also helps to plan treatment of male ejaculatory dysfunction, as reported ejaculatory latency in healthy men is much less than the reported TitOr here. Strengths & limitations: Use of stopwatch to measure TitOr and a large multinational sample are the strength of the study. The absence of a crosscheck mechanism to check the accuracy of the stopwatch measurement is the limitation of the study. Conclusion: Stopwatch measured average TitOr in the sample of women in our study, who were in a monogamous stable heterosexual relationship, is 13.41 minutes (95% confidence interval: 12.76 minutes-14.06 minutes) and certain maneuvers as well as positions during penovaginal intercourse help achieving orgasm, more often than not. Bhat GS, Shastry A. Time to Orgasm in Women in a Monogamous Stable Heterosexual Relationship. J Sex Med 2020;XX:XXX-XXX.
... Além disso, a melhora do fluxo sanguíneo pélvico, da mobilidade pélvica e da sensibilidade clitoriana após TMAP potencializaria não só a excitação, mas também a lubrificação vaginal e o orgasmo. 2,7,8 Assim, ambos, o TMAP e a conscientização da MAP, têm sido apontados como técnicas auxiliares no tratamento das disfunções sexuais femininas por alterarem de maneira positiva a vida sexual. O tratamento com esse foco frequentemente promoveria o aumento do desejo sexual com maior possibilidade de melhorar a excitação. ...
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Introdução: A disfunção sexual feminina é um fenômeno comum entre as mulheres e pode estar relacionado a condições fisiopatológicas dos músculos do assoalho pélvico. O desuso, a debilidade e a hipotonicidade dos músculos do assoalho pélvico estão relacionados com a incapacidade orgástica, gerando prejuízo das relações sexuais femininas com impacto na qualidade de vida. Objetivo: Identificar se o treinamento da musculatura do assoalho pélvico (MAP) por meio da técnica Gyrokinesis influencia na melhora da satisfação sexual e na qualidade de vida. Materiais e métodos: Estudo clínico piloto, não controlado nem randomizado, com sete mulheres voluntárias, com idade média de 44 anos. Foi aplicada uma escala de avaliação da função sexual feminina (FSFI) e questionário da percepção de qualidade de vida (World Health Organization Quality of Life – WHOQOL-BREF) antes e depois da intervenção do protocolo de atividade de fortalecimento da MAP e conscientização corporal, dentro da abordagem Gyrokinesis. Resultados: Observou-se diferença significativa no escore total da FSFI, indicando melhora na função sexual das voluntárias e diferença nas variáveis satisfação sexual, domínio psicológico e relações sociais do WHOQOL-BREF. Conclusão: Os exercícios direcionados à MAP se mostraram benéficos na avaliação da satisfação sexual feminina.
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Background Sexual dysfunction, a potential side effect of selective serotonin reuptake inhibitors (SSRIs), can lead to marital dissatisfaction in remitted depression patients, affecting their quality of life (QOL), and all of these are risk factors for treatment noncompliance. We aimed to estimate the proportion of female sexual dysfunction and its subtypes compared to the general population and correlate it with various factors, including marital satisfaction and QOL, in remitted depressive patients on SSRI treatment. Methods This analytical cross-sectional study assessed 116 women, comprising 58 patients aged 18– to 45 years with remitted depression on SSRI monotherapy for a minimum of six weeks and their age-matched comparative group. Hamilton Depression Rating Scale was used to assess depression severity and Female Sexual Functional Index, to assess sexual dysfunction. Couple Satisfaction Index and WHOQOL-BREF version were used to assess marital satisfaction and QOL, respectively. Results In total, 56.89% of the patients had sexual dysfunction, compared to 39.65% in the general population. Exploratory analyses revealed that overall sexual functioning had a significant positive correlation with education (P = .002), marital satisfaction ( P < .001), and QOL ( P <.01), and a significant negative correlation with the age of onset of depression ( P = .004), total marital duration ( P = .02), and duration of current treatment ( P = .02). Conclusion Sexual dysfunction is common in remitted female depression patients on SSRI treatment, which may further impair their marital satisfaction and QOL. Hence, routine screening for sexual dysfunction is necessary for them.
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Introduction Sexual function is an important area in women’s lives and has repercussions on well-being and sexual satisfaction. The literature identifies relational variables, such as romantic attachment, intimacy in relationships, and dyadic adjustment, as determinants that influence female sexual expression, satisfaction, and function. This study aimed to test a predictive model of female sexual function, contemplating possible relationships between these relational variables. Methods The participants in this study were 267 women in a romantic relationship, who completed, between 2017 and 2020, the Romantic Attachment Questionnaire, the Personal Assessment of Intimacy in Relationships Scale, the Revised Dyadic Adjustment Scale, and the Female Sexual Function Index. Results Data analysis, using structural equation modeling (SEM), indicated an adjusted model. Trust and avoiding romantic attachment were positive predictors of intimacy. Ambivalent romantic attachment was a negative predictor of dyadic adjustment, while intimacy and dependent romantic attachment were positive predictors of dyadic adjustment, which, in turn, was a positive predictor of female sexual function. Age, as well as frequency and interest in sexual activity, was found to be associated with female sexual function and other variables. Conclusions These results are discussed in terms of the importance of contemplating relational variables in psychotherapeutic interventions for female sexual problems.
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The Sexual Quality of Life-Female (SQoL-F) questionnaire was developed with qualitative data to assess the impact of sexual dysfunction in women. Objectives: the aim was to conduct a cross-cultural adaptation and psychometric analysis of a European Portuguese version of the Sexual Quality of Life-Female questionnaire. Methods: Methodological study of the processes of translation and cultural adaptation. This is a retrospective study in which nursing students participated. Data collection: Lime Survey platform in a convenience sample was carried out in two stages, the latter being re-testing data. The instrument analysed, presented as a latent variable, consisted of 18 items on a Likert scale. The study was approved by the Ethics Committee. Participants: the sample was 113 women, mean age 21.99 years (±3.76), attending classes in the first 4 years of the first cycle of nursing. Results: Reliability was analysed and stability was found in the test-retest (rs = 0.658) and in the intraclass coefficient (rs = 0.821). The internal consistency analysis showed an alpha value of 0.846. Discriminant validity analysis using the Mann-Whitney test revealed a higher score of the quality of sexual life of students living with parents/surrogates. Factor validity analysis was conducted using Oblimin rotation with four-, three- and two-factor tests. Parallel analysis of the empirical matrix compared to the random matrix showed that the instrument was unidimensional. Conclusions: the assessment of the properties of the SQoL-F is valuable, as the provision of a valid and reliable instrument contributes to the quality of subsequent studies, including for local and multicentre research.
As India stands in the 70th decade of its independence it has travelled a long way with life expectancy at birth drastically increasing from 36.2 years in 1950 to 69.7 years in 2020; this is further projected to rise to 75.9 years by 2050. The Indian subcontinent is known for its rich heritage and culture. It is one of the most diverse countries in the world with its varied religions, ethnicities, languages, customs and social structures. The most unique feature of India is its unity in diversity. It is home to 1.3 billion people of which more than 8% being elderly making India an ageing nation. As diverse as India is, so is the situation of the elderly in India. The health and wellbeing of the elderly is determined by multiple features ranging from individual risk factors to the socioeconomic, cultural and environmental milieu in which the elderly reside. Their level of education, working environment and living conditions have a detrimental impact on the lives of the elderly. The immediate family, social and community networks of the elderly play a crucial role in providing not only physical but also mental support. This rich social capital is considered most often as the only social security measure that the elderly in India have. Even though there is a national policy and program with many elderly friendly initiatives in place there still exists a huge gap in services that needs to be addressed. This chapter aims to provide a holistic overview of the life of an elderly in India emphasising the need for healthy aging for a healthier tomorrow.
Sexual self-efficacy (SSE) has also been cited as an important factor for healthy and satisfying sex. The purpose of this study was to determine SSE and its related factors among married women of reproductive age.The present study is a cross-sectional, descriptive-analytical study. The research samples were 588 married women of reproductive age. A cluster sampling method is used to select participants. Data collection instruments were the socio-demographic form and the Sexual Self-Efficacy Scale-Female Functioning (SSES-F). Data analysis, Friedman, Multiple LinearRegression was performed through SPSS software version 16. The highest and lowest score was related to body acceptance (77.78) and communication (69.66), respectively. The results showed that age (B= 0.471, P<0.001), marital satisfaction (B= 0.11.3, P<0.001), life satisfaction (B= 3.5, P<0.03) and the economic-social welfare satisfaction were related to SSE. We’ve found that Women with a higher Education, Employment, higher income, and Younger husbands had the highest SSE score.The components of age, marital satisfaction, life satisfaction, and economic status affect the SSE of married women of reproductive age. The results of this study can be useful in the design and implementation of sexual health promotion interventions. Keywords: Efficacy; sexual behavior; women.
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Citation: Memon, A.B.; Rahman, A.A.U.; Channar, K.A.; Zafar, M.S.; Kumar, N. Assessing the Quality of Life of Oral Submucous Fibrosis Patients: A Cross-Sectional Study Using the WHOQOL-BREF Tool. Int. Abstract: The aim of the present study was to evaluate the quality of life (QoL) of oral submucous fibrosis (OSMF) patients using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire. This cross-sectional study was conducted at the Department of Oral and Maxillofacial Surgery, Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro. We used the consecutive sampling technique to recruit patients who were clinically diagnosed with OSMF (n = 112). Data were collected using the WHOQOL-BREF questionnaire, which contains a total of 26 questions. The first two questions, related to overall QoL and overall health status, were evaluated separately. The remaining questions (3-26), which represented four domains-physical, psychological, social, and environmental health-were evaluated separately. Patients were asked questions in their native language (Urdu). The relationship between these four domains of life was evaluated with gender, age categories, functional staging, and habit duration using the independent t-test to determine statistical significance. Cronbach's Alpha was used to assess the reliability of the WHOQOL-BREF domains. The overall QoL of the OSMF patients was considerably poor, and the majority of the patients were unsatisfied with their oral health status. The age variable significantly affected the scores of all domains except for social relationships, whereas habit duration and functional staging of OSMF did not significantly affect the scores of all domains. The domains of the WHOQOL-BREF questionnaire (translated into the Urdu language) showed good reliability, except for social relationships.
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We aimed to investigate whether females with psychosexual disorders were associated with the risk of affective and other psychiatric disorders. A total of 2240 enrolled individuals, with 560 patients with psychosexual disorders and 1680 subjects without psychosexual disorders (1:3) matched for age and index year, from the Longitudinal Health Insurance Database, retrieved from the National Health Insurance Research Database (NHIRD), between 2000 and 2015 in Taiwan. The multivariate Cox regression model was used to compare the risk of developing psychiatric disorders during the 15 years of follow-up. There were 98 in the cohort with psychosexual disorders (736.07 per 100,000 person-year) and 119 in the non-cohort without psychosexual disorders (736.07 per 100,000 person-year) that developed psychiatric disorders. The multivariate Cox regression model revealed that the adjusted hazard ratio (HR) was 9.848 (95% CI = 7.298 — 13.291, p < 0.001), after the adjustment of age, monthly income, urbanization level, geographic region, and comorbidities. Female patients with psychosexual disorders were associated with the risk of psychiatric disorders. This finding could be a reminder for clinicians about the mental health problems in patients with psychosexual disorders.
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The aim of this study was to determine the cumulative prevalence rate of every sexual dysfunctions (SDs) in Iranian population. We searched international database such as: PubMed/Medline, Scopus, PsychNET, and Scholar Google and Iranian database such as Iran Psych, IranDoc, IranMedex, and SID. Search duration was between 1990 and 2013. From 449 articles were retrieved, then 11 articles on male with total sample size of 2142 and 8 articles on female with total sample size of 4391 were selected after critical appraisal. For quality assessment check list to evaluate a prevalence article was contained study population, sampling method, sample size, criteria for SD diagnosis, specific rates, study location, and authors list. In male, erectile dysfunction was 56.1%. In female, pooled estimation prevalence of hypoactive sexual desire disorder in complained group was 65.8% (95% confidence interval [CI]: 51.1-80.6%) compared to general population 35% (95% CI: 17.6-52.1%). Sexual arousal disorder in clinical patient was 59.6% (95% CI: 39-80%) against 33.8% (95% CI: 18.3-49.3%) in general population. Orgasmic disorder in complained was 35.5% (95% CI: 16-55%) and in general population was 35.3% (95% CI: 26.8-43.8%). Sexual pain disorder pooled estimation prevalence were 35.2% (95% CI: 14.5-56%) versus 20.1% (95% CI: 6.4-33.8%) in complained and general population consecutively. The rate of SD in Iran was approximately the same of worldwide except orgasmic disorder which was two times more than the worldwide average.
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With advancing age, there is an increase in the complaints of a lack of a libido in women and erectile dysfunction in men. The efficacy of phosphodiesterase type 5 inhibitors, together with their minimal side effects and ease of administration, revolutionized the treatment of erectile dysfunction. For women, testosterone administration is the principal treatment for hypoactive sexual desire disorder. We sought to evaluate the use of androgens in the treatment of a lack of libido in women, comparing two periods, i.e., before and after the advent of the phosphodiesterase type 5 inhibitors. We also analyzed the risks and benefits of androgen administration. We searched the Latin-American and Caribbean Health Sciences Literature, Cochrane Library, Excerpta Medica, Scientific Electronic Library Online, and Medline (PubMed) databases using the search terms disfunção sexual feminina/female sexual dysfunction, desejo sexual hipoativo/female hypoactive sexual desire disorder, testosterona/testosterone, terapia androgênica em mulheres/androgen therapy in women, and sexualidade/sexuality as well as combinations thereof. We selected articles written in English, Portuguese, or Spanish. After the advent of phosphodiesterase type 5 inhibitors, there was a significant increase in the number of studies aimed at evaluating the use of testosterone in women with hypoactive sexual desire disorder. However, the risks and benefits of testosterone administration have yet to be clarified.
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Background and aim: Sexual dysfunction adversely affects quality of life, self esteem and interpersonal relationships and it may often be responsible for psychopathological disturbances. The purpose of this study was to explore the prevalence and associated risk factors for Female Sexual Dysfunction (FSD) in women with Kurdish culture from western Iran . Material and methods: This was a cross-sectional descriptive survey which included 400 women aged 18-50 years old, married, from Ilam-IR, who were interviewed as per the Iranian version of Female Sexual Function Index (FSFI). The subjects were randomly selected from 4 primary health centres. Results: According to the findings, 185 (46.2%) women reported FSD. Prevalence of FSD increased with age, from 22% in women aged <20 years to 75.7% in women aged 40-50 years. FSD was detected as a desire problem in 45.3% of women, an arousal problem in 37.5%, a lubrication problem in 41.2%, an orgasm problem in 42.0%, a satisfaction problem in 44.5% and a pain problem in 42.5%. The educational level was inversely correlated with the risk of FSD (OR: 1.54 ,95% CI: 1.09-2.13). Patients with FSD were significantly more likely to be older than 40 years (OR: 2.23, 95% CI: 1.12-2.68), who had sexual intercourse fewer than 3 times a week (OR:1.85, 95% CI: 1.23-1.99), who had been married for 10 years or more (OR:1.76, 95% CI: 1.04-1.97), who had 3 children or more (OR: 1.48, 95% CI: 0.97-1.24), who had husbands aged 40 years or more (OR: 2.11, 95% CI: 1.35-2.37) and who were unemployed (OR: 1.34, 95% CI: 1.06-1.63). No significant differences were detected in smoking history, residences and contraception methods used (p>0.05). Conclusion: FSD needs to be recognized as a significant public health problem in Kurd women. Further research, particularly studies on awareness and competency of physicians in the management of FSD, is required.
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This article presents findings from a review of the evidence regarding sexual health for older women from MEDLINE, SCOPUS and the Cumulative Index to Nursing and Allied Health (CINHAL) databases. A total of 10 articles based on primary studies, reporting about the sexuality or sexual health of older women (and older people), and published between 2002–2012, were deemed suitable. The major themes that emerged from the available literature suggest that the sexual health of older people is affected by factors such as physical changes, mental health, changes to their relationship with their husband, chronic ill health and other psychosocial situations. It is concluded that nurses and other healthcare providers have a range of interventions that can be adopted to promote sexual health among older women. These interventions may focus on improving the older woman's sexual health assessment; increasing awareness and knowledge about sexuality in later life; pharmacological and psychotherapeutic therapies; using alternative techniques to achieve better sexual functioning; addressing partner and relationship issues, and advocating the importance of sexual health through media and policy development.
Hypoactive sexual desire disorder (HSDD) is a prevalent and disabling condition for women and their partners. Clinical and empirical investigation into this disorder is still in developmental stages, and many questions about its etiology and treatment remain. Present understanding of HSDD leads to a holistic, biopsychosocial approach to this complex disorder. Emerging treatment views focus on multidisciplinary therapies that often integrate medical and psychosocial modalities.
To evaluate sexuality in elderly couples and have the knowledge of its specific therapeutic options. Review of articles published on this subject in the Medline database, selected according to their scientific relevance together with a reflexion from our own experience. Due to increased life expectancy and the changes in society leading to a life with more than one consecutive partner, couples expect to continue sexual activity after the age of 65. Clinicians are asked to address this issue frequently. With age the frequency of genital sexual relations decreases. Sexual activity should be higher both for males and females. The quality of the relationship of the couple is a key element in maintaining sexual relations in this age group. Sexual satisfaction depends on the understanding, by both partners, of the physical and psychological changes due to increased age. The sexuality of the elderly couple must be analysed using specific criteria. The clinician's task is to explain to the patients the physiological change due to aging and give them advice on how to adapt their sexual behavior accordingly. Management will, at the same time, include pharmacological treatment, notably for erectile dysfunction, in order to restore satisfactory sexual relations. For women, vaginal lubrication products are essential. This global management should allow many elderly couples wishing to continue sexual relations, to enjoy this period of their lives in harmony with what they desire.