Women who were sexually abused as children or sexually assaulted as adults often experience sexual dysfunction and difficulty with intimate relationships and parenting.
The National Women’s Study revealed that 13%, or one of eight adult women, are survivors of at least one completed rape during their lifetime.
Most women feel that sexuality is an important part of their lives even when chronic illness is present. Providing patients with information about normal sexual changes that occur with puberty, pregnancy and postpartum, menopause, and older age is part of routine obstetric and gynecologic care.
Sexual dysfunction can arise from gynecologic diseases such as endometriosis, procedures such as those associated with infertility, and treatments such as pelvic radiation, bilateral salpingooophorectomy, and use of aromatase inhibitors or gonadotropin-releasing hormone (GnRH) antagonists. Sexual abuse can have long-lasting effects on sexuality and other psychophysiological aspects of a patient’s life. Women seen in gynecology clinics may have comorbid illnesses that interrupt their sexual function. Inquiry about sexual concerns and explanation of the implications of a disease and its treatment are integral components of gynecologic care.
The spectrum of normal sexual response varies from one woman to another and throughout a woman’s lifetime (1–3). Physicians should be aware of their patients’ sexual values, attitudes about specific practices, and concerns about their sexuality. Maintaining open communication with patients about their sexuality allows the physician to counsel them about sexual issues and problems and other aspects of their reproductive health.
Sexual Activity Sexual activity among adolescents in the United States increased during the past 20 years (3). The average age for first intercourse for both men and women is 16 years. By 19 years of age, as many as three-quarters of women have had intercourse. Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies. A recent study of North American women, using a large and diverse community-based sample, shows that of the 3,205 women aged 30 to 79 years almost one-half were not sexually active in the previous 4 weeks, with 52% of those citing lack of interest and 61% citing lack of partner as the major reasons. Of those who were sexually active recently, 13.7% noted sexual problems and dissatisfaction with their overall sexual lives (4).
Genital Anatomy For most women, their clitoral tissue is the most sexually sensitive part of their anatomy, and its stimulation produces the most intense sexual feelings and the most intense orgasms. Many women first need to experience both nonphysical and nongenital physical stimulation before clitoral stimulation can be enjoyed. In the absence of arousal, direct clitoral stimulation can be unpleasant and be perceived as too intense and even painful. Immunohistologic studies identified neurotransmitters thought to be associated with sensation concentrated right under the epithelium of the glans clitoris (5). Clitoral tissue extends far beyond the visible portion when the clitoral hood is retracted. It includes the clitoral head, shaft, rami running along the pubic arch, periurethral tissue in front of the anterior vaginal wall, and the bulbar tissue under the superficial perineal muscles surrounding the anterior distal vagina. Other sexually sensitive areas include the nipples, breasts, labia, much of the skin generally, and to some extent, the vagina. Although the lower third of the vagina is responsive to touch, the upper two-thirds is sensitive primarily to pressure. The rich supply of nerves in the fascia anterior to the upper vagina (Halban’s fascia) and the proximity of the clitoral type of spongy tissue around the urethra anterior to the vagina contribute to the pleasurable sensations of intercourse. Many women experience orgasm more easily from direct clitoral touch, possibly provided at the same time as intercourse.