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REVIEW ARTICLE

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

ABSTRACT

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, , 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 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, , female sexuality, vaginismus

INTRODUCTION a broader physical, emotional, interpersonal, social, and spiritual sense of well‑being, in a culturally informed, freely Sex is a motive force bringing a man and a woman into and responsibly chosen and ethical framework; not merely intimate contact. Satisfying usual experience is an essential the absence of sexual disorders.” This can be considered part of a healthy and enjoyable life for most people. the most comprehensive definition of sexual health as it Sexual activity is a multifaceted activity involving complex incorporates many domains like historical, physiological, interactions between the nervous system, the endocrine psychological, interpersonal, sociocultural, and ethical system, the vascular system and a variety of structures that views, including attention to human rights issues.[2] are instrumental in sexual excitement, intercourse, and satisfaction. Though essentially it is meant for procreation, Sexuality is a central aspect of being human throughout it has also been a source of pleasure, a natural relaxant, life and encompasses sex, gender identities and roles, it confirms one’s gender, bolsters one’s self‑esteem and sexual orientation, eroticism, pleasure, intimacy, and sense of attractiveness for mutually satisfying intimacy and reproduction. Sexuality is experienced and expressed relationship.[1] The World Psychiatric Association has defined in thoughts, fantasies, desires, beliefs, attitudes, values, sexual health as “a dynamic and harmonious state involving behaviors, practices, roles, and relationships. While erotic and reproductive experiences and fulfillment, within sexuality can include all of these dimensions, not all of

Access this article online Address for correspondence: T.S. Sathyanarana Rao, Department of Psychiatry, JSS Medical College, JSS University, Quick Response Code Mysore, Karnataka, India. Website: E‑mail: [email protected] www.indianjpsychiatry.org

DOI: How to cite this article: Sathyanarana Rao TS, Nagaraj AM. 10.4103/0019-5545.161496 Female sexuality. Indian J Psychiatry 2015;57:S296-302.

S296 Indian J Psychiatry 57 (Supplement 2), July 2015 Rao and Nagaraj: Female sexuality them are always experienced or expressed. Sexuality is . Contrary to what is depicted in , vaginal influenced by the interaction of biological, psychological, insertion to reach an orgasm is not common. Some women social, economic, political, cultural, ethical, legal, historical, can reach orgasm by pressing the breast alone and a few religious, and spiritual factors.[3] This article is a review of women (2%) by fantasy alone. Some individuals use vibrators female sexuality. for added enjoyment and variation. By , many women need <4 min to reach orgasm.[8] FEMALE SEXUALITY THE SEXUAL RESPONSE CYCLE In the first millennium BC, human cultures clearly experienced a “axial period” in a striking transformation of human Following the pioneering work of Masters and Kaplan, the consciousness. The transformation occurred independently sexual response cycle in both sexes is often categorized in three geographical regions: In China, in India and Persia, as a four‑phase process, desire, excitement, orgasm, and and in the Eastern Mediterranean, including Israel and resolution.[9] Greece. In this cultural transformation, a prevailing mythic, cosmic, ritualistic, collective consciousness embedded in The first stage, , consists of the motivational a tribal matrix with the female in the foreground, slowly or appetitive aspects of sexual response. Sexual urges, gave birth to a male dominated, rational, analytical, and fantasies, and wishes are included in this phase. The second individualistic consciousness. This transition in cultural stage, sexual excitement, refers to a subjective feeling of values began very slowly after the last ice age retreated.[4] sexual pleasure and accompanying physiological changes. This phase includes penile in males and vaginal In a developing country like India, modern Hindu cultures lubrication in females. Plateauing, sometimes classified even today contain a general disapproval of the erotic aspect as a separate phase, is a heightened state of excitement of married life, a disapproval that cannot be disregarded attained with continued stimulation. There is marked as a mere medieval relic. Many Hindu women, especially sexual tension in this phase, which sets the stage for the those in the higher castes, do not even have a name for orgasm. The third stage, orgasm or climax is defined as the their genitals. Though the perception of modern Indian peak of sexual pleasure, with rhythmic contractions of the women is transforming, many of them still consider the genital musculature in both men and women, associated sexual activity a duty, an experience to be submitted to, with in men. Graph 1 shows three different often from a fear of abuse.[5] patterns of orgasm in females. Pattern 1 shows multiple . Pattern 2 shows arousal that reaches the plateau According to Sigmund Freud, both sexes seem to pass level without going onto orgasm (note that resolution through the early phases of libidinal development in the occurs very slowly). Pattern 3 shows several brief drops same manner. Psychologically, the male‑female difference in the excitement phase followed by an even more rapid in sexuality starts only during the phallic phase, with resolution phase. This is the final phase, during which a the appearance of Oedipus complex. However, the general sense of relaxation and well‑being is experienced. difference becomes most clear only during the genital Then, there is a refractory period in males, which is usually phase.[6] Though generally, women are sexually active absent in females. Table 1 shows the physical changes in the during adolescence, they reach their peak orgasmic female during the sexual response cycle.[10] 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 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 Graph 1: Different patterns of orgasm among females

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CLASSIFICATION In ICD 10, the is classified under F52, which is “sexual dysfunction, not caused by Based on the phases of sexual response cycle, both organic disorder or disease.” In DSM V, there are several International Classification of Diseases (ICD) 10 and modifications compared to the previous version that Diagnostic and Statistical Manual of Mental Disorders (DSM) is, DSM IV. Now it is segregated from V have listed a variety of sexual disorders in women. disorders and a separate chapter by name “sexual dysfunctions” is elaborated in DSM V. With respect to Table 1: Physical changes in the female during the female sexuality, an important deviation from the earlier sexual response cycle concept is that the difficulties in desire and arousal often Sexual Physiological changes simultaneously characterize the complaints of women. response Thus, the two entities are merged in DSM V. The sexual cycle desire disorder in women is not listed separately. It is now Desire phase Has no specific physical changes called “female sexual interest/arousal disorder” and is Excitement Vaginal lubrication begins listed under arousal disorders. The Table 2 compares the Inner two-thirds of the expands Color of vaginal wall becomes darker nosological status of sexual dysfunction in females among Outer lips of vagina flatten and move back from the vaginal the two diagnostic manuals. opening Inner lips of the vagina thicken EPIDEMIOLOGY Clitoris enlarges and uterus move upward Nipples become erect In general, there has been an acute dearth of valid or Breast size increases modestly reliable statistical data on the epidemiology of female Sex flush appears (late and variable) sexual disorders. This is particularly true when it comes to Heart rate and blood pressure increase nonwestern settings. General neuromuscular tension increases Plateau Vaginal lubrication continues, but may wax and wane Orgasmic platform forms at outer third of the vagina In a survey of the US general population, sexual dysfunction Cervix and uterus elevate further was more prevalent in women (43%) than men (31%) Inner two-thirds of vagina lengthens and expands further and was associated with various sociodemographic Clitoris retracts beneath the clitoral hood characteristics including age and educational attainment. Lips of the vagina become more swollen and change color Women of different social groups demonstrate a different Sex flush intensifies and spreads more widely Further increase in breast size; areola enlarges pattern of sexual dysfunction. The experience of sexual Heart rate and blood pressure increase further dysfunction is more likely among women (and men) Breathing may become more shallow and rapid with poor physical and emotional health.[11] In England, Voluntary contraction of rectal sphincter used by some a study asserts that about two‑fifths of women (41%) females as a stimulative technique Further increase in neuromuscular tension reported having a current sexual problem. The most Visual and auditory acuity are diminished common problems were a lack of desire, vaginal dryness, Orgasm Onset of powerful involuntary rhythmic contractions of orgasmic platform and uterus Sex flush, if present, reaebxs maximum color and spread Table 2: Comparison of no sociological status of sexual Involuntary contractions of rectal sphincter dysfunction under ICD 10 and DSM V Peak heart rates, blood pressure, and respiratory rates ICD 10 DSM V General loss of voluntary muscular control; may be cramp Lack or loss of sexual desire Not listed like spasms of muscle groups in the face, hands, and feet Sexual aversion and lack of Not listed Resolution Clitoris returns to normal position within 5-10 s after orgasm sexual enjoyment Orgasmic platform disappears Failure of genital response Female sexual interest/arousal disorder Vaginal lips return to normal thickness, position, and color Orgasmic dysfunction Female orgasmic disorder Vagina returns to resting size quickly; return to resting color Nonorganic vaginismus Vaginismus (not due to a general may take as long as 10-15 min medical condition) Uterus and cervix descend to their unstimulated positions Nonorganic dyspareunia Genito-pelvic pain/penetration disorder Areola returns to normal size quickly; nipple erection Excessive sexual desire Not listed disappears more slowly Other sexual dysfunction not caused Other specified sexual dysfunction Rapid disappearance of sex flush by organic disorder or disease Irregular neuromuscular tension may continue, as shown by Unspecified sexual dysfunction not Unspecified sexual dysfunction involuntary twitches or contractions of isolated muscle groups caused by organic disorder or disease Heart rate, respiratory rate, and blood pressure return to Not listed Substance/medication-induced sexual baseline (preexcitation) levels dysfunction General sense of relaxation is usually prominent DSM – Diagnostic and Statistical Manual for Mental Disorders; Visual and auditory acuity return to usual levels ICD – International Classification of Diseases

S298 Indian J Psychiatry 57 (Supplement 2), July 2015 Rao and Nagaraj: Female sexuality and infrequent orgasm.[12] Another study from England Disorder of arousal reports the prevalence rate of sexual dysfunction in The failure of genital response in females is experienced as women as 42%, vaginismus was reported by 30% of them, the failure of vaginal lubrication, together with inadequate and anorgasmia by 23%.[13] tumescence of the . However, a subjective sense of arousal is often poorly correlated with it in that a women A recent cross‑sectional study from a different geographical complaining of lack of arousal may lubricate vaginally, area (Iran) using Female Sexual Function Index (FSFI) also but may not experience a subjective sense of excitement. found a similarly prevalent sexual problems in the range There is also a lack of vaginal smooth muscle relaxation and of 22% (<20 years) to 75% (40–50 years). Problems with decreased clitoral enjoyment. Though, exact prevalence desire were found with 45%, arousal problems in 37%, the is not known, about 35% of women report difficulty in lubrication problem in 41%, the orgasmic problem in 42% maintaining adequate sexual excitement. This dysfunction and pain problem in 42%. Some of the important associated causes marked distress in women. The etiological factors etiological factors were older age, infrequent sexual activity, include vasculogenic, neurogenic and endocrine factors, more than 10 years of , more than three kids and systemic diseases, psychotropic drugs and psychosocial husbands more than 40 years. The authors consider that factors. the female sexual dysfunction is a significant public health problem of women in that nation.[14] Orgasmic disorder Achieving orgasm adequately is highly treasured by The literature on etiological factors associated with women as it is seen as a mark of high self‑esteem, and sexual dysfunction infers that in women, the predominant confidence in one’s feminity resulting in a high desire association with arousal, orgasmic, and enjoyment for sexual activity. Persisting and recurring difficulty problems was marital difficulties. Vaginal dryness was found in achieving orgasm is termed as anorgasmia. The to increase with age after . In general, sexual appropriate, reported prevalence of this disorder is in the dysfunction was commonly associated with social problems range of 5–10%. Women who suffer solely form orgasmic in women.[15] dysfunction may have normal desire and arousal, but have great difficulty in reaching climax. However, the distress SPECIFIC PROBLEMS over inability to reach orgasm may lead on to decrease in desire and arousal. Sexual dysfunction includes disorders of (i) desire, (ii) arousal, (iii) orgasm and (iv) sexual pain disorders.[16,17] Among the etiological factors for orgasmic disorders, the organic factors include neurological conditions that affect Disorders of sexual desire the nerve supply to the pelvis, like multiple sclerosis, spinal It is explained as an independent entity in ICD 10 (and not card tumors or trauma, nutritional deficiencies, diabetic in DSM V as mentioned before). It includes lack or loss of neuropathy, vascular causes, endocrine disorders and sexual desire, sexual aversion and lack of sexual enjoyment. drugs like methyldopa, antipsychotics, antidepressants, Lack or loss of sexual desire is manifest by the diminution of and benzodiazepines. An important psychosocial factor seeking out sexual cues, of thinking about sex with associated implicated in orgasmic disorders is the negative cultural feelings of desire or appetite, or of sexual fantasies. There conditioning. Specific developmental factors like traumatic is a lack of interest in initiating sexual activity either with sexual experiences during childhood, negative attitude a partner or by masturbation. Sexual aversion is defined toward sex and interpersonal factors like hostility toward as a disorder in which the prospect of sexual interaction spouse are also implicated in orgasmic disorders. with a partner produces sufficient aversion, fear or anxiety that sexual activity is avoided. In the disorder of lack of Sexual pain disorders sexual enjoyment, genital response (orgasm) occurs during These are of two types: (1) Dyspareunia (2) vaginismus. , but is not accompanied by pleasurable sensations or feelings of pleasant excitement. Dyspareunia Dyspareunia is defined as recurrent or persistent genital It has been estimated that about 20% of the female pain before, during or after sexual activity. It can be divided population have the hypoactive sexual desire. Chronic into superficial, vaginal and deep. Superficial dyspareunia stress, anxiety, depression, prolonged period of abstinence occurs with attempted penetration, usually secondary to from sex, hostility in relationship with partner, previous anatomic or inflammatory conditions. Vaginal dyspareunia bad experience with sex, childhood , is pain related to friction. Deep dyspareunia is pain related religious taboos, low biological drive, dysfunction of the to thrusting, often associated with the pelvic disease. hypothalamic pituitary axis, endocrinal disorders, ovarian failure, psychotropic, and cardiovascular drugs are the The prevalence rate of dyspareunia reported in the literature various etiological factors associated with low sexual desire. is anywhere between 4% and 55%. The reason for this wide

Indian J Psychiatry 57 (Supplement 2), July 2015 S299 Rao and Nagaraj: Female sexuality range could be that many prevalence studies do not include oriented theorists speculate that this disorder reflects the dyspareunia within their list of dysfunctions or fail to women’s rejection of the female role or as a resistance against distinguish it from vaginismus, as dyspareunia is related to a male sexual prerogative. Learning theory understands this and often coincides with vaginismus. Dyspareunia should dysfunction as a conditioned fear reaction reinforced by the not be diagnosed when it is primarily due to vaginismus or belief that penetration can only be accomplished with great lack of lubrication. difficulty and will result in pain and discomfort. A variety of psychosocial factors may be operative, like religious Traditionally the etiology of dyspareunia has been divided orthodoxy and regarding sex as dirty and shameful. Fear into organic and psychological. The organic factors are of , disgust regarding genitalia and homosexual further divided into anatomic, pathologic and iatrogenic. orientation are other causes. The diagnosis is arrived by a Anatomic factors are congenital factors like agenesis of careful history and unhurried methodical examination. the vagina and rigid hymen. The pathologic factors include multiple conditions like vulvar atrophy, cervical erosion, MANAGEMENT fibroids, ovarian cyst, endometriosis, prolapsed uterus, tender uterosacral ligaments, tender bladder, squamous Success in treatment depends on accurate diagnosis which in metaplasia, infections, etc., Iatrogenic factors are usually turn depends on an elaborate sexual history and appropriate the consequence of a surgical procedure like episiotomy. examination. Biochemical and other investigations also form an essential part of the evaluation. Serum levels of The psychoanalytic and learning theories are the two major prolactin, , progesterone, follicle‑stimulating psychological theoretical perspectives. The psychoanalytic hormone and luteinizing hormone are most commonly theory treats dyspareunia as a hysterical or conversion implicated. The doctor‑patient relationship and the patient symptom symbolizing an unconscious intrapsychic conflict interview are however, the key aspect in management. and considers dyspareunia to be a result of phobic reactions, major anxiety conflicts, hostility or aversion to sexuality. FSFI is a questionnaire that can be easily used by health Learning theory posits that dyspareunia is attributable professionals to complement the diagnosis and to detect to lack of or faulty learning which may contribute to a treatment‑related changes. The FSFI recognizes the need woman entering sexual relations with a set of negative for a subjective criterion in defining sexual dysfunction expectations. Also developmental (attitudes toward and determines, through the nineteen item answers, sexuality), traumatic (prior aversive coital experiences) and five separate domains: (a) Desire/arousal, (b) lubrication, relational (interpersonal disputes with a partner) factors are (c) orgasm (d) satisfaction and (e) pain.[18] Another the other psychological factors. questionnaire widely used is the sexual history form. This instrument, through 28 items, evaluates the frequency of Vaginismus It is a recurrent or persistent involuntary spasm or constriction sexual activity, desire, arousal, orgasm, pain and overall [19] of the musculature surrounding the vaginal outlet and sexual satisfaction for women and men. the outer third of the vagina that interferes with vaginal penetration. It causes severe personal distress. Women with Apart from these general interventions, sexual health in this disorder are even unable to insert tampons or permit the elderly women needs specific attention. Due to increase insertion of a speculum during gynecological examination. in life expectancy and more than one consecutive sexual However, they can go through all stages of the sexual cycle partner, the couple expect being sexually active even after including arousal and orgasm. Vaginismus may be complete 65 years of age. However, age decreases the frequency of or situational. This psychophysiological syndrome may affect genital sexual activity. This issue needs to be addressed. women of any age and most often afflicts highly educated The clinician should educate that the quality of relationship women and those in the higher socioeconomic status. Most and an understanding of the physical and psychological of these cases present as unconsummated marriage. changes due to increasing age play a key role in sexual satisfaction in old age. Chronic ill health and other Vaginismus may be due to organic or nonorganic causes. psychosocial situation need to be addressed. Alternatives Most of the organic causes are lesions of the external techniques are encouraged for better sexual functioning. genitalia which lead on to vaginismus as a result of natural Vaginal lubrication products are equally essential.[20,21] protective reflex to pain. Among the frequent organic causes are hymenal abnormalities, genital herpes, obstetric trauma Managing sexual desire disorders and . Most commonly, however, no organic Historically, attempts to treat hypoactive sexual desire causes can be implicated. Vaginismus is hypothesized disorders typically followed the prototype to be the body’s expression of the psychological fear of developed in 1970s. However, recently researches penetration, hence shares features of a psychosomatic and practitioners have begun to explore concomitant disorder, phobia, and conversion disorder. Analytically psychotherapies.[22]

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• Group therapy in conjunction with orgasm consistency Management of orgasmic disorders training, which consists of directed masturbation and Treatment commonly includes positive sexual attitudes sensate focus exercises[23] work, self‑pleasuring exercises, fantasy enhancement, • A comprehensive program of multimodal cognitive positive body image work, as well as Kegel (pelvic) muscle behavioral approach which entails sexual intimacy exercises to facilitate easier orgasms. Masturbation by exercises, sensate focus, communication skills training, self‑stimulation of genitalia or with a vibrator can provide a emotional skills training, reinforcement training, woman with an opportunity to experience orgasm. Sensate cognitive restructuring, training and exercises to reduce anxiety are also useful.[28] couple sex group therapy[24] • Multistage treatment approach[25] Treatment of dyspareunia • Affectual awareness training: To identify negative Dyspareunia has been a neglected area in sex therapy, emotions through techniques such as list making, probably because of its not so frequent presentation in role‑playing, and imagery clinical practice. Vaginal dilatation is the oldest and most • Insight and understanding: To educate couples about widely used treatment here. A method of the therapy called their feelings using a variety of strategies like gestalt physical therapy, which comprises Kegel exercise along therapy and transactional analysis with other procedures like relaxation, postural education, [29] • Cognitive and systemic therapies are included to and biofeedback has also been found to be useful. provide coping mechanisms as well as to resolve underlying rational problems Treatment of vaginismus • Behavioral therapy is aimed at initially improving Cognition behavior therapy (CBT) has been found to be nonsexual affectionate behavior with an eventual goal most useful and successful in the treatment of vaginismus; of introducing mutually acceptable sexual behavior especially if it is of psychogenic origin. CBT strategies mainly consist of: • If the organic pathology is treatable or controllable, (e.g., by hormone replacement or stopping a particular • Information about the diagnosis of vaginismus including the description of its anatomy, possible etiology, and drugs which may cause disorders of desire) this should prognosis be done • Sensate focus ‑ to reduce performance anxiety • Testosterone administration is the principle • Vaginal dilation in a graded manner either with the pharmacological treatment for hypoactive sexual desire help of instruments or use of self‑finger approach for disorder in women. However, the risks and benefits of desensitization its administration are yet to be clarified[26] • Cognitive restructuring ‑ to change the dysfunctional • For disorders of sexual aversion, interventions are on thoughts interfering with sexual functioning.[28] the some lines. CONCLUSION Management of disorder of arousal The clinician should be able to delineate the disorders Today we are into the 21st century. Yet when it comes to the of desire or orgasm which usually manifest as arousal female sexuality, many cultures, and religions, especially in disorders. If the woman would have experienced arousal the developing world impose social restrictions. This ongoing by a particular way of stimulation, the partner should be restriction for ages has evolved a strong negativity among sensitized about it. Encouraging adequate or use women regarding sex. So even today the first healing step is of vibrators to increase stimulation may be useful. Fantasy to create a factual awareness among them, as well as in the training, use of erotic materials, attention‑focusing skills, entire society as to what is sexuality. This would probably Kegel exercises (voluntary relaxation and contraction of answer most of the problems related to female sexuality. pubococcygeus muscles) and enhancing the partner’s There are several sexual disorders specific to females based sexual skills are the other useful female arousal facilitation on a sexual response cycle. The prevalence of these disorders techniques. Anxiety may inhibit arousal and strategies to is not clear, mainly due to stigma associated with sex. alleviate anxiety by employing distraction techniques are However, there are several therapeutic approaches that can helpful.[16] be utilized in effective management of these disorders.

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