Lesbians and Female Sexual Dysfunction— What Physicians Can Learn from Lesbian Sex

Lesbians and female sexual dysfunction— What physicians can learn from lesbian sex

Michele Tartaglia, DO Katie Riley, CNM, MSN

The objective of this article is to provide a thorough overview of female sexual dysfunc - tion (FSD) in the lesbian patient and to illustrate valuable insights that can be gained from examining certain aspects of lesbian sexuality that may be beneficial to any woman. In several studies, for example, les - bians reported greater sexual satisfaction than did heterosexual women in several studies. In a 2006 survey, Meana et al 1 found that 48% of heterosexual women reported diffi - culty getting sexually excited compared with only 15% of lesbians. Coleman et al 2 report - ed that 46% of heterosexual women reported difficulty reaching orgasm and 15% report - ed inability to reach orgasm, compared with 28% and 7% of lesbians, respectively.

Factors influencing sexual satisfaction This satisfaction gap is likely the result of specific sexual behaviors rather than sexu - al orientation. A longer time spent engaged in sexual activities increases the likelihood of orgasm for women, irrespective of their partner’s gender. Women partnered with women are likely to spend more time in sexual activities than are women partnered with men. 3 Nichols 3 determined those sexual acts that are most likely to result in orgasm in women. These behaviors include sexual difficulties. The following tools and Ⅲ Increased kissing and kissing, nongenital touching, receptive oral techniques represent advice that clinicians nongenital touching sex, and digital-vaginal stimulation. Lesbians can offer to their patients with FSD. As a relationship matures, couples may are more likely to engage in these behaviors spend less time on these two behaviors, than are their heterosexual counterparts. 2 Ⅲ Increased time spent which are likely to increase intimacy and Of course, nothing about these behav - on each sexual encounter set the stage for female orgasm. Physicians iors is exclusively or expressly lesbian, and Providing advice on this matter may include can remind patients about the importance knowledge of these sexual acts may be of discussing slowing the pace of sexual rela - of these behaviors. great use for physicians in guiding any tions with a partner. This discussion should woman who presents with FSD. Examining be approached with great care. The patient Ⅲ Nonpenile stimulation the type of stimulation that women are re - should be advised that achieving this goal Many women require clitoral stimulation, ceiving during sexual play is essential. 4 We may involve dedicating or scheduling time either alone or in conjunction with pene - believe that lesbian sexuality can provide a for sexual activities and making sure that tration, to experience orgasm. The clinician guideline for counseling all women—both these activities take place at a time when both may explore the couple’s willingness to prac - lesbian and heterosexual—who experience partners are feeling relaxed and receptive. tice oral sex and digital- vaginal stimulation.

19 Ⅲ Self-pleasure broadening patients’ perceptions of what con - is the most important part of sexual contact. 3 Studies suggest that women who mastur - stitutes sexual activity. Many heterosexual The norm definition 5 is especially problem - bate are more likely than other women to couples define sex as exclusively penile- atic for women who do not experience orgasm achieve orgasm during sexual contact with vaginal intercourse. This definition is consid - solely from penetration. partners. 4 Physicians can assist women by ered the norm, 5 despite evidence that it is not The clinician may help his or her pa - gently explaining and validating the role of the most effective way for many women to tient by explaining and normalizing typical sexual self-exploration in promoting orgasm. achieve orgasm. 6 Behaviors that are most like - female sexual function. For example, a Beyond recommending specific sexual ly to result in female orgasm are often labeled woman may believe that something is techniques, the clinician may be helpful in foreplay, a term that suggests that intercourse wrong with her because she is not able to have an orgasm with vaginal penetration alone. Her partner may reinforce this view. This shared misperception may lead to sub - stantial distress in the relationship. By reassuring her that many healthy women require clitoral stimulation in order to ex - perience orgasm, the provider can validate the patient’s personal sexual response and direct her to techniques that may result in greater sexual pleasure. Although these recommended tech - niques will not banish all occurrences of female orgasmic disorder, they represent sim - ple interventions that may shift a couple’s thinking about sexual satisfaction and how to achieve it. By broadening the patient’s un - derstanding of sexuality, normalizing her sexual response where appropriate, and dis - cussing specific sexual techniques, the physician may be able to help the patient achieve a greater level of sexual satisfaction.

Sexual dysfunction in the lesbian population Although lesbians bring unique relation - ship issues to the concept of FSD, there is a tremendous amount of overlap between the issues underlying FSD in the heterosexual woman and those underlying FSD in the homosexual woman. The most common type of dysfunction in both populations is hypoactive sexual desire disorder (HSDD), 7,8 and the workup and treatment plans for this dysfunction are identical for all women. There is also a great deal of overlap in the underlying causes of HSDD in both popu - lations, including the presence of young children in the household, hectic work schedules, depression, and economic stres - sors. Because these issues are discussed in depth in other articles in this series of AOA’s Women and Wellness, the present article focuses on some of the unique issues found in lesbian relationships.

20 Internalized homophobia Although lesbians report greater satisfac - tion with sex, many studies have shown that lesbian, gay, and bisexual people report a higher incidence of sexual dysfunction than do their straight counterparts. 9-11 One the - ory to explain this high incidence is the so-called minority stress model, which pos - tulates that as a result of their minority status, homosexual people experience a “unique chronic stress.” 12 Internalized ho - mophobia, the experience of homophobia in one’s daily life, and the stress of conceal - ing one’s sexuality or “being in the closet” can all contribute not only to dysfunction in one’s sexual life, but also to depression and anxiety disorders that physicians need to be sensitive to, as well.

Connectedness: The ’U-Haul’ phenomenon There is an old joke among lesbian women: “What does a lesbian bring on her second date? A U-Haul truck.” Although the joke relies on comic exaggeration, it does capture the rapid, intense bonding experienced in occur in all lesbian relationships. The work being the role of the more “masculine” many lesbian relationships. of Blumstein and Schwartz 15 suggested in partner, and therefore many lesbians avoid This rapid, intense attachment may play the 1980s that lesbian couples have less sex - initiation for fear of that label. 20 Another a role in the causes of sexual dysfunction ual contact than other couples. However, generalization is that heterosexual men are within lesbian couples. Heiman and the validity of that assertion has since been used to being rejected when making sexual Meston 13 reported that the incidence of FSD challenged by many authors who have re - advances and, thus, tend not to internalize increases proportionally with the number of ported evidence that there is, in fact, no the rejection, whereas lesbians, when years in any female relationship. One expla - difference in frequency of sexual encoun - rejected, believe it is a rejection of them as nation for this increase could be habituation. ters within heterosexual compared to within an individual. According to this idea, these As a couple becomes more comfortable with lesbian couples. 2,16-19 feelings of rejection cause the frequency of one another and they begin to “settle down,” As previously noted, the quality of sex - sexual activities in the lesbian relationship the initial sexual intensity tends to wane. In ual encounters tends to be rated as more to decline. 20 a lesbian couple that settles down by the sec - satisfying by lesbian women than by het - Most of these ideas were proposed ond date, as the joke goes, this decrease in erosexual women. Thus, lesbian bed death more than 20 years ago and are now quite sexual activity may occur much earlier than probably should be considered a sexual dys - outdated when one considers the current in a heterosexual relationship. function issue only in a couple with social climate for homosexual women. discordant views on the appropriate fre - Nevertheless, such beliefs remain alive Lesbian bed death quency of sex in a relationship. To assume and well in the minds of many practition - The belief that lesbian couples have less that a lesbian couple with relatively few ers. These stereotypes and inaccurate frequent sexual encounters has become sexual encounters is dysfunctional is to assumptions can lead to alienation of the colloquialized as lesbian bed death. Iasenza 14 stereotype and misdiagnose that couple. lesbian patient and improper diagnoses has called lesbian bed death the “grand and treatment plans. mommy of all lesbian sex myths” and has Stereotypes The practitioner must remain open- defined it as a notorious dropoff in sexual A great number of stereotypes and gener - minded about the many types of lesbian activity that occurs about two years into alizations about lesbian women have relationships and sexual practices (much as long-term lesbian relationships. permeated the literature on sexual dysfunc - he or she remains open-minded about vari - This decrease in sexual frequency is not tion. One such antiquated concept ous types of heterosexual relationships). distressing to all lesbian couples, nor does it describes the initiation of sexual contact as Such an open attitude has been called

21 “cultural humility.” 21 A thorough sexual his - practice. Even when we want to assist our than focusing on the clinician as cultural tory and an openness to learn more about patients with issues of sexual function, we expert, cultural humility emphasizes hu - your lesbian patients and their unique issues are often at a loss for helpful, evidence- mility, flexibility, and respect for the through the practice of cultural humility will based practices with which to guide them. experience of the individual. As described provide the practitioner with most of the All of these factors may lead us to avoid by Tervalon and Murray-Garcia, 21 cultural - tools necessary to serve this population. addressing issues of sexuality in the office ly humble providers “are ideally flexible setting, except in terms of pregnancy and and humble enough to let go of the false Cultural humility prevention of and treatment for sexually sense of security that stereotyping brings. As physicians, we are expected to be com - transmitted infections. 22 They are flexible and humble enough to as - fortable addressing sexuality—though, like These difficulties become all the more sess anew the cultural dimensions of the most adults in our society, few of us were exaggerated in interactions with lesbian experiences of each patient.” Further more, a raised in a context that encouraged frank patients. Physicians’ discomforts in dis - culturally humble provider does not rely and open discussion of this issue. Most clin - cussing homosexuality, misconceptions on generic knowledge of an entire group ical education programs offer only cursory about the nature of homosexuality and as - to substitute for an understanding of the training in sexuality, and this limited train - sociated behaviors, and personal beliefs patient as an individual. 21 ing is often fraught with the biases of a about the morality of homosexuality can Achieving this understanding re quires culture that has a difficult time dealing with result in awkward clinical interactions and the provider to be proactive in exploring sex. When it comes to tackling sexuality inappropriate patient care. 23 the unique behaviors and desires of the in - and sexual dysfunction, our embarrassment, How does the health care provider with dividual patient and to create a partnership not to mention the embarrassment of our no experience and limited comfort with with the patient based on that understand - patients, can set the stage for awkward lesbian or bisexual patients go about fos - ing. Although this task may initially be clinical interactions. tering relationships based on cultural daunting, dedication to developing a cul - Physicians may think of healthy sexual humility? Many of us who received train - turally humble practice with homosexual function as a lower priority than routine ing within the past few decades were likely patients will enhance a physician’s entire health maintenance, but for our patients educated in the concept of cultural com - practice. By letting go of assumptions and sexuality may have substantial impact on petence, which emphasizes appropriate stereotypes and learning the skills of quality of life. Sexual function may assume cross-cultural interaction through, in part, cultural humility, we are more likely to a prominent and sometimes distressing role increased knowledge of different cultural discover important information about all in their lives. We may carry the hidden bias practices. Although an understanding of of our patients—heterosexual and homo - that pleasure is an unimportant and even sexual practices and attitudes among vari - sexual—which will improve our ability to selfish goal for our patients. We may also ous groups is crucial for the clinician, and provide the highest quality care. think of our patients’ sexual function as cultural competence represents a valuable “private,” an attitude that would be negli - step toward greater inclusiveness and sen - Cultural humility gent if applied to other areas of our sitivity, this notion of competence is static. in clinical practice It implies the possibility of becoming an Because homophobia is alive and well in expert in other cultures and ignores the many medical offices, the practice of cul - vast and fluid nature of culture itself. tural humility is increasingly important. The concept of cultural competence also A survey of nursing students revealed that ignores the individuality of mem - 8% to 12% of respondents “despised” bers of different cultures. lesbian, gay, and bisexual people, and Substituting the provider’s 40% to 43% believed that patients should assumptions about lesbian keep their sexuality private. 24 Such attitudes and bisexual behaviors for a must be addressed and adjusted if our rigorous and unbiased his tory patients are to receive the quality health of the individual lesbian or bi - care they deserve. sexual patient can lead to Making one’s office more welcoming erroneous conclusions about to lesbian, gay, bisexual, and transgender the patient’s behaviors and (LGBT) patients is much easier than one treatment goals. might imagine. The Gay and Lesbian These problems are Medical Association has a helpful online why cultural humility 21 may resource of guidelines for care of LGBT be a more useful concept than patients. 25 Many of these guidelines are cultural competence. Rather simple to put into practice: 25

22 Waiting Room Patient Interview General considerations Ⅲ Display brochures that address Ⅲ Remain gender-neutral when asking Ⅲ Advertise your medical services in same-sex health concerns. about the patient’s family and relationship. LGBT newspapers, magazines, and Ⅲ Display posters that feature Ⅲ Keep an open mind and remain newsletters to communicate an open same-sex couples. nonjudgmental throughout the visit. and welcoming environment to patients Ⅲ Post a nondiscrimination policy Ⅲ Never make assumptions about your before they even walk through the door. that addresses sexual orientation patient’s history or sexual behaviors and gender identity. from his or her appearance; always ask. Ⅲ Although many LGBT patients will not Ⅲ Remember that many LGBT patients be “out” to their family or to their co- Intake Forms may have had bad experiences with workers; you are asking them to be “out” Ⅲ Use the term Relationship status health care practitioners. Thus, in your office. Doing so will not be easy instead of Marital status. be sensitive to their hesitation for them, and it will require a great deal Ⅲ Include options such as Partnered to disclose certain information. of support and discretion on your part. along with Married and Single. Ⅲ Prepare in advance for interactions Ⅲ Add the Transgender option with LGBT patients. It’s important The purest practice of cultural humility with to the Male and Female boxes. that you find questions and language your LGBT patients requires that you simply Ⅲ Add the option of Both to that you are comfortable with ask for clarification at any time there is a pos - the Men and Women options and that you stay well informed sibility of miscommunication, such as when when asking the patient to describe about the unique issues faced by you don’t understand a particular term used sexual partners. LGBT patients. or a sexual practice they may be engaging in.

23 17. Hedblom JH. Dimensions of lesbian sexual experience. Arch Sex Behav. 1973;2(4):329-341.

18. Jay K, Young A. The Gay Report: Lesbians and Gay Men Speak Out about Sexual Experiences and Lifestyles. New York, NY: Summit Books; 1979.

19. Masters WH, Johnson VE. Homosexuality in Perspective. Boston, MA: Little, Brown and Company; 1979.

20. Macdonald BJ. Issues in therapy with gay and lesbian couples. J Sex Marital Ther. 1998;24(3):165-190.

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