"I've lost my interest in sex." As psychiatrists, we hear this concern (if we ask) from women in a variety of situations: those who are depressed, postpartum, menopausal, traumatized, and those who have been treated with psychotropic medications. Thankfully, we have many interventions, both behavioral and pharmacological, to use in addressing sexual issues.
Patients are often reticent about bringing up sexual problems or asking for solutions to sexual issues and will wait for the psychiatrist to initiate the discussion. However, psychiatrists themselves may be hesitant to start the discussion. A host of countertransference and practical issues, including time to address concerns, insufficient training, and fear of being accused of boundary violation, consciously and unconsciously, inhibit psychiatrists from asking sex-related questions.
However, psychiatrists must make the effort to start a dialogue, because they are likely in the best position to treat women with sexual difficulties. By talking with the patient and understanding her medical and sexual history, the psychiatrist will be able to assess sexual problems and provide treatment recommendations.
This article briefly reviews some of the most commonly encountered reasons for female sexual dysfunction (SD) and discusses some medical treatment strategies.
A woman's sexual health can be affected by her upbringing. The relationship she had with her parents—whether warm and affectionate or cold and remote—can play a crucial role. Her role models and the type and extent of experimentation and stimulation (eg, too much, too early) impact her sexual health. Her social, cultural, and religious values also may impact her sexuality. Her body image, whether she focuses on positive (or, too commonly, negative) aspects; medical or surgical history; medications; pain; and past relationships may affect her sexual health.
If SD is caused by underlying psychodynamic issues, such as sexual trauma, dislike of her partner, or lack of sexual attraction with a particular partner, medication will not solve the problem. Although psychotherapeutic approaches will not be discussed in this article, a strong therapeutic relationship and willingness to discuss any underlying psychodynamic issues are important aspects of helping women address disorders of desire and responsiveness.
Vulnerable times for sexual function and engagement
Psychiatrists should be aware that there are periods in a woman's life when she may be particularly susceptible to lowered sexual interest and response (eg, premenstrual, pregnancy, postpartum, menopause).
Premenstrual exacerbation of depression and anxiety, premenstrual tension, and premenstrual dysphoric disorder are associated with decreasing estrogen levels before menstruation. As estrogen decreases, so does serotonin, which puts the woman at higher risk for SD.1
One of the concerns most expectant parents have is how pregnancy will affect the most intimate aspects of their relationship. As a woman's body changes, sexual feelings and perceptions may also change. Having a baby can be an affirmation of a woman's sexuality. Both men and women enjoy the increased size and fullness of her breasts. By the last trimester, however, the body changes are dramatic and sometimes unwieldy. Lower back or pelvic ligament pain, pressure on the bladder, and fatigue are not very conducive to satisfactory sexual encounters. Comfortable positions may be difficult to find, and with the baby kicking, it is sometimes difficult for partners to feel alone and focus on intimacy. Some suggestions are:
• Avoid anything that is emotionally or physically uncomfortable.
• If mutually enjoyable, massage each other nongenitally with cocoa butter or oil.
• If nongenital touching leads to intercourse, a side-lying position with the man behind pregnant woman, may be comfortable.
For some women, the postpartum period is a difficult time for maintaining sexual relations because of emotional and physiological factors. A mother often will sexually disengage and turn her attention towards the baby. Furthermore, she often has less time, energy, and privacy for herself or her partner. She is usually "touched out" by the end of the day from all the touching with her baby, and she is physically tired. Prolactin levels are higher in nursing mothers, which may inhibit sexual desire. In addition, there is a drop in estrogen levels from the removal of the placenta, which may lessen the ability to be aroused, and healing episiotomy or cesarean delivery wounds may further inhibit sexual activity.
Menopause is the most difficult time of all to maintain sexual intimacy. There is often loss of an intimate partner due to divorce, illness (according to the Massachusetts Aging Study, 52% of men aged 40 years or more have some degree of erectile dysfunction2), or death of the partner. Physically, estrogen and testosterone levels decrease. Joffe,3 Soares,4 and Pearlstein5 have written about higher risk of depression in menopause, especially if there is a history of depression or if hot flashes persist. Depression leads to anhedonia and anergy, which often translate to diminished sexual interest.
Nonlinear sexual response
We've come a long way since Masters and Johnson in understanding a woman's sexual response cycle. Basson,6 Grazziotin,7 Whipple,8 and others have described that for most women, unlike most men, emotional intimacy is a prerequisite to sexual intimacy. Arousal, greater sexual desire, and emotional and physical satisfaction follow in a circular manner.
Besides emotional factors, physiology, psychotropic medications, and hormones may be involved in a woman's sexual response. Neurotransmitters have been studied, particularly dopamine and serotonin. Prolactin, and nitric oxide also influence sexual response.9 In addition to estrogen and testosterone, the effects of oxytocin and melanocyte-stimulating hormone are currently being investigated.10
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