Sexuality through the life-cycle - Orgasmic disorders

1. A variety of factors – inability to relax,
inconvenient timing of sexual activity, lack of
communication, limited sexual knowledge,
fatigue, body image distortions, absence
of sufficient foreplay, and lack of sexual
interest – have been associated with orgasmic
problems in women.
2. At the same time, many women have been
socialized to view sex as a duty, not as an act to be
enjoyed or considered pleasurable. Sexual scripts,
such as the good girl image, may contribute to
orgasmic difficulties.
3. Primary care physicians can assist their patients
by education and referral to appropriate
therapists.
4. Treatment usually includes assessment of body
image and introduction to masturbation. Self-help
books can be adjunct to treatment.

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Sexuality through the life-cycle - Sexual arousal disorders

1. Sexual arousal involves both physiological and
psychological factors.
2. Physiologically, vaginal lubrication occurs during
the excitement phase of the sexual response cycle.
3. Prevalence of this disorder varies by population
studied. Women with cancer have high rates of
arousal disorders, as do those who have a history
of sexual abuse or trauma.
4. Treatment approaches frequently include sensate
focus techniques and training in masturbation.
Other therapists recommend assertiveness
training for women who have been non-initiators
of sexual intimacy.

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Sexuality through the life-cycle - Common sexual dysfunctions Decreased sexual desire

1. According to the DSM-IV, 4th edition, hypoactive
sexual desire (HSD) disorders are characterized by persistent or recurrent absence of sexual
fantasies and desires, not associated with other
medical conditions.
2. This common disorder has a prevalence from
1–30% in women. The etiology is multifactorial,
including physical, psychological and social
causes.
3. A variety of treatments have been recommended
for individuals with HSD. These range from
the more insight-oriented approaches to
cognitive-behavioral ones. Most treatments use
sensate focus techniques. These exercises are
designed to increase sexual communication
between partners and to identify impediments to
sexual arousal and enjoyment.

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Sexuality through the life-cycle - Sexual relationships in long-term facilities

Older women residing in assisted living and
extended care facilities often lose their privacy and
suffer a loss of sexual freedom.
2. Sexual intimacy between married or unmarried
and consenting individuals may present
difficulties for facility staff who are concerned
about safety and legal issues. Family members
may also object to the expression of intimacy
between their aging relative and others in the
facility. The family physician can serve an
important role in addressing the concerns of the
family and the older patient.
3. Practitioners can advocate for their patients in
allowing privacy and conjugal visits, or
permission medically stable individuals to
participate in home visits.

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Sexuality through the life-cycle - The elderly Dementia

1. Dementia presents special difficulties for the older
woman and her partner. Common sexual
consequences of dementia include anhedonia,
depression, impotence, incontinence, and
anorgasmia. During the early and middle stages of
disease, however, sexual intimacy remains a viable
option for couples.
2. Some individuals feel better withdrawing from
their partners prematurely because of guilty
feeling about continuing sex in light of the
cognitive impairment. Role changes, distaste for
sexual intimacy because of poor hygiene, or as a
means of coping with the increasing demands of
caregiving are also reasons for stopping sexual
relationships.
3. Desexualization of the demented spouse often
helps the caregiver meet the personal and intimate
demands of caregiving.
4. As individuals develop dementia, touch may no
longer be perceived as pleasurable or soothing.
Physical touch and intimacy may result in
increasing agitation or anxiety.
5. Individuals who have a minimental status
examination score of less than 15 are unlikely to
understand the nature of sexual activity and,
therefore, may be unable to give consent.
6. While overt and inappropriate sexual behavior of
demented patients is not common, caregivers may
be at risk for sexual abuse by their demented
spouses, or vice versa. Family physicians need to
explore this issue gently with the caregiver. Such
circumstances may result in the filing of elder
abuse charges.

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Sexuality - Interest

1. Most studies of middle-aged and older women
demonstrate that interest in sexual intimacy
continues into advanced old age. Prevalence varies
by area, country and population surveyed. From
30% of community dwelling US women older
than age 65 to 95% of community dwelling Danish
women the same age have stated that they have
regular intercourse. According to a length study
conducted by the Consumers’ Union, most
women over age 65 engaged in sexual activity at
least once a week.15 Older women report less
sexual activity than men the same age, correlating
with the availability of a socially sanctioned
partner.16
2. The most important correlation between
continued sexual activity in older women is
availability of a healthy partner. Women often
marry older men, who may develop chronic
illnesses, disability, or die before women. Women
who are widowed, divorced or single are less likely
to continue their sexual activity. Various studies have noted a sharp decrease in sexual interest and
activity among women in their late 60s. For many
women, this may be a source of considerable
frustration. Societal expectations and
misconceptions about the physiological effects of
aging on sexuality contribute to this distress.
Aging signs may result in feelings of decreased
sexual attractiveness.
3. For women without a partner, masturbation may
be an option.
4. However, sensitive inquiry about sexual beliefs,
practices, and concerns will be needed before any
recommendations can be made. Providing
education will enable the woman to make
informed decisions.
5. Many social issues may contribute to a lack of
sexual interest or responsiveness, such as
monotony, preoccupation with career and
finances, physical and mental fatigue,
overindulgence in food and drink, and fear of
failure in sexual performances. Excessive life
stressors, socioeconomic issues, patterns of
disinterest in sexual activity as a young adult also
may decrease middle age sexual intimacy.
6. Arthritis and stiffness can make sex difficult.
Asking the partners to come into the office in
comfortable clothes or sweatsuits is a method of
helping them to try different and more
comfortable positions. Taking an acetaminophen
or NSAID before sex may help stiffness.
7. Refraining from alcohol and heavy meals before
sex is helpful.
8. Reviewing drugs used by either partner may allow
the substitution of one that affects sexual
functioning.
9. Lubrication with exogenous creams may help.

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Aging Midlife

1. Women in midlife, age 40 to 65, can use guidance
regarding the impact of chronic illness, hormonal
changes, and medications on sexual functioning.
Women at this age may be experiencing changes
in family structure and the psychosocial
adjustments these demand. The variety of needs is
amazing. Midlife women may be trying to become
pregnant, be menopausal, be widowed, or caring
for young children or grandchildren.
2. Women may express fears about the effect of time
and hormones on their self-image and desirability.
Information about physiological changes that do
occur and exploration of the woman’s beliefs
about sexuality at this age are essential.
3. Most physiological changes associated with aging
affect the sexual response cycle of the older woman.
Estrogen-deficient vaginitis, insertional dyspareunia,
and reduced lubrication are common complaints
associated with menopause. The use of artificial
lubricants can reduce the symptoms and pain.
4. As women age, the excitement phase of the sexual
cycle can occur more slowly. For many
menopausal women, it may take 5 minutes rather
than 10 to 15 seconds in the excitement phase to
achieve lubrication. More and more direct genital
stimulation may be needed during the arousal
or excitement phase.
5. The plateau phase may also become longer. The
orgasmic phase may become shorter and orgasms
may be painful. Contraction may be spasmodic
rather than rhythmic. Nonetheless, women retain
the potential to return to the excitement phase and
to experience multiple orgasms.

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Facilitation

Facilitation
1. Physicians can best assist their patient to maintain
healthy sexual functioning by taking a sexual
history and exploring a patient’s sexual concerns,
fears, and expectations.
2. Physicians may suggest positional changes,
environmental changes (placement of pillows, use
of hot tubs or waterbeds) and alternative activities
to penetrational intercourse such as hugging,
caressing, cuddling, and mutual masturbation.
3. Both the patient and her partner must be willing
to consider suggestions regarding alternative
positions and practices.
4. Good communication between the partners is
essential. The partners should be encouraged to
discuss their concerns and reservations.
5. Referrals to certified sex therapists and to chronic
disease support groups or on-line support groups
or chat rooms may be helpful.

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Chronic illness

Many individuals begin to experience the onset of
chronic illnesses during the fifth and sixth decades of
life. Diseases such as cardiac and circulatory problems,
diabetes, arthritis, osteoporosis, chronic obstructive
pulmonary disease, hypertension, neurological disorders,
and depression, among others, have a profound
impact on sexual functioning (Table 6.1).
1. Heart disease
The effects of cardiac illness on men have been
well researched. Few studies have addressed the
specific issues of women following a cardiac event
and their unique counseling needs. Women may
receive less counseling, including referral to
cardiac rehabilitation, than men do. Resumption
of sexual activity following a cardiac event may
elicit fear and anxiety. Women may choose to
avoid returning to their previous level of sexual
activity fearing a reinfarct or death. Symptoms
such as chest discomfort, shortness of breath, and
excessive sweating are deterrents to the
resumption of sexual activity in women.
a. Women can resume sex when climbing two
flights of stairs no longer causes anxiety or
chest pain. Education regarding the impact of
the sexual response cycle on cardiac function
is essential.
b. Explaining the number of metabolic equivalents
(METs) used during sex as compared with
common daily activities can help to reduce
anxiety. Patients must understand the need to
avoid heavy eating and drinking prior to sex to
reduce the potential stress on the heart. Patients
should be advised to discontinue sexual activity
if they become short of breath, experience chest
pain, or become too anxious, and to notify their
physician of their symptoms as soon as possible.
Reassurance and education can help to reduce
anxiety among women with cardiac disease.
2. Hypertension
Hypertension medications may affect the sexual
response cycle negatively (Table 6.2).
3. Diabetes
a. While impaired or decreased sexual functioning
is a complication of diabetes in men, the sexual
impact of diabetes on women is not well defined.
Early studies found that women with diabetes
often suffer significant orgasmic difficulty.10
Few more recent studies have investigated this
information. Results of subsequent research
have been inconclusive or contradictory.
b. Sexual dysfunction has been reported in 42%
of women with type 2 diabetes and in 18–27%
of women with type 1 diabetes.11 Women with more diabetic complications are more likely to
have sexual dysfunction.
c. Neuropathies alone have not been found to
contribute to sexual dysfunction in women
diabetics.
d. Many psychosocial problems that are
associated with diabetes can impact sexual
functioning.
e. Renal failure has been linked to several types
of sexual dysfunction in women. Anhedonia,
decreased vaginal lubrication, and anorgasmia
have been associated with women on
dialysis.12 Women with chronic renal failure
often have a hypoactive sexual desire disorder.
The source of this dysfunction may be
multifactorial, including chronic disease,
medications, and psychosocial issues.
4. Spinal-cord injuries
a. Spinal-cord injuries result in multiple types
of losses for the patient and her partner.
Self-esteem, perceptions of body image, social
roles, and feelings of dependence are all
affected. The degree of impairment dictates
the effect on sexual function. For example,
muscle spasticity may make penetration
difficult.
b. Therefore, an assessment of the patient’s
sensory capacity and mobility are important
in offering anticipatory guidance.
Recommendations may include encouraging
the patient to improve self-esteem and
self-image and to make advanced preparations
for sexual intimacy. The woman should tend
to bowel and bladder care before initiating sex
to avoid any accidents that would have
psychological consequences.
c. The timing of the sexual activity may be
important to avoid fatigue or spastic
responses.13 Sensate focus exercises may be
helpful to the patient and her partner.
Experimenting with different positions may
also be helpful.
5. Decreased mobility problems
a. Diseases that result in decreased mobility or
flexibility, such as multiple sclerosis, arthritis,
or connective tissue disorders, often lead to
sexual inactivity. Joint stiffness, decreased
flexibility, muscle spasms and increased tone,
pain and other symptoms affect a woman’s
ability to engage in sexual intimacy.
b. Multiple sclerosis has been associated with
decreased libido, delayed and decreased
lubrication, decreased orgasmic capacity, and
anorgasmia in many women. Fatigue,
spasticity, contractures, loss of manual
dexterity and incontinence may contribute to
sexual problems.14
c. The use of assistive devices, muscle relaxants,
and vibrators may help to alleviate the distress
and disability caused by contractures, muscle
weakness, and spasms.
d. Bowel and bladder training programs may be
recommended when incontinence is a problem.
e. For some patients, the use of corticosteroids
has produced improvement in sexual
functioning.
f. For women with arthritis, timing of sexual
activity to coincide with optimal physical mobility and pain relief may help. Specific
suggestions, such as positional changes
(side-by-side, woman on top, use of chairs, or
use of hot tubs) can aid the arthritic woman
maintain her sexual activity.
6. Scleroderma
a. Scleroderma can have negative effects on
sexual functioning. Women with scleroderma
and Sjogren’s syndrome have high rates of
sexual dysfunction.
b. Common problems include vaginal dryness,
dyspareunia, and decreased orgasmia. Other
changes such as joint pain, contractures,
and muscle weakness may interfere with a
woman’s sexuality.

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Disability

1. Studies have addressed the sexual needs of
spinal-cord injuries, little research has assessed
the sexual health needs of persons born with
physical and intellectual disabilities. Societal
attitudes toward sexual expression among people
with intellectual disabilities have not been
favorable. Families, fearing exploitation and
abuse, may shield their impaired children from
obtaining any sexual knowledge or keep them
from participating in appropriate sex education
programs.
2. Clearly, an assessment of the intellectual
capabilities of the individual is needed to
determine the person’s ability to consent to sexual
overtures. Similar problems may arise among
individuals with congenital physical disabilities.
In both cases, the physician must address the
concerns of the parents, provide education,
anticipatory guidance to the child or young adult,
and encourage responsible sexual behavior.
3. Appropriate confidentiality is important also.
Treading the difficult line between giving the
non-independent woman appropriate confidential
information and consultation and helping her
work within her family system may be
challenging. Understanding guardianship and
family relations will help.

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Breast cancer

1. A diagnosis of breast cancer brings numerous
psychological, emotional, relational, and sexual
ramifications for the woman, her partner and her
family. Cultural and personal views of the breast
as a symbol of femininity and attractiveness and
conversely as a source of life and nutrition,
play a role in how the woman and her partner
respond to the diagnosis.
2. Assessing the woman’s self concept, her body
image, expectations of fertility, and her sense of
femininity when discussing treatment options are
important. Women also fear the response of their
partners to potentially disfiguring surgeries.
Involving the partner in the treatment is
important. The adjustment process can be
improved by encouraging the partner to view
the surgical site early, discussing issues of
revulsion or avoidance (of the breast and the
partner) and addressing concerns about sexual
activity causing pain.
3. Sexual dysfunction occurs frequently among
breast cancer patients. However, the source of the
dysfunction has not been linked solely to the
diagnosis and treatment of breast cancer. The
sequelae of treatments, premature menopause,
depression, the impact of medication and
chemotherapy and preexisting sexual problems
may all contribute to dysfunction in breast
cancer patients.
4. A relationship exists between menstrual status and
sexual functioning in the woman who has breast
cancer. Chemotherapy induced menopause causes
vaginal dryness, and other hormonal changes
exacerbate sexual problems.8 Women who have
had chemotherapy and younger women who have
had premature menopause are more likely to
have problems with sexual function.
5. Women who have undergone reconstructive
surgery following mastectomy often complain of
loss of sensation and pain in the breast.9 Direct
stimulation of the breast is no longer as
pleasurable and may affect the quality of the
sexual interactions between the woman and her
partner. Women who have had total mastectomies
and reconstructive surgery are more likely to
experience significant sexual problems than those
who have undergone lumpectomies.

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Gynecological cancers

1. While the sexual consequences of gynecological
cancers vary according to the treatment needed,
dyspareunia is more common among women who
have radiation than surgical interventions.6
2. Vaginal dilators may be used for women
experiencing dyspareunia following radiation
treatment or surgical interventions. Use of the
dilator two or three times a week may reduce
anxiety about pain and enable the woman to
resume sexual activity more comfortably and
experience penetration without pain.7
3. Different positions may be used so that the couple
can find the better ones for themselves.

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Medical problems and sexuality Cancer

1. The diagnosis of cancer has a profound effect
upon the woman, her partner and her family.
Loss, fear, anxiety, anger, and depression are
common responses to the diagnosis. Loss may be
related to expectations of fertility, of experiences
as becoming less whole, less feminine, and more
vulnerable to the exigencies of life. Fears
associated with the treatment, pain, loss of
control, change in perceived desirability, and
death are frequent responses. Those cancers that
affect sexual organs are traumatic for the patient
and her partner. Since cancer provokes crises in a
woman’s life, exploring the nature and quality of
significant relationships is essential.
2. Partners of cancer patients also experience
reactions to the illness that may include fear
of loss and hurting the patient, irrational fears of
contamination or contracting the disease, or a
decreased sense of her desirability.
Communication between partners is crucial.The physician can facilitate communication,
provide information about the treatment and
outcomes, and explore the patient’s understanding
of what cancer means to them.
3. Pain, or the anticipation of experiencing pain,
may have a negative effect on the woman’s interest
in sexual intimacy. Premature resumption of
sexual activity before the woman is ready
physically, psychologically, and emotionally may
occur in order to relieve anxiety about her
partner’s perceived sexual needs and a need to
affirm her desirability as a woman.

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Postpartum

1. Following delivery, women gradually return to
former levels of sexual desire and interest,
although physiological factors such as vaginal
bleeding or dyspareunia may contribute to
decreased sexual interest during the postpartum
period.
2. Fatigue, lack of sleep, psychological concerns, role
overloads, and stress may also have a negative
impact upon the resumption of sexual activity in
the new mother.
3. The husband’s fear of injuring his partner may
impact the couple’s resumption of sexual activity.
The family physician can offer guidance as to ways
to cope with the numerous adjustments a couple
experience when they become parents.

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Pregnancy

1. Pregnancy creates many physical and
psychological changes in the woman’s and
couple’s relationship. The woman may have body
image changes, physical discomfort, and fears for
the safety of the pregnancy.
2. Sexual desire decreases during the first trimester,
increases during the second trimester, and
decreases again in the final trimester. Some studies
have linked advanced pregnancy to decreased
sexual desire and satisfaction.
3. For couples who want to continue sexual intimacy
throughout pregnancy, the physician may
recommend positional changes that are more
comfortable for the woman and can accommodate
the enlarging fetus. Use of pillows under the
woman’s head and back or reclining to decrease
the shortness of breath that comes with lying flat
will help the sexual relationship. Alternative
positions, such as side to side or the woman on
top, may be preferable. Sex without penetration
may be more comfortable.
4. Unless the woman is at high risk for or develops
premature labor, there is no medical reason,
except discomfort, to stop having sexual relations
during pregnancy.

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Sexuality and adolescence Initiation of sexual intimacy

1. Adolescence is a time of great physiological,
emotional and psychological change. It is a time of
exploration, emancipation, and a search for
self-identity. Sexual intimacy is one aspect of
accomplishing this transition.
2. Many women, especially teenagers, define
themselves by their relationships to others. Having
sexual relations may cement these relationships.
3. In the USA, more than three-quarters of boys
and two-thirds of girls have had sexual intercourse
by their senior year of high school. Nearly half
of all 15–19 year olds have had sex at least once.1
By age 19, 70% of teenagers have had sex.
4. US teenagers are waiting longer on average to
have sex than they did previously. Three-quarters
of girls state that they started sex in the context of
a relationship with a “steady” boyfriend.1
5. The onset of sexual intimacy varies among
adolescents. Peer pressure, feelings of love and
attraction, curiosity, and wanting to be “grown
up,” are all among the reasons cited by teenagers
for initiating sexual experimentation.2 Family
factors such as divorce or single-parent homes and
abuse also influence the initiation of sexual
activity.3 Environmental and behavioral factors
such as drug and alcohol use, delinquency, poor
self-esteem, and decline in school grades have also
been linked to premature sexual experimentation
among adolescents.4
6. Physicians should be sensitive to the issue of
emerging and possible confusing sexuality in gay
and lesbian adolescents. As many as 10% of all
adolescents have concerns about sexual identity
issues.5
7. In some teenage girls, sexuality is related to poor
self-esteem. Reminding them that they have a
right to refuse, to enjoy, and to request is
important.
STDs and pregnancy
1. Relatively few adolescents admit to planning
sexual encounters. However, more sexually
experienced teenagers are using contraceptives
and most of these are using condoms, especially at
first intercourse.
2. Lack of comfort with their bodies, poor
self-image, and embarrassment may interfere with
a teen’s willingness to consider contraception.
3. Teens may be reluctant to discuss these issues with
their physicians. Establishment and assurances of
confidentiality and its limits will help create an
atmosphere of trust.
4. Adolescents, especially those who begin their
sexual activity at a younger age, are more likely to
have multiple sexual partners over time,
exhibiting a type of serial monogamy, which also
places them at a higher risk for STDs or
pregnancy.
5. Adolescents need reassurance of their normality
and the normality of their concerns, reaffirmation
of the need for contraception and prevention of
STDs, and confirmation for their right to
enjoyment and lack of pain and ability to refuse.
6. Exploring the teen’s understanding of sexuality,
including dreams, fantasies, homosexual thought,
masturbation, hormonal and body changes,
reproduction, contraception and prevention of
STDs is important.

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Sexuality through the life-cycle

Introduction
1. Sexuality is a significant aspect of all individuals’
lives. Physicians and health care professionals who
provide continuing care to individuals and
families have an opportunity and responsibility to
provide appropriate counseling, anticipatory
guidance and education. Many women consider
their physicians as experts in the area of human
sexuality.
2. Sexual issues are frequently ignored in practice.
Sexuality provides individuals a way to express
their feelings, demonstrate caring and
communicate and develop intimacy with another
person. Sexual expression becomes a source of
pleasure and fulfillment. For couples, it is a
powerful form of conversation.
3. Many medical, psychological, and developmental
concerns impact sexual behavior. These include
psychosocial development, contraception, STDs,
and the impact of various illnesses such as
depression, substance abuse, physical disability,
heart disease and diabetes on sexuality. If not
discussed, this may be ignored.
4. When talking with the woman about sexual
histories and concerns, consider the age, culture
and religious background of the individual. For
some this may be embarrassing or inappropriate,
whereas many women will seize the opportunity
with welcome relief.

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