Taking back female sexual function
Harper is an ob-gyn at the Texas A&M College of Medicine, and founder and CEO of Rosy, an application for women to explore evidence-based resources for decreased sexual desire. Laurie Mintz, PhD, is a sex therapist and psychologist specializing in sexual intimacy and relationships.
Female sexual function is often overlooked. According to a 2018 study in Cureus, 44% of women experience some type of sexual problem—whether it be desire, arousal, orgasm, or pain. The important part, said Harper, is to help the patients that experience distress because of these issues, which was about 14%.
Approaching a sexual problem requires ob-gyns to consider multiple biological, psychological, and physical factors. Cultural factors include a lack of sexual education, which results in a false image of female pleasure; shame-based messages from family, schools, or religious views, including purity culture. Many women also experience negative socialization messages, like, “if it’s good enough for him, it’s good enough for me.” Many women also experience internalized sex-shaming.
Individual factors may also be hindering a patient’s ability to improve their sexual health. Those factors include body image—especially body-image self-consciousness during sex, pressure to “perform,” no emotional connection during sex, and general depression and anxiety. Of course, a history of sexual assault, trauma, and/or abuse are also hugely impactful.
Mintz discussed the PLISSIT model for approaching female sexual dysfunction: Permission, Limited information, Specific Suggestions, and Intensive Therapy are all tools ob-gyns can use. Giving patients permission to try new things during sex, sharing information about the nerve endings in the vulva and clitoris, and even suggesting the use of a store-bought lubricant are a few things ob-gyns can do. “Research shows that, in fact, 80-95% of sexual problems can be solved without therapy,” Mintz said.
The language we use when discussing female sexual health is critical, Mintz said. “We are linguistically erasing female sexual function when we call entire genitals by the part that is more sexually useful to male partners than the women themselves,” she said.
There are several medical factors that can impact a woman’s sexual dysfunction, including:
- Hormonal changes during postpartum and menopause
- Neurological issues—something in the spine, a cyst, a childbirth injury, etc.
- Neurotransmitter changes
- Vascular occlusion
- Pelvic floor issues relating to tone, trigger points, or scarring
- Vulvar hormonal and/or inflammatory pathology
- Aging and chronic pain, and
- Medication side effects.
How can you determine if it is a medication side effect? For starters, patients on psychotropic medications may be impacted more than others. “Depression and sexual disfunction are frequently comorbid to one another,” said Harper. “SSRI users had overall better sexual function than those with untreated depression. The major prescriptions that can impact sexual function are citalopram, fluoxetine, paroxetine, sertraline, and venlafaxine.” Additional medications that may be contributing to patients’ sexual problems are benzodiazepines, histamine blockers, hormonal medications, and, importantly for obstetrician-gynecologists, long-acting reversible contraception—levonorgestrel, copper IUD implants—should also be considered.
“The last step is simply talking to them about lower sexual function as a tradeoff for not being able to get out of the bed in the morning,” Mintz said. “There is even data that shows that vibrator use (pulsing air wave tech—womanizer) increases sexual function in patients on SSRIs.”
When approaching a treatment plan, Harper and Mintz recommend a few simple steps:
- Call a vulva a vulva. “When we’re in the operating room teaching medical students, in the exam room talking to patients, and at home teaching our children, this is the languaage we should be using,” said Harper.
- Using plain language when having conversations with patients and explain these terms to patients.
- Ask the right questions, or add a screener to your intake forms.
- Educate yourself and your staff. Seek out evidence-based books, applications, and websites to better understand the issues your patients are dealing with.
- Do what you know how to do. “If you’re not taking a good look at the vulva or the clitoral hood during exams, you should start,” added Harper.
- Consider referring the patient to sexual therapy or a sexual medicine/pelvic pain specialist. “You want to have an awesome sex therapist like Laurie,” Harper said. “The great thing now is that many of them offer their services over telehealth. Aasect.org is a great place to do that.”
- Consider a referral to pelvic floor physical therapy.
“Get your tribe together,” Harper said. “Women deserve access to sexual health resources and we area the keepers of those resources.”
1. Harper L. Mintz L. Recharging Women’s Sexual Health. Presented at: 2022 American College of Obstetrics and Gynecology Annual Clinical & Scientific Meeting; May 6 to May 8, 2022.